Editorial Thursday 29 March 2012: The replumbing of power

We have builders with us at the minute, which is always a good laugh. Seeing right into the DNA of how your house works is disconcerting, particularly when you find a live water pipe down the middle of a wall you're removing.

Houses live on electricity and water, coursing around it like blood and oxygen. (Gas isn't networked in the same way, usually going to only two points - boiler and kitchen hob).

When water leaks, it can fuck a house up spectacularly.

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For water, read money in the NHS.

And the current system-wide top-down reorganisation of the NHS is having the builders in to the maximum.

Commissioning is going from PCTs to authorised CCGs, under the benign paternal grip of the Nicholson Commissioning Board, which HSJ reveals is to appoint commissioning support services leaders, and to replace or franchise them if necessary.

Now, keeping control of the financial plumbing is obviously vital.

There are, however, some emerging practical problems here.

The Nicholson Commissioning Board has to be the host body for ex-PCT and ex-SHA CSS until April 2016, when the 'market' selling their services to CCGs is meant to emerge.

The Nicholson Commissioning Board is also tasked with ensuring that CCGs have tightly-fitting plumbing that won't be leaking any money and ruining the building.

Part of this is not letting money leak out via redundancy payments in areas where the CCG doesn't want to work with the ex-PCT and ex-SHA people who have been assigned to the CSS (which have not in all areas been made to look like great places to work).

Can you spot a small conflict of interest for the Nicholson Commissioning Board there?

Now, the CSS won't be the biggest part of the financial plumbing challenge facing CCGs: let's face it, they've got £25 per head of population to play with, and there's only so far wrong you can go with that sort of sum. (Concerns are developing that CSS may become 'eyes and ears' of the Nicholson Commissioning Board - of which there may be some risk, although the best ones clearly won't.)

There are two obvious ways for the financial plumbing of CCGs to go badly wrong. [In saying there are two, we're assuming here that a) a competent and non-criminal finance officer is in place, and b) the top-slice 'borrowed' by the Nicholson Commissioning Board is relatively of a piece with the level currently taken from PCTs.]

The first obvious way is widespread non-compliance  with prescribing and referral policies by a CCG's own member practices.

The Nicholson Commissioning Board can grip this problem and make it go away: it will hold the GP practices' contracts, and will simply revoke them in such an eventuality.

It is not clear how many GP practices have fully captured this.

The second obvious way is through failure to monitor providers' overperformance against contracts. Contract monitoring is the sort of thing that "bureaucrats" do, and as we have been repeatedly shown, "bureaucrats" are bad.

Current providers have clear incentives to overperform, with the exit of the private patient income cap on FTs and the downwards pressure on the tariff. New providers have incentives to get what they can.

And of course, we are moving towards an all-FT provider landscape as fast as possible, so that all contracts will be legally binding.

And there won't be anything the Nicholson Commissioning Board can do about that.