Editorial Wednesday 30 November 2011: NHS Alliance conference plenaries

Dr Michael Dixon’s speech can be found Click here for details of 'Flora Stalinism, leadership as partnership and loving the evil bastard. OF! There’s a nasty little sting in the Annex, too …', the new issue of subscription-based Health Policy Intelligence.

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Life and death on a budget – keeping quality up and costs down in chaotic environments - Dr Marc DuBois, Medecins Sans Frontieres
Medecins Sans Frontieres is a front-line organisation, working in the field across the globe. We are AKA Doctors Without Borders to avoid worries about us being perceived as some kind of international drug cartel!

Three words from Mike Dixon’s speech resonate – passionate, principled and determined – those are the values of MSF. Doing budget, cutting from £147 million to £123 million – significant.

Cutting budget in MSF is blood on the floor will hear back from field, cutting healthcare from those who have no other access. I expect to hear it back, if I didn’t, I would worry about the calibre of our people in the field.

MSF international humanitarian organization, providing emergency relief in field for 40 years, and it’s largely privately funded. 23,000 field staff in 65 countries.

Goal not to deliver emergency healthcare: is to preserve life, alleviate suffering and protect human dignity using 2 means; medical aid and temoinage – bearing witness.

The top 5 places MSF spends its budget, to give context Haiti, DRC, South, Niger, Pakistan. We compromise on quality based only on necessity; need same kit and clinical standards as would expect to deliver ion West. Necessity is the mother of invention.

It's not enough just to deliver the care - it has to achieve the right outcomes for the people we serve.

'Plumpy Nut' is a peanut paste for children acutely non-nourished, replaces corn and soy bean mixes =which aren’t appropriate. Using Plumpy Nut has turned around recovery times, and reduced fatality rates in our centres. Governments of world didn’t want to pay for it. Corn no good for 18-month children. Innovation is done elsewhere, we do our best to push it into use.

Innovation in HIV – have to simplify using treatment adherence groups (as not all can afford to travel, pool a budget and one goes to pick up drugs or if sick) – more effective, as people couldn't afford to come every month. or home-based care. integrated care vs. vertical programs. HIV AIDS care involves task-shifting delegating downwards, but false positives are an issue - and we can only do a second quick test. We see a return to clinical skills: retired clinicians are often very relevant in MSF as a younger doctor will ask 'where is haematology, microbiology, serology or radiology'? Usually 300 miles away.

We use telemedicine: camera link in Somalia, expert elsewhere. My very first delivery where the baby came out flat ad I didn’t have oxygen, so do mouth-to-mouth. The doctor-patient relationship at core of everything MSF does: delivery of clinical care and bearing witness: not accept fact child starving in Congo or has HIV AIDS and no drugs or healthcare. Our budget cut means that we're shutting down our Columbia and Iraq programmes; and the sums in questions are absurdly small when trillions are spent bailing out banks or on wars which cause need for MSF. Humanitarian organisational action as protest

Dame Barbara Hakin, DG of commissioning, DH
If we all remember that presentation of Marc’s, it will really put into context the difficulties we face in getting thorough the next challenging but exciting year – we can remember that some challenges are not as great as others.

I want to reiterate the centre’s absolute commitment to make clinical commissioning work. To this audience, I hope nobody doubts my commitment to primary care and clinical commissioning. Nobody should be in any doubt about commitment of centre and the Prime Minister’s, shown by his message that Michael Dixon read you, and ministers – or that of Sir David Nicholson, NHSCB CE-designate to make this really different, a really new way to improve services by putting clinicians really at the forefront to make provision better - as provision is what your patients experience.

Sir David Nicholson talks of the huge budget the NHS is given to turn into the best healthcare we can. And that's just the same as you CCGs will, with hard-earned taxpayers’ money ... the responsibility you have, to turn into the best you can be.

Why will CCGs be different? I don't need to convince this audience that we need primary care at the centre of commissioning.
1. We need clinical understanding and input into design and delivery of services
Patients need to be at the heart of everything we  do – none know patients better than primary care, as you have so many walk through your door.
3. The population focus of general practice, often the GP will be well-known in the community, and the practice can act as a centre of the community.

In all you do, I hope you'll keep those three things (clinical understanding, patient focus and community focus).

I aspire that one day we'll see real change, because no matter how good commissioning organisations were in the past, they were pretty anonymous and most patients haven’t even heard of a PCT. It would be fantastic if we get to point where patients see primary care not only as the first point of call for provision, but as where they go when they want to raise an issue or have an influence on health services.

That CCGs can connect commissioning to the public in a way the NHS never has before.

Commissioning is basically about three (complex) things – planning; agreeing; and monitoring, so as you move forward in CCGs, make sure in all aspects your focus will be maintained throughout

Please don’t underestimate, know frustrations in room, lots of good intentions, transition always difficult, we’re not yet in the new system, and we’ve not really let go of the old system. I echo the line in Mike Dixon's speech which is a salutary warning: when we get to the new world, CCGs will be based on member practices, and their arrangements will depend on what their member practices need them to be. Many of you CCG leaders, lose your practices and clinicians in those practices at your peril. CCGs' strength will be built from the bottom up and by clinicians wanting to make a difference.

Commissioning is not just planning and monitoring; it will also demand that you as CCG leads put aside some personal views to work in partnership with others (local authorities, other clinicians, staff in social care, other CCGs, and the NHS Commissioning Board which commissions a lot). Unless there's good integration of commissioning, how can we possibly expect providers to deliver integrated care to patients?

There's critical work to do with local authorities on getting relevant public health professionals' advice on patient needs. There's also work to do together with secondary care colleagues, to plan precise services for patients.

And there's also a significant degree of need for managerial support, using the special expertise longstanding mangers can bring to the commissioning process. In areas like procurement, patient input will be less of an issue, and their input will have come earlier in recognising the need for a service or change. procurement and agreeing services and contracts. CCGs will need strong and great leaders who are managers by background, as well as strong and great clinicians.

Likewise monitoring quality, some of which is work for front-line clinicians but some involves loads of data collecting and analysing, to help CCGs understand the quality of care they're getting their patients.

The centre is now trying to do what it can (not just DH; NHSCB now exists as a special health authority), to help you CCGs be the best you can be. It's absolutely Sir David Nicholson's ambition for CCGs 100% authorised by April 1 2013 if that what they want, and if they can be authorised without conditions, that would be even better.

