Systems Goverance is Confused in the NHS White Paper

The English NHS is in for further reform as the flurry of consultation documents and the White Paper evidence. Overall, NHS reforms have been generally weak in having a thought-through systems governance approach. I think in part this arises from perceived problems with two areas: the role of the private sector: the systems governance of previous reforms has tried to ignore this sector, and in effect partition the health market certainly in England, with the result that a single playing field for providers couldn’t emerge. This was compounded by the previous government’s views that NHS providers could fail twice before being of public concern (a silly and ideologically driven position). The second problem has always been the purchasing side (a.k.a. commissioning), where there has been over the years feare of ‘letting the market rip’ (as if we somehow markets are generally regulated anyway), anxiety about purchaser impact on provider viability (again an ideological position on the how to deal with failing public institutions — the usual response it to prop them up with more money). or more generally a plethora of initiatives (such as World Class Commissioning — I wonder when this one gets buried?), whieh exuded more style than substance.

And so it continues with a failure, I think, once again to get the commissioning side of the health system balance sheet cleaned up.  One of the key things that needs to be central to systems governance is clarity of mission of the various bits that make it go, and how conflict is managed, mainly for systems-level problems that need to be resolved within the system, rather than constantly being taken back into the political machinery for resolution. Given that the coalition government wants to create some distance between the Department of Health and the regulatory oversight structures themselves (Monitor, CQC, NHS Commissioning Board seem the main statutory bodies here plus the GP Consortia and providers as agents), the possibility of conflict emerging between the Board and the other two regulators is real.

The NHS Commissioning Board will have oversight of GP Consortia, and in effect givea them a licence of fitness to practice; though this isn’t the exact terminology used, the Board does decide if GP Consortia are handling financial risk well, within the overall clinical frameworks and other guidance. And what of failing GP Consortia?

I am troubled in particular that the Board will be commissioning services for primary care and for national and specialist services. This is where the core problem for system governance lies, as the Board has a potential serious governance conflict between its oversight and regulatory role and its activities as a purchaser (sorry, commissioner…).

Who oversees the NHS Commissioning Board’s commissioning and why should anyone trust them to do a good job in absence of suitable oversight — are they not both poacher and gamekeeper? Since the Board will be commissioning, and also overseeing commissioning by GP Consortia who must commission within the any willing provider framework, will the Board be similarly constrained? While GP Consortia’s behaviour is subject to oversight by the Board in respect of commissioning decisions, the Board appears not to have any oversight in this respect (apart from the usual warm words that folks will consult and work in partnership, etc.) My worry is that the collective effect of GP Consortia commissioning may have some relationship with the desirability or not of specific national or specialist service commissioning. I am also worried about the logic underpinning what national and specialist in fact are, as this type of thinking is really ‘old school’, and is a remnant of centrist thinking. The epidemiology and service logic at work here could also find itself at odds with the possibility of unbundling and decentralising or otherwise restructuring such services (where capabilities, technologies, and opportunities present themselves), a possibility that innovation might unleash, but which cannot be anticipated by this particular solution. As well, we are too aware of the failure of prestigious providers to fail in their quality (do we need to mention neonatal heart surgery?)  So the assumptions underpinning the centrist logic of national and specialist commissioning should fall both within the remit of CQC and Monitor and under the wing of GP Consortia.

The proposed NHS System Governance System, 2014

Apart from all the other things that the Board will do (a very long list) adding into this mix managing commissioning relationships with providers seems not just a task too far but a source of considerable and likely conflict. This is to say absolutely nothing about how they will handle the commissioning of GP and other primary care services, which entails commissioning services from people that, in an different guise as GP Consortia, they in effect regulate.

How to do that? Well… Critical to effective commissioning is ensuring that adequate analytical capacity exists at the levels at which decisions are being made. If, and I see no reason to doubt this, GP Consortia do their jobs well with excellent analytical capacity to inform their decisions, they can, in some collective form, create an appropriate structure to handle the commissioning of national and specialist services. This will ensure the better integration of commissioning decisions, smooth the flow of patients and resources across the borders of GP Consortia, and clarify referral protocols. It will ensure that these national services are really national or specialist and are governed by common standards of regulatory oversight. Importantly, it avoids the potential for gaming the system, as it removes an incentive for providers to lobby for the creation of national or specialist services as a way of protecting their service infrastructure, and ensures that any complacency in service quality improvement is avoided by being able to for specialist providers to forum-shop for a regulator.