The pathfinder clinically led commissioning consortia (to use their proper name) are well and truly off and running. To what ultimate destination is less clear, but the imminent report of the Future Forum “reforming the reforms” may dispel the mists and give us all a roadmap. Will the governance of consortia be up to what is bound to be a rigorous journey? Will they be fit for purpose to do tough commissioning (and decommissioning) business upon arrival? We wonder about that, judging by the latest “guidance” on the subject from the BMA’s General Practitioners Committee .
Diversity is fine, provided….
Whether large, small or federated, there is nothing inherently wrong with having diversity in commissioning consortia shape and size so long as it makes geographical sense and is able to address local health needs and inequalities. There is a balance to be struck between, on the one hand, not being too prescriptive about governance lest we re-create those villains of the reform narrative the PCTs and – as the the GPC guidance sets out to do – only seeing the need “to identify a framework, or set of principles, that describe the appropriate functionality of a consortium.”
The BMA (motto “standing up for doctors”) clearly thinks this is sufficient to send the consortia off on their difficult journey. They say:
This will ensure that a consortium is a viable, transparent and accountable organisation, has a sufficiently strong GP voice, involves other clinicians and other stakeholders at the right time, and above all has the confidence of the local population on whose behalf it is working.
It’s that final phrase that concerns us the most. Will the governance of the consortia command the confidence of the local population they serve? The answer is in how accountable they are and are perceived to be.
Holy grail of local accountability
Local accountability is the holy grail of public service reform across the sectors. We like the concept, so have to ask the killer question: Will this governance guidance for consortia deliver, above all, an accountable organisation which has the confidence of local people?
To find out, first let’s first look at the key features of the BMA’s governance framework. It says each consortium shall have
1. an “accountable body” made up of representatives of the constituent practices which would be “accountable to the public, patients and practices, in addition to the NHS Commissioning Board and Health & Wellbeing Board”.
MAC says – does this mean a board of directors? The BMA is emphatic that it does not mean this, and the Bill does not prescribe them either, but frankly the guidance is bending so far over backwards on the point about not having “boards” that it risks breaking in half.
If the “accountable body” is composed of representatives (does this mean only clinicians?) from the constituent practices, then the guidance must say in what way(s) it will discharge accountability to the public and patients. The guidance is silent on this “how?” question.
2. an ‘executive/strategic group’ to “hold the decision making functions for the consortium and include the Accountable Officer and other key personnel.”
MAC says – this is an example of confusion between governance and management and the distinction between strategy and operations. Governance and strategic decision making should be the preserve of the “board” acting on behalf of the owners of the consortium, which morally means the local community it serves. But since there are no representatives of the community on the “accountable body” aka “board”, this cannot happen. Delegating it to a group essentially controlled by the “accountable officer” cuts the “accountable body” off from the organisation and is a recipe for confusion and weak commissioning.
There are not even to be any elected councillors on the top body because of the “risk” of decision making becoming politicised. The guidance says: “the contribution of local councillors is important, but it is not essential for them to sit on a decision-making body as this would risk politicising the commissioning of local health services.”
3. an “audit group” whose job would be to “hold in check the Accountable Body and Executive/Strategic Groups and ensure the probity of the decisions made.”
MAC says – this is an essential part of governance, we agree, but independent audit has to be exercised by independent people with the appropriate skills and access to the information required. The BMA guidance explains nothing about who will carry out the function and how they will do it and what will happen if there is a problem. Commissioning organisations responsible for £60bn of public money need much, much stronger and transparent probity mechanisms
Governance principles to support structures
In addition to these permanent structures, the BMA guidance wants a number of principles to apply to whatever governance arrangement a consortium chooses within the recommended framework. This includes quite sensible things: financial accountability, legitimacy of the consortium leadership, clinical involvement, probity, GP majority, practice engagement, minimal bureaucracy.
After that recitation, the guidance finally gets to what we think is the meat of the matter, namely the three principles of
“Patient engagement – there must be genuine and meaningful engagement with patients at some point in the commissioning decision-making process. Patient representatives could sit on one of the groupings described above, or they could be observers to those groups. Consortia should consider which of its decision-making groups should meet in public. It is important that patients can see that decisions are made fairly and transparently and that they are part of this process.”