The NHSCB depends on great CCGs, all doing at centre trying to find way to make system good as possibly can be. My objectives evolved over the past twelve months in two major ways:

1. Getting the architecture right, which is dominantly about getting CCGs as good as they can be – some about writing guidance, model constitution or docs, much of which do with Coalition so 200-300 organisations don’t waste time reinventing wheel or starting from scratch.

2. Sorting out the authorisation for CCGs, to get clinicians involved and meaningful; not just a tick-box exercise, but seeing how far along the journey. We want the authorisation process to be as meaningful as can be to help CCGs commission better services. The development programme aims to get organisations trained leaders of CCGs, offering people the right development opportunities to take on this very big task.

Please don't underestimate how tough this is – in the past, when organisations doing things like this existed, they did so under the umbrella (and sometimes the restrictions) of other statutory organisations: neither primary care groups (PCGs) nor PBC consortia were statutory. CCGs will be statutory, and very different.

Another important part of the architecture will be the NHS Commissioning Board: for its commissioning; for ensuring CCGs collaborate with each other; and for its role in commissioning support. Money is going to be incredibly tight, and any increase is likely to be spent on clinical leadership. If we don’t find economies of scale in commissioning support, it’s going to be very tough.

I know some of you are frustrated process not fast enough, but there's a very big train coming down the track. This time next year, we will be so close. The need is for us to move quickly and for you to work with us to sort out configuration; the way you’re going to work; who your leaders will be; support for authorisations - the speed will be dramatic.

We here to try and help, let’s not let the pace down on this and I hope in a year's time we will be close to something very, very different.

Reactions
Professor Steve Field
Over the past nine months of leading NHS Future Forum, I've been inspired by innovation, from Stoke on Trent telemedicine and human beings, to integrated care in Torbay. innovation in every part – got to balance innovation with providing national nationwide integrated NHS everywhere. NICE guidelines and treatments not being evenly applied

As a provider NHS is failing in places to provide competent care. culture; need to recognise need for disruptive innovation. It's a national disgrace that the average age of death of a homeless man in London is 40 years and 3 months. We can still see areas where patient can’t access GPs and healthcare; we have to address how we provide a national service while stimulating innovation. I think we can have both, with you as leaders inspiring innovation and making happen

I believe we’ve lost the plot on provision in primary acre: you must not tolerate poor services and unacceptable variations in primary care

Dr Niti Pall
This is a 'perfect storm' moment, I've been operationalising primary care in India, where you need innovation or you get nothing happening, and there are real opportunities here just as there. We have inconsistent application of evidence-based care. I’ve seen innovation in India because they have no money to do medicines compliance. Commonwealth Fund on being good case managers – productive integration.

I have a warning for Barbara about the system’s attitude to failure - playing safe doesn’t mean failure won’t happen; you’ll still get failure, but just without innovation.

A few key points:
- first mover advantage is key
- impacting quality and cost requires a new era of private-public partnership
- we need to go back to basics and focus on ourselves
- we need to trust in ourselves and each other

Dr Shane Gordon
The NHS faces unprecedented challenge. I’m humbled by Marc’s presentation, and I want the vested interests in the NHS to listen to that. And I also want to cling to the ideas of quality and care. There’s a financial gap: the Office for Budgetary Responsibility forecasts 6.6% economic output has been lost to the UK economy for good. So the QIPP Nicholson Challenge £20 billion probably underestimates the real challenge of the NHS – if we love the NHS, we must be dissatisfied if it’s provide same old thing.

George Bernard Shaw said ‘the reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man’. I am the unreasonable man, and I hope you will be unreasonable too – we must be unreasonable about poor access to care.

Dr David Jenner
My presentation is called ‘plus ca change – innovate or play safe?’ Nick Timmins has pointed out that NHS CEs traditionally keep their jobs by avoiding risk and balancing the books. Has this changed?

I don’t think it has. And now we have an economy in trouble. And yes, Barbara, a lot has changed in the past year... now all the health unions oppose the Bill.

We’re looking at lots of known unknowns (especially on the quality premium). The NHS Commissioning Board has complete reserve power to take over CCGs and mandate them to do things even if SOS does not mandate those things. Will Monitor and the CQC judge us on innovation – or on compliance and financial balance?

Realities: it's 'supersize-me CCG' time. In last election, health didn’t feature, satisfaction as high, next election 2015.

These are the Old NHS Rules: balance the books, keep the noise down and deliver key targets – now of course, not targets but outcomes such as the 18-week outcome

It’s still possible to innovative, but have to take local clinicians people and Daily Mail. David and Barbara still tell me what I have got to do: think 111 and getting three community services tendered this year.

The New NHS rules, I think, are: balance the books, keep the noise down, deliver key outcomes targets … but please also keep patients safe, innovate where you can, and beware tiger traps and the Daily Mail.

Questions and comments
NP: Small businesses can provide lot of good care – small does not mean terrible. CF report shows as integrators for frail elderly demented important have great general practice, ca work together if system has incentives right (not just about sticks). Talking about money is not bad, pretend really terrible should not talk about it.

SF: Clare Gerada is my very good friend: we wrote a paper together for the RCGP on federated GP practices, I think we do need to work like that. I also admire what she does in her own practices, she's the biggest London provider of primary care; she employs over 100 doctors; she's won more Darzi centre contracts than anybody else. She's providing care on a different model and I think we should listen to her.

DJ: If we want GPs involved, don’t engage them in legal IT bureaucracy. So I think size does matter. If we go back to PCGs and Health Authorities, that actually worked. PCTs involved me in dull bureaucracy, so I left and so did many like me.

CH: You are serious that you’d have CCGs as sub-committee of NHSCB?

DJ: Yes!

SG: I wouldn’t do that because without CCGs being statutory bodies, power will graduate to who holds the chequebook.

The size question is about leadership and engagement – it's to do with the number of GPs prepared to do something differently because they understand population needs, not just their small business needs or the needs of an individual patient in front of them. If we make CCGs too big, so that people don’t know and trust leaders, will not follow them. real tension between financial stability at a bigger size, one CCG in our area is a single practice of 18,000 patients, and they've made the most change most quickly as they're all connected and trust each other, and we mustn't lose that.

Q from delegate in Lincolnshire about being told by clustered PCT that they have to take OD support from one particular (un-named) provider.

BH: on size, that’s a big issue. We’ve consistently said want to support CCGs to choose the right size for them, but also right to ask ‘please show us how you are going to manage’ – some advantages, but difficulties to be small. Is the best way to do things as separate smaller statutory bodies, or is it about having a larger CCG which devolves power to people through localities? We're working on principles and rules, but in the final analysis, it'll come down to where CCGs could work well being small with neighbour. We all know that some chose to be small as they want to have collaboration and close relationships with neighbours v poor. Bringing un-like groupings together will be hard … we're trying to get the best decision locally.

