Just before the Christmas break the NHS Commissioning Board issued its ‘planning guidance’ to the 211 clinical commissioning groups (CCGs) that are to take control of local budgets from April. Everyone Counts sets out the ‘what’ and the ‘how’ of commissioning in the reformed NHS. It replaces the Operating Framework that, for the past few years, has set out what is expected of the NHS, including targets and other ‘vital signs’, as well as tariff prices to be paid to providers.
So what message does Everyone Counts send to CCGs? I had expected to read a very direct message about the new role they are taking on, how the Board will work with them, and priorities for 2013/14. While many of the ambitions in the guidance are laudable – for example to improve the data that commissioners have available to them – my concern is that it fails to give CCG leaders the clarity they will need.
First, it is not clear who the document is addressed to – David Nicholson addresses his foreword to all NHS staff. Does this include staff working in trusts and foundation trusts? Some issues are addressed to providers as well as commissioners. This appears to miss the intended distinction between the NHS Commissioning Board and the NHS Executive it replaces, whose role involved a more direct relationship with providers.
Second, it sends mixed messages about the level of support/challenge CCGs can expect. Some aspects of the document are quite directional: CCGs will do this, are expected to do the other. Elsewhere in the document it talks about ‘assumed liberty’ and the Board’s ‘offer’ to local commissioners. While there is a clear desire to move away from performance management to a relationship of support, phrases such as ‘rigorously support’ reveal the difficulty that the Board will have in letting go.
The Board will also not set ‘improvement requirements’ – newspeak for targets – but will, instead, allow commissioners to prioritise local indicators. Yet on waiting times, in addition to the rights that patients have under the NHS Constitution, the Board has set out ‘additional safeguards’, including zero tolerance of waits of more than 52 weeks and no patient to experience a second cancellation of an urgent operation. It seems targets are here to stay after all.
The document is clear that if the level of ambition of local commissioners is judged to be insufficient they will be challenged by the Board. And there will be financial consequences – in the form of a reduced quality premium – if targets are not met.
Finally, Everyone Counts does little to inspire change and improvement in the areas set out as priorities in the NHS mandate. In a bid to maximise local discretion the document fails to be clear about national priorities, such as dementia, long-term conditions, and mental health. Its commitments to reducing inequalities are to be welcomed, but a bit like the first draft of the mandate, Everyone Counts does not articulate what the priorities are clearly and fails to provide an inspiring vision of the improvements that CCGs will deliver in patient care.
Having said all that, the document is ambitious in a couple of respects; first, its commitment to offer ‘the best customer service in the world’. Yet this seems totally at odds with the current financial position facing the NHS. Of course the NHS must improve the experience of care for patients and their families and better ‘customer service’ would help this, but can we really afford Four Seasons Hotel customer service? Second, the document is radical about the amount of data to be collected and published, as well as implementation of information systems such as electronic patient records and paperless referrals. The big question is whether these are deliverable, given they have so far eluded the NHS despite a great deal of investment and effort.
There is a risk that the NHS Commissioning Board will give away power and lose a grip on some things, like money, but also that it will not provide sufficient flexibility to allow CCGs to do commissioning differently. The real test will be whether CCGs see this document as their marching orders or chose to assume their liberty and pursue local priorities. I imagine that those leaders of CCGs who found time over Christmas, between preparing for authorisation, to read Everyone Counts, did not find it easy reading and will be none the wiser about what 2013 holds.
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