The unaccountable super-quango at the heart of NHS reforms
The government White Paper that started the reforms was called "Equity and excellence: Liberating the NHS". This conjures up an image of hospital doctors shackled to bedsides, chain gangs of nurses in wards and wan-looking diagnostics staff blinking in the sunlight during their brief exercise period when released from the path-lab. Liberation would end all of this.
But the type of liberation that the government intended was very different. The free market model that Lansley had planned could more accurately be described as the government liberated from the NHS rather than the NHS liberated from the government. Lansley did not want (and still does not want) to run the NHS – he is the first Secretary of State for Health whose primary objective is to legislate away his job.
The word "local" was key to the original policy. Lansley sold his White Paper to the public with the promise that it would make decision-making more local to the patient. We were told that local GPs would replace distant and faceless Primary Care Trust managers.
Early on in the discussions over the White Paper it was clear that the government could not be "liberated". In fact, the White Paper publication was delayed by three weeks while the Treasury made changes. It pointed out that Lansley's plans would "liberate" a huge chunk of money (initially reported to be £80bn) from the country's coffers and spent by organisations with no accountability. The Treasury, quite rightly, added extra accountability to ensure that this money would be wisely spend, but this added more bureaucracy.
As the policy developed, it became abundantly clear that it is not possible to provide healthcare for 60 million people in the ad hoc fashion that Lansley envisioned. Services have to be planned, facilities designed, funding secured, and staff have to be recruited and trained. This is not something to leave to chance – or the market. So early on in the process the Department of Health began to centralise decision making.
Lansley's original plan was to create the National Commissioning Board to take over much of the work carried out by the Department of Health. The idea was to make the NCB "independent" and there was a concern that the government would fill the board with figures from private healthcare. We still do not know who will be on the NCB board, but we do know who will be the most important of that board: the chief executive. It is rumoured that Lansley wanted to appoint KPMG Global Head Of Health Mark Britnell as chief executive. Britnell told a conference for private healthcare companies last year "the NHS will be shown no mercy".
But the Treasury overruled this decision. Instead, the job has gone to the current Chief Executive of the NHS, Sir David Nicholson. This makes sense since Sir David is NHS through and through, and understands the true magnitude of the £20bn "efficiency savings". However, since his appointment was announced, it has become clear that the NCB will become far more significant than the White paper suggested. Rather than Lansley's free market of hundreds of competing providers, commissioned by local GP groups and overseen by an independent board, the board is centralising power, taking on much of the decision-making that is currently carried out locally. Sir David Nicholson as chief executive will become very powerful.
Lansley has consistently said that GP commissioning groups will make the decisions over treatments, but when the Bill was published it became clear that the NCB will have sweeping powers to control how these commissioning groups operate. The board will produce commissioning "guidelines", effectively telling the commissioning groups how to do their work. It will also offer "guidance" over the constitutions of the commissioning groups. The board will also approve the boundaries of the commissioning groups, have final say over whether commissioning groups can merge or be dissolved, and determine the financial allocations for each commissioning group.
Commissioning is currently carried out by Primary Care Trusts, 152 of them, covering around 300,000 people each. The impression that the government is keen to promote, is that local GP groups will take over this commissioning. This is not the case. In March, while giving evidence to the Health Select Committee, Lansley pointed out that a large amount of decision-making will be centralised in the NCB. In response to questions about the amount of commissioning GP groups would be required to do (Q514) Lansley pointed out that although PCTs currently spend about 80% of NHS funds, the new groups will spend about 60% and the difference will be taken up by the NCB.
This is partly because GPs have to be commissioned (and clearly the new GP commissioning groups cannot do that). Currently the 152 PCTs use local knowledge when commissioning GPs, but in the future this will be carried out by the national NCB (or, more likely, by one of the four regional outposts). In addition, this new central quango will be responsible for commissioning specialist services (like organ transplants) which is currently carried out by the ten Strategic Health Authorities. Work that was carried out regionally will be performed centrally. Commissioning of dentists, opticians and pharmacies will also transfer from PCTs to the central NCB. Whatever happened to localism?
The NCB will determine the "national tariff" which is the fixed price list that currently covers about half of hospital work (and the government wants to extend tariffs to almost all hospital work and into primary care – GPs – too). The power that this confers on the unaccountable NCB is immense. It will determine how much hospitals will be paid and it will determine how much GPs can spend.
Such a powerful, central power must surely be accountable to our elected representatives? No. The whole point of the Health Bill is to remove any responsibility for the provision of healthcare from the Secretary of State and to shift the decision-making to the unaccountable NCB. The board will have a "mandate" from Parliament that will be renewed annually. In other words, if the board oversteps its mark our elected representatives will have just one chance a year to hold the board to account.
This is stripping a huge amount of power from Parliament and handing it to an unaccountable quango. Further, if there is an election and the government changes (say, elected on a mandate to increase NHS funding, or to change how treatments are delivered) they will not be able to enact that policy until the once-yearly mandate is renewed. The Bill will specifically make it illegal for the Secretary of State – representing the elected government – from changing NHS policy.
This immense power and unaccountability was not challenged during the "listening exercise". Indeed, the resulting Future Forum report hands even more power to the NCB. The Forum says that the Bill must be changed to create clinical senates (which will advice the GP commissioning groups) and these senates will be part of the NCB. Further, clinical networks (which integrate care and were threatened by the initial Bill) will also be part of the NCB. In response to concerns about GPs being unable to take on commissioning to the ambitious timetable produced by Lansley, the Future Forum suggests that commissioning groups should only do commissioning "when ready". So who will do the commissioning until then? The NCB.
The NCB will now have the responsibility to impose a "choice mandate" on the NHS. The NCB will also impose "personal budgets" on patients. Personal budgets are deeply unpopular since many patients see them as a form of rationing. They are, however, very popular with politicians because they shift responsibility to patients – not only the responsibility for the management of their condition, but the responsibility for the cost of their condition. Politicians have found it hard to convince patients to move to personal budgets, and so now the government will make the NCB do this dirty work.
The Secretary of State has been liberated from his duties. But instead of devolving power he has centralised it into an unaccountable quango: the National Commissioning Board.
Richard Blogger writes about the NHS and social policy at NHS Vault.
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