We developed the model contract so there’s a template, and because it’s foolish for every organisation to write separate contracts. There's great flexibility on what CCGs can put into contracts - quality standards and additional standards. We think patient choice should drive change, but in most instances where patients not in position to choose, those out to tender, not just want to see big elective contracts, but AQP in wheelchair services or patients choice.

Ali Parsa, Circle Health
Many of you in process of setting up own organisations – commissioning and provider. We are good in Britain at addressing what and how of a service, but forget to focus on why – can say how do more productive  efficient, but why. Many argue private companies develop services. The more you focus on WHY you're doing something, the more successful you'll become.

I used to be evil, was investment banker – profit is necessary to sustain yourself, but profit can never be purpose of life, and it isn’t in Circle. Most successful organisations have purpose. The difference is the reason why. Founder of Sony wrote in his prospectus before he even had the company, ‘Sony is going to bring ingenuity of Japanese people to solve technical problems of world’. Martin Luther King said “I have a dream” – not a business plan.

Why in health participants in unsustainable sector we can do this. did with food distribution to sort rationing, or automotive - cars don’t break down anymore.

value proposition is patient experience and health outcomes divided by cost

It's not about competition it's about innovation, meaning & motivating teams

If you look at the basic value proposition, value = quality over price. In the NHS over the past ten years, I think rightly we tripled denominator of equation of price. Quality has risen significantly, but not by three times. If you compare that with a computer from 10 years ago, its power was 40 times less and its price was double that of today. The value proposition of computing has gone up by 84.

Our job not to focus on denominator, relentless focus on nominator of clinical outcome and patient experience. Circle Bath has Norman Foster design, Michelin star services, and it delivers care to NHS patients at at NHS prices – that’s motivated not by vanity but to change patient experience. We’re not driven by competition, but because we believe clinical outcome of care is fundamental.

We have not got all the answers: nobody does. No matter how much you know about healthcare, you do not know as much as IBM bosses who were making 90% of profitability inb the technology world of the 1970s. They say choosing IBM doesn’t get people fired, but IBM did get people fired because in 1975 the personal computer was invented, and IBM were overtaken. Then Yahoo, then Google, Microsoft, You Tube, Facebook.

Innovation will come from outside this sector, we need to unleash and free people in structures, while focusing on patients and on the value proposition.

If we want to open the market, and let people in and create, we need to do it wholeheartedly with all 100% you’ve got. Humans have 83% same genes as cockroach, the other 17% is what matters. Don’t give it 83%.

We believe that there is no growth without the finance. if you look at the economy, scale doesn’t usually work

People in healthcare came here to do good. We’ve had far more flak form the private sector than the public sector, who have been quite welcoming

Health outcomes + patient experience / cost = the value of what we do

A view from the bridge – Sir David Nicholson, NHS chief executive
This is the sixth year I've done the NHS Alliance conference, and we’ve grown tantalizingly close to achieving the vision of Mike and we’re absolutely at a place where it is almost in reach. That’s a great tribute to people in this audience. There’s been 18 months struggle, White Paper, furore, listening exercise, but you’ve been keeping hold of vision of clinical commissioning central to what NHS Alliance is about and across system as a whole.

I saw a copy of Michael Dixon's speech, which was as pugnacious as you expect, and if this is the French revolution, am I Robespierre, Louis XIV or Napoleon?

Mao-Tse Tung’s comment on the French revolution's success was 'it is too early to tell' – but we want to know if clinical commissioning is working right now. `It’s great to have practice managers in platform, and two were dynamic, changing things and I said have you ever thought of working in a PCT and they told us a long list of reasons why they wouldn’t. I went to my people and said, can’t we make PCTs organisations these people would want to work in … and then we had election.

Now we’re creating something new and different, which is what we need for the future. Recycling the past will not deliver the great step forward that Ali and people on panel discussed

Ali Parsa talked about purpose and that is where I start, in the NHS , if we lose sight of purpose, we lose the point, our staff, patients and the public. So purpose is really important to great changes ahead. Challenge of improving quality and cost, which many economic sectors have done, and we’re at the epicentre of that for healthcare.

This is the future world, one of small if any financial growth in coming years, and we need to reinvent ourselves in ways that really drive the value proposition Ali talked about. Greater outcomes through integrated care. Quality and outcomes are what patients need, so what does this mean in practice, how turn into reality?

Think about service for dementia – need primary acre, memory clinics, hospitals organized inpatient care around need of patients with expertise, social cares, and end-of-life care for people during last period of existence. what purpose means in practice.

But how to get to that? The answer is clinical commissioning, as the mechanism to turn the vision into reality for our patients and population, and it’s so important as we go forward

What are we trying to do? To build a clinical commissioning system; not just organisation(s) to take patients and population thorugh. That starts for us with GP practices, all else is built on that. Which is why we said originally 'beware of GPs with maps and pens': it's not abut drawing lines on a map, it’s about working together with knowledge, based on population.

Successful CCGs will build on the support understanding knowledge and commitment of their practices. Then CCGs will bring not just GPs but other clinical professional and patient to think  about the consequences of how they’re commissioning services for that individual population.

You’ve all been building your CCGs over the last year or so. Some fantastic CCGs are already delivering a difference for their local population, redesigning healthcare bys significantly shifting investment.

I’m sure you’ve been discussing whether size is important, and now you know the management allowance, and about how we’ll do authorisation, now in public domain and we can now get on.

Reflecting on the earlier conversation about culture, I want to make clear that we want this to be driven bottom up. It’s very important CCGs are driven locally. But in size terms, there is not right size for clinical commissioning. Nor is there a right place to put organisational boundaries. If you want to be small CCGs, you need to show how you can work with colleagues – if large, you have to show how you’re really engaging practices.

There is no right size, but there are sensible drivers of looking at the amount of money available, and you have to give yourselves the best chance of success. We’ve been risk-rating CCGs – it is not a pass or fail. If  you’ve been red-rated, that’s not a fail, but it does mean that there looks like big risks.

So the question is not how to fight failure, but how to reduce risk by co-operating with other organisations. That process is about getting size right, and it will be very difficult to press on without that.

90% of CCGs have been risk-rated green or amber, still some red, and we need to work with you, use peer review, talk to the NHS Alliance / NAPC Clinical Commissioning Coalition about how get best outcome for population. But it’s very important to do that in the right way, as it will determine culture between CCGs and NHSCB. I say risk rating, but culture turns it into pass or fail. We need not to question each other's motives, but to understand each other’s motivation and work with that. Myself and colleagues nationally are doing all we can to make this a reality.

