Editorial Monday 30 July 2012: Minutes of SOS Lansley accountability meeting with Sir David Nicholson and Professor Grant, NHSCB

The DH's minutes of the latest accountability meeting between Secretary Of State For Health Andrew Lanlsey and NHS Commissioning Board Authority chair Professor Malcolm Grant and CE Sir David Nicholson have now been published.

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Click here for details of The red ties that bind Comrade Sir David: postmodern NHSCB to commission itself (oh yeah, and what cowboy drafted this mandate?), the new issue of subscription-based Health Policy Intelligence.

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NHS Commissioning Board Authority Accountability Meeting
Monday 25 June 2012, Department of Health, 14:00-15:30

MINUTES
Rt Hon Andrew Lansley CBE MP, Secretary of State for Health
Richard Douglas, Director General for Strategy, Finance and NHS
Andrew Sanderson, Deputy Director, NHS Commissioning (Secretariat)
Private Secretary to the Secretary of State

NHS Commissioning Board Authority
Professor Malcolm Grant, Chair
Sir David Nicholson, Chief Executive
Bill McCarthy, Managing Director

Introduction and actions from last meeting
1. THE SECRETARY OF STATE welcomed NHS Commissioning Board Authority (NHSCBA) colleagues to the meeting. He thanked them for ensuring, as agreed at the previous meeting, that the Authority’s Business Plan fully reflected the priorities set out in his letter to Professor Grant of 23 April.

The agenda for the meeting would consist of:
• a report of the monthly official-level accountability meetings between the Department of Health and the NHSCBA;
• an update on transition and recruitment to the Board;
• an update on the development of clinical commissioning groups;
• a report on the NHSCBA’s plans for promoting equality and tackling inequalities – which was one of four “fixed points” in designing the Board; and
• an update on the other three fixed points: the NHS Outcomes Framework, the NHS Constitution and the Board’s resource limit.

Update from senior departmental sponsor
2. RICHARD DOUGLAS (Director General for Strategy, Finance
and NHS, and senior departmental sponsor of the NHSCBA) gave an update on his monthly accountability meetings with the Authority. These had covered:
• the key risks facing the Authority (this was a standing item);
• the principles that should be followed when the NHS Commissioning Board “hosted” services (such as commissioning support services). In particular, any hosting of functions should be temporary, with a clear plan and timetable for achieving a permanent solution; and
• the sponsorship relationship between the Department of Health and the Authority. This was generally working well, but there was more work to do to ensure that the Department as a whole fully understood that it would have a different role in future.

3. THE SECRETARY OF STATE noted this update and emphasised that the Department’s changing relationship with the NHS would require a shift in behaviour from the Department and its Ministers, and central government more widely to understand that autonomy and accountability implied less direct interference.

4. PROFESSOR MALCOLM GRANT (Chair, NHS Commissioning Board Authority) added that the Board could only be successful if the Department of Health was successful in this, and that it was essential to have trust on both sides.

Update on transition and recruitment to the Board
5. SIR DAVID NICHOLSON (Chief Executive, NHS Commissioning Board Authority) reported on progress in recruiting to new positions in the Board. Recruitment was already under way for national directors, and would soon start for local area team directors. This process should be largely complete by the end of July, and would pave the way for the recruitment or transfer of the majority of the nearly 4,000 staff that the Board would employ.

6. Continuing, he said that the transition period of creating the Board would be challenging, but that the Authority was taking steps to mitigate risks. For example, many staff, including people working on the administration of family health services, would join the Board through a “lift and shift” transfer from their existing organisations, rather than through open recruitment. This would help provide continuity.

7. Concluding, he said that the Authority was using the recruitment as an opportunity to carry out a systematic assessment of leadership skills and capability. One positive thing this had illustrated, for instance, was that having more clinicians in the organisation was bringing fresh insights and new ways of working.

8. THE SECRETARY OF STATE noted the progress being made, and in particular that there was now a high-quality team of non-executive directors in place for the Board, with a wide range of experience.

Update on developing clinical commissioning groups
9. PROFESSOR GRANT summarised progress in developing clinical commissioning groups (CCGs). There was great variety among proposed CCGs, ranging from Corby CCG (with a registered population of 68,000) to North, East, West Devon (with a population of 901,000), though most had a population of between 150,000 and 300,000. The Authority had a plan for assessing all 212 emerging CCGs for authorisation. CCGs would be assessed in four “waves”, with Wave 1 starting in July.

10. Continuing, he said that until the assessments started, it was not possible to estimate how many CCGs would need to be authorised with conditions, or what kind of conditions would be needed. However, the relationships with emerging CCGs were working well, and the Authority was impressed by the progress that many CCGs were making.

