Life After Restructuring…

(Published November 2006)

Mike Sobanja, NHS Alliance Chief Executive and Non Executive Director of Health Direction suggests that the latest changes to the NHS structures will not be the last!

The NHS has moved on again, the customer environment now has 10 instead of 28 Strategic Health Authorities and 152 instead of 303 Primary Care Trusts. Life will now settle down again once the jobs merry go round comes to a halt, and we can all get back to normal, right? WRONG… wrong, wrong and wrong again. For a number of reasons.

Firstly, the restructuring and politicians' reassurances that we are now at an end to structural change are simply not true – even now there are arrangements being put into place for the joint management of PCTs which will merge the organisations in all but name and then we have London. 31 PCTs are not likely to survive much beyond the local government elections next year and many would argue that nor should they. The Mayor of London has already made it clear that he’s not dealing with 31 separate bodies and indicated a number of 10-13 might be manageable. Once the dust has settled on the local government elections with the inevitable result of a pasting for the party in office, I think we will see more changes. What about co-terminosity I hear you say? (Well I would if we all understood it – that twee notion of health bodies and local government having the same boundaries). Well yes - but we have now the clearest indication yet that local government itself faces major restructuring over the next few years as government tries to sort out the mess created by two tier authorities, with the outcome being anyone’s guess – but you can be pretty clear that it won’t be what it is now – and health will follow again.

Secondly, there’s practice based commissioning. If ever there was a misnomer that is it. This is not Practice based, nor is it commissioning alone. Across the country, there are now nearly 700 practice based commissioning “groups”, “clusters”, neighbourhoods”, and so on. These groups will take on the real job of designing and redesigning patient care with an impact on prescribing and care pathways. For those who regard the NHS as their customer, “spot the commissioner” is a game to be played for some time yet as the real relationship between PCT and practice groups starts to mature and becomes mutually supportive (I hope).

Thirdly, there is the issue of specialised commissioning. Following the review last year, the DH ministerial team has still to pronounce on the new structure which should simplify the nonsense of tier 1 and tier 2 services, but this conjures up a new set of relationships – where exactly will the new specialised commissioners fit in the system and what will there links be to SHAs, PCTs and PBCs – watch this space!

Oh yes, and then there are clinical networks – how are they going to fit in? Will they migrate to SHA areas, and again are they servants, partners or masters of PCTs and PBCs? Only time will tell.

So what’s going on – why are we all going through this trauma (again)? The agenda is clear. Firstly Government has to get the commissioning side right and there is little doubt that the old arrangement of 303 PCTs simply did not provide adequate “clout” for commissioning, and dissipated the available managerial and commissioning skills. Concentrating effort is wise and laudable but we do need to make sure we have means of staying in touch with local communities – on this the future of the NHS depends – remember the notion of a “fully engaged population” by Derek Wanless? Only then was a publicly funded NHS sustainable. I don’t see much of the “fully engaged” scenario emerging quite yet. Secondly, there is a need to sort out provision and moving to the much vaunted Foundation Trusts are one part of that – but whether they were necessary is debatable and anyway they only represent one sector in the NHS system. But now we have started let's get on with it, but we badly need to define and develop sustainable provider models right across the NHS system and particularly in community and primary care.

Then we need to join up the two sides with some mechanisms that avoid division and behaviour which sometimes feels pretty adolescent as our immature market develops. The most pressing need is to sort out the future destination of Payment by Results with its notions of funding real outcomes in theory, but short in practice, and making real the commitment to introduce a real IT system that gives the NHS the where with all to simply know what it is doing, when, and how much it all costs – a simple requirement – but one that is turning into a real trial just now – let's hope David Nicholson’s review pulls that one out of the fire.

What’s left then? Just that issue of regulation – how on earth can we join up CHI, NICE, QOF and the myriad of other regulatory tools so that we have a clear and simple set of mechanisms that regulate for market entry and exit, quality and price and don’t pay through the nose for a set of mechanisms that are looking increasingly out of touch with what a truly modern and effective NHS needs.

So a little way to go then? I’d say so, and that’s just on the structural and systems side, never mind the far more important issues of relationships, capability and development of individual and organisations truly fit for purpose, and not just to tick the box of the mad magician.

So it’s all done and dusted you thought – quite the opposite, to paraphrase Churchill more like the end of the beginning, rather than the beginning of the end. A couple of things are sure, the first one is that the NHS will keep on changing as the politicians of whatever colour attempt to find ostructural solutions to what is essentially a cultural and behavioural conundrum – how to make the NHS work; and secondly, those doing business with the NHS can't take their eye off the ball for one minute if the strange world of the NHS is not to transform their noticing. Did I say National Health System by the way, or is it National Health Service? Now that would be information worth knowing…

Speaking of restructuring........... Lisa Hudson from our database editorial team tells us the latest on Northern Ireland

The 18 trusts in Northern Ireland are going to be replaced by 5 Health and Social Services Trusts, which have now been legally established and are shadowing the existing trusts until these cease to exist in April 2007.

The Local Health and Social Care Groups (LHSCGs) have been formally stood down by the government, as part of the re-structuring in Northern Ireland, this was effective from 30th September 2006.

Local Commissioning Groups (LCGs) are due to start operating within the HSS Boards and are to follow the 7 councils within Northern Ireland. The LCGs have yet to be announced.

By April 2008, all existing organisations will cease to exist and the new Strategic Health and Social Services Authority, Local Commissioning Groups and Patient and Client Council will become fully operational.