Then there’s commissioning support – how to get that right to support CCGs’ work. It’s an important and little-discussed part of the process, and we’ve set up a list of providers so that there is some commissioning support to buy, because there was a worry that there would be nothing available, so we’ve done that to support and help you in the transition. Be absolutely clear: CCGs will be deciding for themselves once authorised where to buy support from.

I think we can do more earlier, so that you can choose between individual PCT clusters for commissioning support, to put a bit more grit in oyster and make choice a reality. I think we should take that forwards.

Then there are the clinical networks, which will cover wider geography, like cancer, where we need bring people into networks to deliver greater outcomes. Then we need to look at patterns of service, so if we add up all the little bits, what does that make? Hence senates to provide clinical advice and look at the big pattern.

The development of the NHS Commissioning Board aims to help you to get great outcomes and to help each CCG be the best it can possible be. The whole point of building this system is from practice to CCG to networks, to senates to board, all supporting same clinical commissioning system. That’s the great prize as we go forwards, and we’ve got to give it the extra percent of effort as Ali says.

We’ll have one chance in our career to make it genuinely a clinical commissioning system. And it’s going to be very tough, the external environment couldn’t be more difficult but provides burning platform, but I think we have the creativity and I look forward to the next few years to make clinical commissioning a reality.

Responses
Dr Richard Vautrey, BMA: The BMA want clinical colleagues to be bolder, and to create structures that enable every clinician and colleague not just to accept what Sir David says, but to form their own organisations big enough to do commissioning for ourselves, and not be disempowered. We think bigger groups will need to maintain engagement at grassroots level.

Dr Donal Hynes, NHS Alliance: As GPs and clinical leaders, this is our responsibility. If we don’t step in, we will not have an NHS in five years’ time, and we need an utter review of everything in how we provide healthcare - so thanks, bankers for creating the immediate crisis; but this level of unsustainable inefficient spending on NHS healthcare was going to happen and the only group who can do is the vested interest doing all the referring: that's us.

To have sustainable NHS in 5 years time, we have to deliver: yes, there are problems. It's our responsibility; not the population's, managers' or patients' responsibility. ours.

Chris Ham: Do you understand people’s concern over the draft guidance on commissioning support organisations?

DH: I don’t know what new animal of commissioning support organisations (CSOs) will be like. It will not be like PCTs; CSOs will be different animals. Many of our greatest commissioners in Somerset were leaving as they couldn’t see a vision of a job for them in the future. I think CSOs will have to be very big, they have a huge job, so I think they will be relatively few and huge, but if they are, then that loosens up CCGs without the drudgery of commissioning support and lets them be radical. And we need them to be.

Dr Robert Varnam: Two words from Sir Davids’s speech struck me: “freedom” and “grip”. You hear "grip" a lot around Westminster, and “freedom” a lot the further from Westminster you get.

How can we encourage behaviours in the NHS infrastructure to match the vision and purpose of clinical commissioning?

DN: You can polarise the debate in that way if you want. Look, some things you have to grip tightly; some you can let go. We’re trying to pull off unprecedented productivity gain in a time of low financial growth and rising expectation and service need. Given that all that is happening, what do we need to do?

One of the big issues is financial control in the system. I have put some things into the system which you would describe as grip, which are essential to take us forward. When CCGs start, I want them to have no inherited debt or recurring financial difficulties in the NHS: that’s easy to say, but very hard to pull off in a financial system as complex as the NHS. But I am absolutely determined this is what we will get.

So we say to every PCT pull back 2% spend non-recurrently, as you’ll be able to decide every year. Increase surplus, so we have resource in the system to sort out legacy debt next year.

There are sensitive and insensitive ways of doing this we have lost 15,000 people from PCTs and SHAs,  and we’re losing another 10,000 – most of whom were doing fantastic jobs. Not everyone agrees what we’re doing is right thing to so. People who don’t agree take short cuts and use blunt instruments.

RVautrey: why do we need a major reorganisation if controlling finance is so central? Couldn’t we just have put GPs in charge of PCTs? We could even now invert PCT clusters to be the true clinical lead organisations.

DN: That’s the subject of the Parliamentary process, and I don’t want to get into discussing that. That's the vision of the Government of how the NHS will operate. Nearly half of the PCTs’ budget is now delegated, which I think is remarkable, that’s over £30 billion under control of CCGs, and we can already see benefits. Is that sustainable? Yes, but it’s tied in with governance and giving practices more power. It's been necessary to make those changes

DH: We need answers to all the questions on governance etc, as then CCGs can get on and look at what matters most, which is investment and disinvestment decisions. And CCG leaders need to bring your local public with you: local democratic legitimacy is crucial

R Varnham: understandable we look at our feet, big wins partnering across artificial divide, where will improve patients safety, quality experience and

Reforms: are we still on same track or heading in a different direction?
Stephen Dorrell MP: “The answer to the question lies in this room and with your colleagues. The big win to have would be to move away from a world where managers do commissioning to clinicians and to a world where the clinical community is engaged in commissioning as a principal player. If the Health Bill’s new institutions achieve that, it will be a big win, but it will not be determined in the Palace of Westminster”.

Dorrell also quoted Chou En Lai on the success of the French Revolution: "It is too early to tell" (and gets the author of the quote right, which Sir David didn’t, ascribing it to Chairman Mao).

Niall Dixon: “The issue reflects the failure of purchasing, or commissioning – it was meant to have a big impact, which I spent 16 years at BBC trying to explain. None of the various iterations had the bite or caused the kind of change we wanted them to. I’m not sure if the proposed model will work or not, but the questions the NHS is facing are more pressing now than they have been for the last 20 years: pressures from comorbid elderly; not being a 24-7 service; the challenge of unprecedented low growth in the service over the longest time yet proposed means that the question's importance is unprecedented. It’s not about ‘does this or that structure work?’ There’s a real impact on ground for many clinicians’ work

Ursula Gallagher: We need to be conscious of the provider reform agenda – not to obsess on structures and size. We’re still at the difficult time in change about trust, and looking at command and control returning. If we don’t find ways of having more honest conversations, we won’t move anywhere and that would be the biggest problem for the system. Should we still be on the same track? Yes, if it means we focus on quality and address underlying issues.

A show of hands on whether the Health Bill should be dropped or passed had a handful against, about half of delegates voting to pass the Bill and the rest not voting.

