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Support, not rule

Support, not rule

Interview: Sir David Nicholson

Sir David Nicholson is tired. Granted, he's just delivered an hour-long keynote speech at the Healthcare Innovation Conference in London. But with intense focus on the role and responsibilities of the NHS Commissioning Board (NCB), of which he will be Chief Executive, he could be forgiven for feeling the pressure, even with his experience. It's supposed to be "up and running" by 1 October.

NHS Chief Executive since 2006, Nicholson seems excited by the prospect of heading up the NCB, describing it as "a huge opportunity for us to do things in a way we've never been able to do before." He is adamant that GP commissioning consortia will be given the freedom to innovate and implement new, high-quality patient services that the NCB will help to spread nationally.

"For all consortia, I genuinely mean this thing about, 'I want the GP consortia to be the best they can possibly be'. That's my job," he says.

But with the excitement comes uncertainty. Not only has the board line-up yet to be announced in any detail, but the British Medical Association (BMA) has already suggested that GP consortia's accountability to the NCB could replicate just the kind of centralised, top-down structure that Andrew Lansley's health reforms were brought in to abolish.

At the BMA's Special Representative Meeting (SRM) in March, members voted overwhelmingly for the union to pursue an amendment to the Health and Social Care Bill that would ensure "the powers of the NHS Commissioning Board do not lead to central domination over clinically led commissioning consortia".

Dr Richard Vautrey, Deputy Chair of the BMA's GPs' Committee, who put forward the motion, gave a virulent warning to SRM members, talking of "sweeping and potentially draconian powers of the NCB that could make consortia simply puppets and prevent local GPs from standing up for their patients". The BMA had already raised concerns that the NCB would be able to dismiss consortia's Accountable Officer and bring in a self-imposed replacement, and would be able to dissolve consortia and change consortia areas, without consultation.

But Nicholson's vision, he insists, is not so imposing. "I just do not see it is some kind of bureaucratic relationship, with the NCB at the centre and all of the consortia out there. In lots of ways it's the other way round: consortia are the patient-facing, significant part of the system and we're there to support them," he says.

Even his appointment as the NCB's Chief Executive had led many to believe that localism, advocated so vehemently by the health secretary, was something of a hollow promise. After all, Nicholson himself has been viewed as favouring central control, helming the NHS just when all health-related decision-making seemed to lead to Whitehall.

As Vautrey said, referring to the NCB's Leeds base: "Already the Board is being moulded in the likeness of its Chief Executive, and the risk is that, instead of the sounds of bed pans alarming ministers in Whitehall, they will be rattling the walls of Quarry House – and it's the must-dos from Leeds that must be obeyed, or else, in future."

But Nicholson rejects this. "It's certainly not a centralised control system, because the relationship between consortia and the NCB will be very different from the relationship between the Department of Health and primary care trusts," he says.

"The relationship will be one of: we will allocate resources, we will identify commissioning guidance and we will measure performance and allocate the 'quality premium'" [a sum paid to consortia to reward good commissioning performance]. "So we're one much more of incentives rather than one of direct management: we wouldn't want to get involved with direct management of consortia, unless they fail. It's quite a different approach [to an autocratic body].

Earlier that day, Nicholson had told delegates that the NCB "puts the 'N' in the 'NHS'" – that its role was to ensure that where one consortium improves outcomes, that performance can be replicated elsewhere. He draws a distinction between this role of spreading good work and of dictating across the regions. Yet he does admit that this involves a degree of centralisation.

"What the NCB work will involve is to ensure consistency for patients," he says. "We want to make sure that all the consortia are improving outcomes. So I don't think that's centralisation but it is being really clear about what only you can do centrally. I mean, you can only have one really good identification of what a great service looks like. You can't have 10. So using that information to support consortia is what we're about."

So the NCB will not just be stepping in when consortia fail? Not if the Board will achieve its aims to improve outcomes, says Nicholson. "You don't do that by just dealing with the 'trailing edge', you have to move the 'middle' better and you have to support the innovators. So it's really important that we give [innovative consortia] the kind of support that they need."

But if consortia wanted to get on and make changes in their area, would they need to seek approval from the NCB first? "No, as long as they're consistent with the rules of the way the service operates – so they weren't going beyond the idea of 'free at the point of use' and universally available or they weren't using things that had some evidence base behind them – then I think we would let people get on with it," says Nicholson.

Even now, the senior line-up of the Board seems vague – "my guess is that the chair will be appointed in May," says Nicholson. "Then at that period we propose to set out what the top management structure will be." Will that include any GPs? Vautrey has said the NCB's appointment system "can't just allow for political fixers… it needs to involve clinicians with a current understanding of what it means to work in the NHS today".

Nicholson can't promise anything yet. "Obviously it's all subject to the legislation going through Parliament, so anything we do is subject to that," he says. "At the moment it says that we have five executive director members of the Board and six non-executive members, and it hasn't specified what the executive director members will be – apart from a chief executive, finance director and a chief nursing officer.

"So the rest of them we simply haven't had the opportunity to get round and work out how we're going to do it. But general practice is going to be right there. GPs shouldn't be worried that there won't be real opportunities for them to operate at every level."

Stuart Gidden


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