St Sir David’s Missal for Managers

We could just as easily have titled this “Transformative Epistolatory Approaches to Transition Management”, or for the popular version, “Eyes Wide Open and Watch Out for the Banana Skins”.   You will see what I mean when you read through NHS CEO (England) David Nicholson’s most recent (10 September) output of letters and guidance about managing the Liberating the NHS transition.  His “dear colleague” missives get longer and more entreating in direct response to stress levels in the service I suspect.

Is the letter reassuring?  Yes, but only about the monumental scale of the change required and the short time in which to get things done.   I suspect reading between the lines will tell some recipients in PCT management echelons to organise their exits now before they have to be accountable for all of this on a greatly reduced management budget.

Lack of per capita money to run the new consortia commissioning system is turning out to be  the biggest rub from our local GPs’ perspective.  And if winter turns nasty, then all bets are off anyway whether H1N1swine flu makes a reappearance or not.

The FAQ paper accompanying the 10 September letter does makes more interesting reading – FAQs always do – and this one reflects what managers have been asking at meetings over the past several months.   The answers Nicholson provides take the old “how to make a camel” story (definition = a horse designed by a committee)  into a whole new dimension.

Here’s the camel recipe broken down into seven easy steps.

First, take independent small businesses of varying capacities, interests and qualities called GP practices;

Second, weld them together – including the reluctant players and the chronic poor performers –  into commissioning consortia;

Third, leave them to form relationships with each other and with local authorities they may scarcely be aware of but who have to become their new best friends if they want to get anything done;

Fourth, make the consortia statutory bodies in the new Health Act;

Fifth, appoint to each one an accountable officer and CFO but fudge the rest;

Sixth, shower them with commissioning money but not enough management allowance to handle it effectively;

Seventh, don’t specify any other governance structure for the consortia like Chair or Board members.

And finally when the mixture is starting to bubble away nicely – light the blue touch paper and retire to a safe distance in early 2013 when the PCTs turn off the lights (asssuming there is anyone left around to do that).

I cannot think of anything more awkward in governance, management and accountability terms than a big herd of unhappy and unstable camels.

I worry that’s what we might be getting.  But Ministers profess not to be worried by this lack of specificity:  Earl Howe told the Kings Fund conference on GP commissioning on 13th September that it was all about trust:

There is no set model.  Consortia are going to evolve and grow organically in the interests of their patients. So when we get down into the minutiae of organisational structures, oversight mechanisms and financial management, let us always keep in mind the reason we are reforming health in this way.  It boils down to trust – this government trusts the men and women of the Health Service.  And we believe that by trusting them, by trusting you to organise healthcare, we will see markedly better outcomes for patients.

We hope this works, but entrusting £80bn of public money essentially “on trust” with little in the way of governance infrastructure and assurance controls does not strike us as low risk.

Looking in from the outside, it is hard to imagine what the patients  and the public will make of this diversity.  How will they perceive the benefits of the new arrangements?  If they don’t improve services and make it all feel close to patients, they won’t inspire either understanding or, much less, loyalty.

The NHS brand is precious and powerful, but reputation can prove to be a fragile construct if the customer experience is not positive.

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