UG: Some enthusiasm is going as realism’s coming. We’ve got a big problem with variation in where people accessing what they should do. There’s crucial stuff around PbR variations and best practice tariff, and until these things catch up with one another, disenfranchisement will continue. What is going to be role of networks and senates? Will it be to duck out of difficult decisions?

ND: My sense is that much of the medical profession has packed its bags, and is getting on with the day job. If it stays that way, it’ll be a disaster for the system.

A show of hands for ‘are you more enthusiastic, less or same as you were a year ago?’ was roughly equally split, with a third of delegates voting for each.

Delegate question: are bail-outs of failing organisations to continue?
SD: Nobody wants to see a world where trusts run deficits. Will providers occasionally fail? Yes, and if they’re state-owned, the question what to do rests inescapably with the owner. How would you react as Secretary Of State? Send them money and ask them to carry on as before? Presumably not, nor can you close them if their services are crucial.

Delegate question: Where should senates be hosted?

SD: There’s a danger if senates are hosted at the NHSCB level, they will be used in a way that will be not just advisory. Post-Future Forum, we’ve seen more responsibility going to HWBs and the creation of senates. But they must remain advisory, separated to an extent from NHSCB, and the clinicians who’ll serve on them probably don’t want to be on NHSCB.

ND: The least interference from centre will bring more innovation.

Secretary Of State For Health Andrew Lansley
From my point of view, I've very much appreciated over years the opportunity to be at these conferences. Just as in the preface of a book, there’s a long list of people I’d wish to thank, but any errors are entirely my own. If you see errors and omissions, you can ascribe them to me, and you take credit for the vision.

It’s always important to have a vision.

The White Paper was about putting patients at the heart of everything we do, for you as clinicians. To patients, it didn’t seem as if the NHS responded to them as individuals, and so we’re giving them choices – no decision about me without me.

The principle of clinical leadership is essential to any healthcare system, driving the shape of services, referrals etc should be combined directly with commissioning decisions about how services should be available - not only to individual practices but on a  system-wide basis.

This is about making continuous improvements on system-wide basis. We’ll only know for sure we’re doing that if we measure outputs continuously to see whether we’re doing as well as we can by benchmarking our perofrmance against each other and against other countries facing up to the same issues and dealing with the same problems

I want to focus on how we bring clinical leadership right to the forefront.

It is about unleashing the power of clinical commissioning. I’m not sure the public would know what clinical or commissioning meant, but it’s simply the decisions you’re responsible for, individually and collectively. It’s about making the right decisions for our patients as often as possible – not every time; we can’t achieve that utopia, but as often as we can. Everything we do in modernising the NHS is about unleashing the potential of clinical commissioning

Sometimes you, like me, must read the media and say ‘this debate going on doesn’t bear any relationship to what we are doing’.

It’s time to say ‘we need to stop having the debate about the fact we are taking these responsibilities’. People are changing things on the ground, fast. From April next year, I expect PCTs to devolve £29 billion to CCGs for clinical services, which is nearly half of PCT budgets.

And we’re seeing clinical service redesign yielding results. We’re beginning to reap the benefits of the QIPP efficiency drive, with £4.3 billion released this year for better care and an estimated £5.9 billion next. And it’s not being lost to the NHS, every penny is crucial for reinvestment to respond to demand and quality through innovation.

And, perhaps most importantly, power is really beginning to be handed over to those who will lead the NHS through the next phase of it’s life – to you and the people you serve. As I’ve said before, power is a zero-sum game, and to empower CCGs and patients, have to disempower the DH.

But we must also be clear that ultimately, the Secretary Of State is responsible when things go wrong

I just want more things to go right. And I want to say thank you to NHS Alliance NAPC and the new Clinical Commissioning Coalition is an important mechanism by which people can share experience and have a voice, your voice, about what you want to see in terms of commissioning for future

The NHS is an extraordinary institution.  For more than six decades, it has saved and transformed countless lives for the better.

It is there to pick up the pieces when things go wrong.  To support us and help us during our darkest moments.  To care for us when we need help.
The NHS, rightly, has a worldwide reputation as a truly universal service – for giving all our people a decent standard of healthcare no matter what their income, background or circumstances.

This was confirmed yet again when I was in Washington earlier this month for the annual meeting of the Commonwealth Fund.  Once again, we came top among developed countries for equity.  For providing healthcare for all of our citizens, free at the point of need.

The fundamental values of the NHS have stood the test of time.  They are the solid granite upon which the NHS has been built, enabling it to weather many a storm.  And they will continue to see it in good stead in the years and decades to come.

But while our reputation is hard to beat in some areas.  In others, it still needs work.

There are really two big challenges for the NHS.  Quality and efficiency.  And by modernising the NHS, and through your efforts, we’re beginning to make headway in both areas.

First, let’s look at quality. About a year ago, we published the NHS Atlas of Variation.  I hope you’re all familiar with it.

It sets out just how well every PCT performs against 34 clinical outcome indicators.  From stroke to cancer to mental health, PCTs are benchmarked against their peers.
Some do fantastically well.  Others do not.  What is quickly plain is that the degree of variation is considerable – and unexplained by simple differences in population.
• A 5-fold variation in the proportion of diabetes patients receiving the recommended level of care;
• A 4-fold variation in emergency admissions for under-18s due to asthma;
• A 4-fold variation in the number of emergency bed-days for patients with the respiratory disease, COPD;

As soon as clinicians get a true picture of how they are performing, of where they can help others do better or where they need to do better themselves, then they can get on to the important business of improving patient care.

We will soon publish an updated Atlas.  This will cover even more areas of care in even greater detail.  It will support clinicians and commissioners to identify variations in prevalence, spend, outcomes or service use.  Helping you to understand more clearly what is happening in your area.

And the Atlas is just one in a long line of evolving ways in which we are creating a more open, transparent NHS.

• For GP practices, we’ll publish prescribing and clinical outcomes data to help patients choose the best practice for them and to drive up standards;
• We’ll publish complaints data by hospital so patients can see what is happening at a hospital and to help that hospital to make better decisions;
• We’re ramping up the number of clinical audits;
• We’ll publish staff satisfaction data by NHS provider;
• And with the GMC, we publish data on the quality of post-graduate medical education by provider.

Working with the Royal Colleges and others, we are shining an ever more brilliant light on to every part of the NHS.  Opening it up to scrutiny like never before.  Extolling excellent care, exposing and driving out poor care.

