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Will the NHS Commissioning Board liberate or shackle CCGs?

Clinical commissioners were promised the headquarters of the NHS would be in the ‘consulting room and clinic' in the 2010 NHS white paper. Two years on, and the latest document on the NHS Commissioning Board puts a very big question mark over this original declaration. Published last month, Design of the NHS Commissioning Board does little to persuade CCGs that the centre will loosen its hold.

The language of the document has already raised the hackles of some GP commissioners. It describes the board's role as to develop ‘commissioning strategies, processes and best practices' that will put into action its ‘overarching' strategy for improving outcomes. And a read through the small print of this new structure casts further doubt on how ‘lean' and hands-off the board will be in practice.

Staff numbers

While the headcount for the board will be just 3,500, instead of the 8,000 currently doing comparable functions, some £13.5m of services including payroll, legal advice and procurement support will be outsourced as the board ‘models the change it expects to see in CCGs'. So while the headcount has gone down, so have the functions being done in house.

Drilling down to the structure of the board, it seems there will be 2,500 staff for the 50 local offices – covering the same areas as current PCT clusters – with around 50 at each. Four ‘sectors' – based on the areas now covered by the SHA clusters – will employ some 200 staff. These 200 structure staff, combined with an additional ‘800 at the centre', mean there will still be over 1,000 staff at Richmond House in London or Quarry House in Leeds – almost a third of the the organisation's overall headcount. These employees will form part of a substantial hierarchy placed over the heads of CCG chairs. ‘There should be no more than five layers of management in each directorate', the recommendations say.

From the GP perspective, five layers is already quite a lot, but two of the directorates – performance and operations – will have an additional layer. Add in the chief executive, and you have up to seven layers of bureaucracy above every GP commissioning chair.

Dr Mike Dixon, chair of the NHS Alliance, describes all this as ‘frightening': ‘It just feels wrong. Very top-heavy and top-down. Judging by this, the HQ of the NHS won't be at the front line.'

Board-watchers feel the plans fail to resolve the inevitable tension in attempting to retain a national perspective while devolving power to the front line.

Dr Nigel Watson, chief executive of Wessex LMCs and a member of the Department of Health's GP commissioning strategy group, says the question of how the central board can engage at the local level is the key one: ‘If it's all about central control, it won't work.'

GP representation

But judging from the first meeting of the NHS Commissioning Board in December, the instinct to control from the centre is alive and well. Among its first decisions was a plan to adopt NHS corporate livery wholesale, right down to the same colours and typeface.

Little has changed so far in terms of faces. While the board chair Professor Malcolm Grant, a barrister and former provost of University College London, is an NHS newcomer, chief executive Sir David Nicholson and medical director Professor Sir Bruce Keogh have simply been transplanted from Richmond House. The interim finance director is on secondment from NHS West Midlands, a chief nursing officer post is currently being advertised and the other six members of the senior team – chief operating officer, chief of staff and national directors for commissioning development, improvement and transformation, patient and public engagement,  and insight and informatics – will be in place by the end of the month. But there are no GPs so far – and, realistically, few posts for them to apply for.

This is a big mistake, according to Professor Nick Bosanquet, professor of health policy at Imperial College London and chair of Volterra health consultancy. He says unlike with previous manifestations of the NHS, GP input at the highest level is now absolutely crucial: ‘The board will need a very strong voice from primary care to ensure it develops the full potential of commissioning that it's supposed to be about.'

Natasha Curry, senior fellow in health policy at the Nuffield Trust, sees the new NHS as something GPs do have some control over – but that they need to grab while they can: ‘CCGs are going to have to move quickly if they want to balance out the board.'

Alisdair Stirling is a freelance journalist