11. Concluding, he said that the Board would relate to CCGs in two ways, which would need to be balanced carefully. On one hand, the Board would have a quasi-regulatory role, formally holding CCGs to account. On the other hand, the local area teams of the Board would be a local partner of CCGs, working with them jointly on Health and Wellbeing Boards and on local commissioning.

12. THE SECRETARY OF STATE invited other comments, and the following points were made in discussion:
a. There was no “right number” for the size of CCGs;
different services needed to be commissioned at different scale, and CCGs would need to show they could work flexibly with their neighbours where necessary to achieve this.
b. Most emerging CCGs had realised that they would need to draw on some external commissioning support in order to manage their costs within the administration limit of £25 per head of population. Using commissioning support did not in any way reduce CCGs’ own statutory responsibility for commissioning, and CCGs would have freedom to choose what support they used.
c. Commissioning support services were going through a checkpoint process to ensure they were fit for purpose. Three potential commissioning support organisations had recently been told that they were unlikely to meet the required standards; their functions were now being distributed among other support services.
d. In some areas, the cost of CCGs’ estates and facilities had not been fully identified, and some further work would be needed on this.

13. Summing up, THE SECRETARY OF STATE welcomed the progress being made, and reaffirmed his ambition that as many CCGs as possible should be ready and willing to be authorised fully, without the need for conditions, by April 2013.

Inequalities and equality
14. BILL MCCARTHY (Managing Director, NHSCBA) explained
that promoting equality and reducing inequalities were at the heart of the NHSCBA’s plans in designing the Board, in three ways:
• The overall context was provided by the Board’s legal duties and the Secretary of State’s Mandate, which was likely to make equality and inequalities a priority.
• The work of the current NHS Equality and Diversity Council would be moved into the Board. It would be adapted to fit the new system, and its remit would be expanded to include health inequalities.
• The NHSCBA was recruiting a Director of Equality and Health Inequalities, who would report to the National Director of Transformation, Jim Easton. This would bring an important senior leadership focus to promoting and improving equality and reducing inequalities across the work of the Board.

15. THE SECRETARY OF STATE invited comments, and the following points were made in discussion:
a. There were opportunities for the Board to make significant reductions in inequalities by improving, for example, health services for travellers and homeless people, prison health, and public health services for young children.
b. Local authorities often had a very good understanding of the character of inequalities in their community. Health and Wellbeing Boards would help NHS commissioners work with councils more effectively, for example in understanding the links between health and other local services such as housing.
c. Creating the Board as a single national commissioner for many services would enable much greater consistency and focus – and it would also draw attention to the wide variation in services that existed already.
d. Community pharmacies had been under-used in the past as a means of tackling inequalities, and this would be a good time for the NHSCBA to engage them more actively.

16. Summing up, THE SECRETARY OF STATE emphasised the importance of this agenda and said he would welcome further updates on progress.

Update on the other “fixed points” in designing the Board
a) NHS Outcomes Framework
17. SIR DAVID NICHOLSON explained that the Board would organise itself around the domains of the NHS Outcomes Framework, rather than around individual clinical conditions such as cancer or diabetes. This might be a challenge for people who were used to seeing programmes and teams focused on clinical conditions. However, as more patients were living with multiple long-term conditions rather than single diseases, it was increasingly important to move away from thinking of services in terms of individual conditions, and instead to focus on the needs of the whole person. The Outcomes Framework would fundamentally change the way that staff in the NHS thought about their work.

b) NHS Constitution
18. THE SECRETARY OF STATE said that he would shortly publish his first report on the effect of the NHS Constitution (he was legally required to do this by 5 July 2012, under the Health Act 2009). The report would highlight that more staff than patients knew about the Constitution; that it was possible to raise awareness (and the more aware of it people were, the more important they thought it); but that there was no evidence that the Constitution was yet being used actively by staff or patients as a lever to drive improvements in services.

The NHS Future Forum were looking at how the Constitution might be strengthened, and this would be important in addressing some of the themes likely to emerge from the Mid-Staffordshire Inquiry.

c) The Board’s resource limit
19. RICHARD DOUGLAS said that work was under way to develop a shared financial agreement between the Department and its key arm’s-length bodies, including the NHSCBA. This would ensure that all parts of the system had common assumptions, for example, about managing risks and contingencies.

Conclusion
20. THE SECRETARY OF STATE thanked NHSCBA colleagues for a constructive and open discussion. These formal meetings would be a vital part of discharging his new duty to keep the Board’s performance under review, in support of his overarching accountability for the NHS and the requirement to promote a comprehensive health service.