And we’re already seeing the power of this sort of exposure.  The 100 unannounced, nurse-led inspections that I asked the CQC to conduct showed how the care given to older people is all too often unacceptable.  They are now conducting 700 more.
What they found – what they’ll find – may sometimes be shocking.  But these inspections, combined with all the other data coming to light, means we can really start to hold people to account for the care they provide.  And really get to grips with driving up standards.

Care available in some parts of the NHS, by some GP Practices and some providers, is among or even better than the best anywhere in the world.  

The challenge now is to raise the quality of all parts of the NHS, and to raise the quality of the poorest parts fastest.

The second is to do more with what we’ve got.

Now, even though we again did extremely well in the Commonwealth Fund’s assessment of providing value for money – we spend half as much on healthcare as the US does as a proportion of national income and yet provide far better access to services – it would be a colossal mistake to assume that this isn’t also a major challenge for us.

For even though we compare well internationally, and even though David Cameron, George Osborne and I are committed to increasing spending in real terms for the NHS, we all know that it’s not enough.

That’s why the QIPP challenge is so important.  Because we all know that we can release extra funds by giving patients better care.  

• The operation, prevented.  
• The hospital stay, shortened.
• The long-term condition, managed.  
• The lifestyle, improved.

The more funds we release by being innovative, by increasing productivity and by providing patients with better care, the better we can keep pace with rising demand and the more we can improve health outcomes.

The heart of the answer lies in clinical leadership. I have never believed that government has all the answers.  That a Secretary of State or a group of mandarins in Whitehall, no matter how skilled or experienced they may be, can come up with all the answers. I don’t think that because I shadowed the job for six years, I can internalise to DH what we should do. It’s better to trust the 1 million qualified people across the NHS.

The NHS Commissioning Board will be the N in NHS; providing that leadership, commissioning specialised services and publishing quality standards of what good looks like. It requires clarity of what the centre should do – which is not the same as trying to exercise control from the centre. The best placed to decide are those closest to services and patients, which is the leaders and staff of CCGs. You ‘re best placed to achieve change.

We now have CCG pathfinders across virtually the whole of England, conferences like this you can show how you are working had to get under the skin and deliver for your local population. The central focus of what you do is about delivering services to patients, and getting the right services and pathways in right places is key, and to support that, you need the right structures in place.

And a key task is driving ups standards as CCGs, making your systems of corporate governance open and transparent. A vitally important part of establishing yourselves as Clinical Commissioning Groups is making sure that your systems of corporate governance deliver open, transparent and high quality services.

As you develop your CCGs and move towards authorisation, you will all need to ensure they have strong, clear and responsive systems of governance in place. Good governance isn’t just about meeting your statutory duties.  It’s about securing the highest quality services with the best outcomes for patients and the best value for taxpayers.

It’s far more than just a tick-box exercise, an administrative hoop through which to jump before you can get down to business. It is your business.

Organisations that practise good governance are far better able to adapt and change, to seek feedback and take actions, to challenge their leadership and place accountability right at the heart of their push for continuous improvement.

And just as important as getting the processes right is getting the culture right.  Creating a culture where people understand how good governance is an essential driver for change.

This is particularly important in the NHS, where decisions taken can have such an immediate and significant impact on people.

So it’s vital that you demonstrate from the start that good governance and proper accountability are 'front and centre' of clinical commissioning.
Your foundation document will be your constitution.  It will determine how you work, how you conduct your responsibilities, how you are governed.

This needs to be right.  And we’ve been working closely with a wide range of organisations – pathfinder CCGs, and the wider NHS– to get it right.

That is why in the next few days we will be setting out our thinking so far.  We will share this draft guide with emerging CCGs, the NHS and other key stakeholders over the following weeks for further discussion, before publishing it in the New Year.

It will describe how you might make decisions in ways that ensure safety, improve quality and secure best outcomes for patients.  All while demonstrating good stewardship of public money.

It will help you as you develop a constitution – demonstrating transparency, assigning leadership roles and working in partnership with others.

But before we do that, I think it’s important to be clear about a few things.

First, that you are member organisations and as such are very much in control of your own destiny.  How you decide to run yourselves is your decision and nobody else’s.

Second, that the governing body will be the responsible body for the CCG, deriving its authority from the CCG’s members.  It will be the governing body’s role to make sure that all decisions are made properly

Third , there has been some confusion as to whether the most senior roles – like the accountable officer and the chair of the governing body – should be filled by clinicians or not. The whole point of clinical commissioning is to put clinicians at the heart of commissioning. I believe it is imperative that senior clinical leaders should hold at least one of the CCGs senior leadership positions.'

The accountable officer and the chief financial officer should also both be on the governing body, reflecting those challenges of improving clinical outcomes and ensuring the very best use of resources so that the key decisions and the decision makers cannot be alienated from the governing body and its responsibilities.'

The job of the NHS Commissioning Board is not to tell CCGs what to do or how to do it in the same way as nearly six years ago David Cameron and I said we ought to move to a NHS where we on behalf of the taxpayers are clear about what we are setting out to achieve, what are the objectives but we're not going to tell it day by day how to do it.'

Looking at the costs of governance, they do bear comparison to a governing body of a school. For a CCG of 100,000 we are talking about £2.5m running costs. The budget could be £150m. Most schools are doing it on the basis of 1,500 children and a budget of less than a couple of hundred thousand for administration.

Our experience is only the past experience of the NHS where big is always better. If you look outside the NHS it is perfectly possible to do it. Maybe a bit of looking outside the NHS is not a bad idea. Schools mange to meet their statutory accountabilities on a small budget.

We have to have a mechanism for ensuring public money is spent properly and delivering cost improving quality of care. Not a top-down centralised system of command-and-control: we’re turning top down to bottom-up, front-line led system, working with local authority in delivering population health and care. An NHS shaped by the front line, created by clinicians, in co-production with patients. to deliver best outcomes in world.

You are already doing so much to make this a reality in your communities.  I want to thank you for all of your work to date and to wish you the best for the work to come.

But with you in charge, with local clinical leadership guiding the way, I know we can have an NHS that not only leads the world on equity, but on quality too.

Day 2

David Flory – The financial picture
The 2% headroom (top-slice) will be used for transition costs over the next year, but after that the NHS Commissioning Board will manage it.

At the moment, nine NHS organisations are not able to manage within their budget, and viability of commissioning system will be undermined if the deficit starts to get bigger.

We’re building a strong position for CCGs, with proper headroom, and we need in this next year of transition to drive hard on operational efficiency and also service transformation. There are emerging financial pressures in parts of system other than three trusts in London, and we will need to use the headroom budget to support double-running costs.

