It’s surely a good time to be Dr James Kingsland (pictured). Recently re-elected as President of the National Association of Primary Care (NAPC), the Wirral GP has been a high-profile champion of locally led commissioning long before the coalition government’s radical NHS England reforms put GP-led clinical commissioning groups (CCGs) in the spotlight – indeed, his PMS practice was an early practice-based commissioning (PBC) adopter and a first-wave CCG pathfinder.
Dr Kingsland’s views and experience are therefore valuable to the government, and consequently his stock has risen even further. He is now the Department of Health’s special adviser on commissioning, with a direct line to ministers, including Health Secretary Andrew Lansley. With this power and influence, it’s not surprising that leaders of the NHS Practice Management Network were quick to contact Dr Kingsland to demand recognition for practice managers in CCGs (see box below).
As reported in the last issue of MiP, practice manager influence at board level has been varied across the country, with many feeling their skills and PBC experience has been overlooked while peers elsewhere are taking up board positions. So, as an authority on clinical commissioning, what’s Dr Kingsland’s view – do practice managers have a role to play?
“Oh crikey, yes,” he says emphatically. “For a start, practice managers are great at the analysis of the practice-specific data – the information locked in primary care systems – and have expertise in managing the business, which has taxpayers’ money within it.”
This valuable role as experts in local population data is clearly understood by the most senior figures driving through the reforms. At the NHS Alliance annual conference in November, Dame Barbara Hakin, Managing Director of Clinical Development at the Department of Health, spoke of the “very special expertise that longstanding managers can bring to the commissioning process.”
Hakin said that data monitoring would be critical for commissioning to help CCGs understand the quality of care patients receive, adding: “CCGs will need to have strong leaders who are managers by background just as they need strong leaders who are clinicians by background.”
Dr Kingsland says that while practice managers would have only a “relatively small” role in managing commissioning budgets, “still the expertise of a practice manager could [enhance] the expertise of a CCG. There may be back-office functions that practice managers may do better than primary care trusts (PCTs) have done,” he says.
Dr Kingsland goes on to list those functions: “Payroll, HR, staffing, recruitment, estates management, consumables, tracking the patient journey, analysing costs within prescribing and certainly the budgets that practices are going to be required to manage – all that is going to be required for the larger organisation of the CCG,” he says.
Finance and waste
He is adamant that practice managers have a vital role in arguably the biggest challenge facing the NHS: the need for the health service to make efficiency savings of 4% by 2015. “I think practice managers will spot inefficiencies and waste in the system far faster, possibly, than the PCTs who did it on a very, very large basis. We’ve got to get really granular with this,” he says.
Dr Kingsland is acutely focused on what he sees as an inextricable link between clinical commissioning and the pressing financial challenge. He insists a centralised system cannot solve the problem, but it will only be effectively tackled by “every practice” in “every community” reducing wasteful spending.
At the recent Management in Practice Event in Birmingham, Dr Kingsland told delegates that the government’s “bottom-up” reforms had to be a genuine, fundamental change to previous delivery, and that practices would have to become “more productive with what is protected”.
“The idea that we’ll solve the [efficiency] problem by producing CCGs that are bigger organisations than PCTs and by putting a few clinicians in the place of expert managers is one of the biggest myths flying around the system,” he said.
The financial challenge facing the NHS has been described as “unprecedented” – not least by Sir David Nicholson. In a recent interview with MiP’s sister magazine GP Business, the NHS Chief Executive said: “We have never delivered savings on this scale before or have been as ambitious about what we need to do.”
However, Dr Kingsland insists that the challenge is “not unprecedented” in general practice and claims that in the fundholding era, practices had managed to achieve such efficiency gains over several years. “That’s what we really need to get back to [in order to deliver] what is expected by these reforms,” he says.
He describes the money squandered spent on, for example, unnecessary referrals and duplication of work, as “frightening”, but believes that surgeries in England can turn this around thanks to the reforms. “We’ve got so much waste in the system it isn’t very difficult for the average-to-good general practice to make quite wide-ranging changes by just having ownership of the budget,” he says.
A recurrent criticism levelled at the government’s reforms in England is that the new structure, with the national NHS Commissioning Board (NCB), headed by Nicholson, that will oversee CCGs, risks recreating precisely the same bureaucratic order that limits local decision-making.
This concern has even been articulated by those close to Dr Kingsland. NAPC Chair Dr Johnny Marshall recently told the NHS Alliance conference: “The practices are the CCG and the CCG the practices. Anything less risks recreating PCTs and little will change”.
The Alliance and the NAPC’s new Clinical Commissioning Coalition has furthermore voiced concern over suggestions of “coercion or bullying” by PCT clusters over how CCGs should be established. Added to this is a call for an equal relationship between the NCB and CCGs to avoid a hierarchy where, to quote Mike Ramsden, NAPC Chief Executive, “tablets of stone [are] handed down from above”.
Dr Kingsland does not believe this is likely but does not flinch from the hypothetical consequences. He says the system would “fail spectacularly” if another centrally led system arose. “But I don’t believe that is in the NCB’s agenda, nor do I think in any sense that a new centralism would work.”
Echoing his earlier comment about “granular” detail, he advocates smaller CCGs working in a more concentrated fashion than PCTs, the suggested recreation of which he vehemently opposes. “If we recreate the bureaucracy that this legislation is trying to get rid of, if we recreate 150 CCGs [each] with about 300,000 populations, there should be a public outcry because it would be a scandal,” he says.
The idea that the NCB could interfere with local CCG decision-making is, he argues, simply impractical. “The NCB is going to have to give guidance and support to CCGs, but the idea that they could possibly do the CCGs’ work locally and change behaviour in day-to-day practice… I just don’t see how that could work. PCTs couldn’t do that, and that’s one of the reasons they’re being abolished. The new organisation is a fork in the road; it’s a completely different direction, completely different in terms of function.”
‘We’ve got to move forward’
The Health and Social Care Bill in England is still facing widespread opposition, including from GPs (a survey by the Royal College of GPs (RCGP) of its members found that more than 70% did not support the bill) and the British Medical Association.(1)
But Dr Kingsland insists this is no time for turning back and rejects “the idea that somehow the will be blocked and there’ll be a u-turn… a u-turn to what? We’ve largely dismantled the old system. Part of it is crumbling. There’s nothing to go back to. We’ve got to move forward and improve what we’ve got, which is almost embryonic at the moment, but that’s got to flourish,” he says.
Again he insists the reform drive is critical to the funding issue. “It would be disastrous for our NHS to do anything but progress – but progress in ways that strengthen the fact that we need better outcomes for the public purse, strengthen the fact that we’ve got to be more productive,” he says. “We’re moving from ‘just quality’ to ‘quality and cost’, which is the value system. If that changes, I don’t know what the alternative is.”
He boldly envisions general practice as the saviour of the NHS, saying, “We’ve got massive inefficiency in the system and when general practice gets hold of it we will reduce duplication of work, which is a waste of taxpayers’ money and is sometimes dangerous for patients, and we will reduce inefficiency and waste.”
But is general practice committed to the ‘quality and cost’ drive? It must be, he says. “What we can’t do is waste enthusiasm or spirit at the moment. Because if we lose that, that would be the biggest waste of all.”