MAC says – the flaw in this is the phrase “at some point”. What is required is continuing engagement, not a one-off. The BMA thinks only of patients and their representatives – which ignores the general public entirely.
“Accountability to the public – the contribution of local councillors is important, but it is not essential for them to sit on a decision-making body as this would risk politicising the commissioning of local health services. Councillors would be welcome as observers, and will also have an important role to play in the proposed Health and Wellbeing Boards.”
MAC says – the accountability to the public question is again dodged here because the guidance does not cover engagement with the public, merely with patients and to some extent with carers. Even if local elected councillors were included, “the public” is much bigger than the town hall.
“Lay management – it is essential that consortia have the right expertise available to fulfil their functions and it is therefore likely that every consortium will employ lay managers (or external commissioning support) to assist with the commissioning process. Consortia should be designed to ensure that lay managers support the elected representatives of the organisation, and do not, as with previous primary care organisational structures, start to exclude clinicians from direct commissioning decisions.”
MAC says – this is demonisation of managers for ideological effect and shows a fundamental misunderstanding of what “management” means. It is much more than giving “support to elected representatives of the organisation” – that’s administration. In using this phrase, there is lack of clarity whether it is the “accountable body” or the “executive/strategy group” which is meant. The term “lay managers” is also curious and ignores the fact that PCTs which were successful at their job had many managers who came from clinical backgrounds. This “them and us” approach is a recipe for weakness.
Accountability is not just semantics.
The BMA governance guidance shows a lamentable lack of understanding of accountability as a concept and how it is discharged through structures in the organisation. There are many definitions of accountability available, but let’s reflect the view that the King’s Fund gave about the NHS practicalities of this in its recent report. It all comes down to who is accountable, for what and to whom: “a relationship involving answerability, an obligation to report, to give an account of, actions and non-actions.”
The King’s Fund maps out the accountability duties of a commissioning consortium in terms of the formal accountability relationships for management, regulation and scrutiny. This is their framework:
- management relationships
- the new national NHS Commissioning Board
- the Secretary of State through ‘standing rules’
- regulatory relationships to Monitor, reconstituted as a new economic regulator
- scrutiny relationships to no less than four bodies
- new Health and WellBeing Boards based in local authorities
- a separate health and social care ‘scrutiny function’ in local authorities
- Local HealthWatch organisations, which are to take over from LINks
- the National Audit Office of consortia consolidated annual accounts
None of these “answerability” relationships are adequately reflected in the BMA’s governance guidance. Indeed some are not even identified. If you look for the scrutiny role of LINks soon to be Local Health Watch towards consortia in this guidance, you will not find it.
Accountability test failed
Words matter because they guide an organisation’s thinking and actions. If the words describing accountability are insufficient, the risk is the consortium’s “answerability” behaviour will be wanting.
We have recently suggested that one good way to guard against this happening is to have lay people closely involved with the consortium authorisation process and have outlined an authorisation process for consortia with the NCB in which local people and elected councillors would have a deciding role. That should be part of consortium governance, as well as responding to complaints of poor performance once it is doing business. None of this dimension, of course, exists in the BMA’s framework.
Will the holy grail of local accountability be achieved? The King’s Fund conclusion is pessimistic: Overall, although the reforms mean a greater reliance on local mechanisms for holding providers and commissioners to account, we are pessimistic about whether the changes will strengthen the accountability of the NHS at a local level.
MAC’s conclusion about consortium governance based on the BMA guidance is in parallel to this. As outlined by the BMA, the governance arrangements for consortia will not be fit for purpose and will not deliver either an effective internal organisation or one that is accountable to and commands the respect and support of the local population which is it meant to serve.
We underline what the Prime Minister’s Five Pledges on the NHS Speech on 7th June said:
Taxpayers put a lot of money into the NHS, it’s only right that when they use it, they should have the power to shape and design the healthcare they receive. But there’s another argument to be made for real patient power. When patients do have their say, and are able to make choices, it makes a massive difference. When they get involved in their care they get better results, and they manage long-term conditions more successfully too. … No decision about me, without me.
That’s the simple yet profound message the BMA is studiously ignoring in its guidance to consortia. We look to the Future Forum’s report to redress this imbalance and to get the reforms back on track for the benefit of the local populations which the consortia are meant to serve.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.