That should be fine for a commissioner, as it’s good to take a broader system perspective, but once we are taking work out of acute settings, then unless each acute trust takes some of its costs out to match, the whole system’s financial viability will be undermined. We have to retain strength in commissioning side to ensure balance and at same time drive these improvements in providers sector.

If we plan for success built on strong foundation and deliver it, there’s every chance of success. If we plan for or anticipate failure, that is where you are likely to end up. So we must stick firm to financial balance: it does get a lot tougher. The Office for Budgetary Responsibilty issued a revised forecast for inflation via GDP deflator, and we now anticipate inflation as measured by GDP deflator will be greater next year. So the allocationsthe Secretary of State will make in a week or two to PCTs will now be based on real-terms inflation.

The level of cash increase will significantly less than it was 2-3 years ago. so the urgent task of transformation can’t wait till finances go wrong: tough decisions need to be taken now.

Targets remain crucial to the success of the service, and we’re moving more to outcomes measures of success and progress - and as well as that, defining how that works and how NHS organisations will achieve those benefits for patients.

We need a set of levers to make providers work in ways to drive up efficiency while maintaining quality and access. A healthcare payment tariff will always be controversial. We need to enforce contracts so we don’t have collusion over inefficiency, or more importantly, over substandard care. Commissioners who say ‘we don’t want to be too hard on local hospital’ simply have to use contract mechanisms, or they will end up colluding over inefficiency and substandard care, which will undermine us.

The 2012-13 Operating Framework was not set up for me and Sir David Nicholson to manage a in top-down way: it’s absolutely to empower CCGs to take charge, but I want to hand over a system in strong financial control. I am absolutely confident you’ll be able to do it.

Professor Sir Bruce Keogh - How will clinical senates and networks support CCGs? How will they work together?
David Flory’s words about a “hand over” shows the magnitude of the current change of responsibility and accountability. These are exciting times, and ones of great opportunity.

The NHS has a duty to turn tax money into good healthcare; also a duty to balance resource use. We're entering dangerous times: many organisations making up the NHS as we currently know it are being disassembled, yet many of the new organisations have not yet reached the level of maturity required for handover. 169 statutory organisations are being dissolved, to be replaced by CCGs and NHSCB. A bit of vacuum can create a fantastic opportunity for new ideas, freedoms and leadership.

There's a risk we are not innovative enough, and try to repackage what we currently do and how we do it. This reform offers us the best chance since 1948 to disassemble and reassemble the system, but there's a risk of drifting into us-and-them behaviours; Commissioning Board vs. CCGs, primary care vs. secondary care, public health vs. health authority. It's a risk we must resist, because inclusiveness and integration are key to what we are trying to achieve.

There will be some loss of independence due to firstly, statutory accountabilities for improving health outcomes and secondly, doing so within the budget of the government of the day.

External influences include the economy and technology; the professions; professional and public expectations, including to be treated in one's own home.

Our challenges are to improve clinical outcomes, reduce variation including in access to clinical outcomes, and use data. It's clear everybody can’t be expert in everything, and that’s where the concept of clinical networks starts to creep in. They need to look at the evidence that changes in care improve outcomes and reduce variability.

There are lots of kinds of networks already: formal clinical networks; research clinical networks, which are very important to medicine and UK PLC; then managed clinical networks; highly specialised like neonatal intensive care; general specialist such as cancer or cardiovascular, or more general networks.

The issue is how to make networks useful to you as a new paradigm evolves in the NHS, so we've asked Kathy McLean to work on developing an operating model to be standardised across networks. We know some function well and others poorly, and how they function is important.

Networks must be influenced by the needs of and demand for primary and secondary care. The DH draft report will look at how they might function, then go out to wider consultation in the new year. I want  networks to be useful to you and to get the right patient to the right place at the right time for the right treatment.

Clinical senates are a more difficult issue, I think, concept emerged form Future Forum, and created most puzzlement as people try to flesh through what they mean. The idea emerged from observations that the Darzi workstreams to bring primary and secondary care clinicians together to improve care pathways and services had been successful, because had been inclusive and brought right people together

I see senates having two roles:
- problem-solving forum, discuss problems and issues of service redesign, and can provide proactive and reactive consensus, and
- conduit of communication between NHSCB and CCGs. seems that channel of communication between NHSCB and CCGs trying to make them work is vital.

The NHSCB’s real role is to help CCGs to do what they want to do, and can see how senates might form not only forum for consensus bit conduit to feed up to NSCB. But senates must add value or they don’t have a purpose, challenge of all this reorganisation is how to bring simplicity out of what is quote complex org.

I think senates have to be your project, not a DH project, so we’ve asked the Kings Fund to work on senates. With DH colleagues, we’re still very much in the listening phase, but two words I want to see are inclusivity and integration (probably in that order) for networks and senates. I thought I would have much more to say when I accepted the invitation to speak here, but I’ve tried to underline the broad philosophy.

Questions and answers
DF: (asked about losing underspent money in-year which can’t be carried forward) We will find way in system of taking some forward for flexibility – but you can’t carry all forward, or most forward.

An audience questions about ’will there be air cover from the centre for closing acute capacity – yes or no?’ was not answered.

Regulation, guidance and inspection – working together?
Judith Smith, Nuffield Trust – There’s always a national-local balance to be struck: the public, politicians and NHS staff have the right to expect national consistency of NHS offer, as well as certain level of quality. National and local needs to be both … and … rather than either … or.

NICE is now internationally respected, not only for technology appraisals, and CQC is making strides, but it’s early days yet. Inspection will start to show where practice is actually improving.

So where from here? We’ve built an incredibly complicated health system: I gave 2 days of evidence to the Francis Public Inquiry to explain how NHS works. And it took 2 days … and is just as complex in the new world. But CCGs have real potential to be NHS Local, pull together guidance, evidence, outcome frameworks from NICE, so my challenge today to clinical commissioners is this - who will know in future if a hospital or practice is failing to deliver really good care?

Where does performance management sit alongside outcomes? I am not sure we are there on answering this question yet.

Andrew Dillon, NICE - Integration, coherence and value added are not always words associated with national bodies which have attempted to support the NHS. I have seen systems to inform and stimulate NHS and social care to provide good-quality services come and go.

One thing is critical: unless we can demonstrate that we work together to create more than the sum of our parts, we won’t be seen as useful additions. At worst, you will just discount what we do and at best find workarounds

New national organisations need to get together to examine critical business relationship and ensure they’re working together to create the right offer. We have to have point of reference to provide uniform approach

We as patients expect the system to work together, by and large. NICE and CQC provide different types of support, but in future we will make sure it is entirely complementary. NICE guidance is not a counsel of perfection; it is what I want if I get ill. NICE guidance helps you understand where you could be.

Integration is critical, and it’s happening in NICE: we’re distilling guidance into a suite of 150 quality standards over the next couple of years, and that will inform the QOF and COF from 2013. It all ties back to the evidence base and is connected. I will make sure I work effectively with Cynthia Bower, David Bennett and David Nicholson to build those business relationships to be integrated, coherent and useful locally.

Dame Jo Williams, CQC - I want to put people right at heart of what we do – and I adopt the Darzi definition of quality: composed of safety, outcomes and patient experience. CQC is the first regulator across the health and social care system, and has not realised its potential at this time, but can add real value.

Our standards are essential, not minimum, making registration process smooth and effective. Regulators play part, but small part of system, public want rightly for things not to go wrong. When we talk about choice and empowerment and citizens, thinking of them as enforced whatever, want to hear more about what is patents’ experience of care. It brings challenges and dangers, but is a feedback mechanism. The regulators are doing our best not to duplicate each other’s work. We want to use the patient voice of HealthWatch.

How can CCGs get ready for inspection and regulation as part of the way they work, and minimise the effort?

JW: important thing not pleasing regulator, about pleasing patient, look at quality assurance d systems and what they contain.

JS: CCGs support and capacity for undertaking and assuring standards, if not commissioning for quality and outcomes not sure what point is. We need to get back to idea of CCG as NHS Local, a community health organisation. Nick Mays and I did piece on brain and conscience of local system. Capacity? Data crunching, patient experience can be aggregated, but the brain and conscience function, along with HeathWatch, be guardians and stewards: it’d be great if CCGs known for that in the way PCTs weren’t.

So exactly where next?
Professor Paul Corrigan, Dr Jonathan Shapiro and Professor Chris Drinkwater

Professor Paul Corrigan: Two big options suggest themselves for where the NHS ends up in 2015: one is probably overly pessimistic; the other overly optimistic. My experience of doing work around NHS, is that I turn up and talk to people, and the main thing on their minds is what will happen to economy, and is it the end of their and children’s world? People are very anxious about the next few years and next two decades.

Then we talk about dealing with 4% Cost Improvement Programmes, and the two worlds have to come together in their minds and visions of future. The average family will lose 7% of their income from 2009-2014, and this is not something that can be sustained, and so we can’t assume that the proportion of money the NHS is going to get will remain as it is.

So the economy will bear down and make things go from difficult to ferociously hard. So we need to look at current issues of saving and value.

The OF 2012-13 deals with savings, and CCGs will see 2% of the budget top-sliced, into an inefficient hospitals fund. We’re now maintaining £2bn as steady necessity slush fund and probably more. It’s the result of a top-down approach: part of an assumption that top-down is the only way of coming at stringency, whereas it’s probably the last thing one should do. The only way to deal with this scale of challenge is to have local organisations to deliver healthcare.

The reason the NHS is in and will be in problems, as all developed health services, is that the model of value sees it being produced by a combination of medical personnel, their kit and drugs. So more value = more inputs - but it won’t be as we can’t afford it. The demand of our ageing population is 3-4% a year, which comes to a lot over 10 years. If our only source of value that, we’ve had it.

In other industries, different sources of value are discovered. We now see patients as sucking value out of staff, drugs and kit, and if we carry on with that perception, we’ve had it.

Patients are a potential source of value for constructing a new kind of health service. Most of you know this morally and medially; I’m expressing it economically. And change is an economic necessity. Banking and supermarkets have both learned to use customers to co-produce value, and unless we get to co-production of health in the next 4-5 years, the economics do not stack up. We have to face the starkness. There are 18 million people with long-term conditions.

Dr Jonathan Shapiro – The key word for me is ownership, and the two basic healthcare issues of all developed countries are the need for comprehensiveness and equity and the lack of cash. Governments don’t like to ration, as they think they won’t get re-elected if they do, so they devolve rationing to the service, and ownership of problem goes to members of organisations. Who then spend their budgets this way or that because it is not our money. ‘We’ll always need a hospital here / always need doctors’. There is little incentive to save money among staff in acute trusts – if they’re not too big to fail, they’ll be too important geographically to fail.

Models of commissioning have been quasi-civil service models organisationally, too far away and not enough ownership, with middle managers making decisions which didn’t matter to them. Clinical ownership in CCGs may make progress as it’s a personal investment. PCGs were good as they felt owned by GPs; as did fundholding, offering a sense of being left to get on with it and a lack of micro-management

There is clear tension between the libertarian decentraliser Mr Lansley and the great centraliser Sir David Nicholson. There is a risk we will lose CCGs as we did the 'corpse' of PBC; an expectation raised and dashed being worse than no expectation at all. Tories won’t do this – needs Labour govt to make this happen.

Chris Drinkwater - The worst-case scenario is that the GP as independent generalist will have disappeared, sitting in a specialist-dominated HMOs, in a two-tier insurance system, with premia going up year-on-year and most of population unable to afford insurance. US acutes hovered up community services.

In a best-case scenario, the DH and government rediscover general practice as providers. Right now, they see us as commissioners, but GPs are good as providers. Isn’t genera practice to=he community and rapid access teams? need to look at locality clusters of practices, built for offering a range of activities in the community. They need to recreate themselves as community organisations with local people on the board – add value through gift exchange and co-production in economic circumstances heading towards.

What would work to turn the centralisation around in the real politics of the next few years?
PC: There’s a tactic around HWBs addresses how get out of centralisation. Local government is very used to attempts to centralise, and is used to fighting back. If I were running a CCG and wanted to defend my locality, I’d get really stuck in with HWBs. Saying to Sir David Nicholson ’my local authority won’t like that’ will be much more powerful than saying ‘I don’t like that’. It’ll be in the interest of local authorities, who will wonder about the possibility of making an alliance with the NHSCB if GPs in a CCG walk away.

So I’d align with the local authority, then say ‘this is what we want and if we don’t get it, we can’t do the job’. Find allies in local government, as they spend ¾ of lives trying not to be pushed around by national government or national bodies.

JS: The French revolt, the Brits subvert … GPs can bankrupt the system very easily. Being threatened? Threaten back. Better to say 'if you help us, we can help you'. As GPs, our walking away is behaving as we damn well please.

PC: I can’t describe politically how bad government would look if the GPs walk away from this.

David Colin-Thome: A disaffected even more knowledgeable group of people, whose best mates are patients, public and local authorities …