THE NHS Commissioning Board’s role in NHS reform is still widely debated. Pf looks at how it will direct the NHS of the future.

The new NHS Commissioning Board (CB) is unique in three respects. Firstly, it stands to take on more power than any arm’s length body in NHS history. For up to three years at a time, it will be entrusted by the Government to run the NHS and allocate its entire commissioning budget, without regular scrutiny by Parliament.

Secondly, it stands to hand over more power than any arm’s length body in NHS history. Of its annual £80bn
commissioning budget, £60bn will be delegated to the 212 Clinical Commissioning Groups responsible for commissioning local services. While the CB will commission primary care from the CCGs and ensure that they deliver on the NHS Outcomes Framework objectives, it will allow them to devise their own solutions and choose their own partners.

The powers of the SHAs are being delegated ‘upward’ to the CB, while the powers of the PCTs are being delegated ‘downward’ to the CCGs. The widespread concern about a potential gap in responsibility led Sir David Nicholson to say: “The NHS Commissioning Board could turn into the greatest quango in the sky. So it needs to have clinicians at its heart and the powerhouse for change in the system must be the
clinical commissioning groups.”

Andrew Lansley’s letter to the CB’s Chair, Malcolm Grant, in April about the Board’s strategic objectives stresses that its first responsibility is to make a “shift of power from national and regional organisations to CCGs, Health and Wellbeing Boards, local providers and patients.” The CB will not be a monolith within a static system: it will be a facilitator of future NHS transformation. That dynamic role is the third unique
feature of the CB, and the most important.

TAKING THE REINS

The DH plan Developing the NHS Commissioning Board (July 2011) outlines the intended structure and functions of the Board. It will have two broad national roles: to commission primary care and specialised services, and to ensure that the entire commissioning system is “cohesive, co-ordinated and efficient”.

Using £20bn of its annual budget, the CB will commission GP services and specialist health areas, including dentistry, maternity, community pharmacy and ophthalmic services. The Board will not govern the CCGs in a traditional way: it will “support” them and “hold them to account” while allowing them “freedom to innovate.” This support includes authorisation, an outcomes framework, guidance tools such as model pathways, and a means of intervening when CCGs are in difficulty.

The CB will host clinical networks to advise on specific areas of care and multi-disciplinary clinical senates to support CCG decision-making. Another key role of the CB is to lead the NHS Outcomes Framework by supporting local clinical improvement, providing “more services outside hospital settings”, improving acute care and the management of long-term conditions, and ensuring that CCGs implement NICE and other national standards.

In addition, the Board will lead patient-centred care by overseeing “the extension of patient choice and the expansion of information available to patients” and promoting both integrated care and innovative self-care.

Finally, it will develop a “medium-term strategy for the NHS” that will combine with the local priorities identified by the Health and Wellbeing Boards to provide a basis for local commissioning plans.

LEADER OF THE PACK

According to the 2011 outline, the CB will work in “partnership” with many other organisations: patient groups, healthcare professionals, healthcare providers, local government, industry and national organisations such as NICE.

The Board’s relationship with suppliers will “support its strategic approach to innovation and development” – in other words, it will play a part in the dynamic evolution of services and provider relationships.

The CB will be organised nationally around the five domains of the NHS Outcomes Framework, with a national lead for each domain. It will also divide its local teams into four ‘commissioning sectors’ reflecting the four existing SHA clusters, each with a sector lead.

The Board will take over functions performed by 8,000 people. It plans to reduce that number to 4,000 – a reflection of its ‘light touch’ approach.

RIDING THE WHIRLWIND

According to Lansley’s letter to Grant, the CB has a responsibility to “contribute to” improved health for “the whole population”, improved care and outcomes “for all patients”, and improved efficiency. Within this context, the Board Authority’s strategic objectives include “transferring power to local organisations” and “establishing the commissioning landscape”. The new NHS will then develop under its own steam, with the clinical networks and senates providing “leadership and insight rather than oversight and compliance”. The authorised CCGs will have the “assumed liberty” to design local services independently.

In addition, Lansley says, the CB will have a “vital leadership role” in enabling the personalisation of care by improving patient choice. This includes the use of personal health budgets. At the provider level, the CB will play a “crucial part” in developing a “level playing field” for competition.

In short, the role of the NHS Commissioning Board is to facilitate the evolution of a rapidly changing healthcare system. These changes will come not from the Board or the DH, but from the decisions of CCGs and their commercial partners.

Roche’s Tarceva (erlotinib) has been recommended in final guidance as a first-line option for people with EGFR mutation-positive non-small-cell lung cancer (NSCLC).

NICE’s independent Appraisal Committee concluded the treatment was a clinical and cost effective use of NHS resources, when supplied under an agreed Patient Access Scheme.

Professor Carole Longson, Director of the Centre for Health Technology Evaluation at NICE, said the Institute was “pleased to be able to recommend another treatment option for this stage of the disease.”

As part of the appraisal, the Committee discussed the results from the updated analysis comparing Tarceva with Iressa. On balance, the Committee concluded, the sums of money either spent or saved are small given the uncertainties associated with the data.

Therefore, when supplied under the Patient Access Scheme, Tarceva is recommended as an option with patients who have locally advanced or metastatic EGFR-TK mutation-positive NSCLC.

The emerging CCGs are suffering from a lack of willing GP leaders, according to the Royal College of General Practitioners.

Clare Gerada, chair of the RCGP, said that only “about 25 GPs” in England were actively interested in leading local commissioning.

Most GPs were keen to support provider reform in clinical terms, she said, but the “transactional” aspects of commissioning as a business did not appeal to them.

Gerada quoted an NHS director of business development as saying: “The level of GP interest in being a lead for a given condition or pathway in some areas is disappointingly low, and in some areas there has been no interest at all.”

The same source added that CCGs “hold a limited attraction for the vast majority” of GPs.

According to Gerada, GPs are “interested in the transformational stuff, but not in the transactional stuff” – which might have to be outsourced.

“No one asked GPs if they wanted to commission,” she added. “I think there are about 25 GPs in the country who want to do it.”

This speech came just before the BMA’s membership voted to campaign for the repeal of the Health and Social Care Bill – a motion not supported by its leadership.

NICE’s decision to recommend the use of Zytiga (abiraterone) in final guidance to treat prostate cancer has left Janssen “delighted”.

The treatment originally failed to get backing from NICE in combination with prednisone or prednisolone after the Institute deemed it to be too expensive – despite its clinical benefits.

However, after Janssen provided additional patient data and a revised Patient Access Scheme (PAS), NICE said it was happy to recommend the treatment as an option for the NHS.

Martin Price, External Affairs Director, Janssen UK, said the company had gone to “significant lengths” to find a solution that allows patients to be treated with the “innovative, UK discovered medicine, routinely on the NHS”.

The decision to recommend the treatment has also been backed by Dr Heather Payne, Consultant Clinical Oncologist, University College London Hospitals. She commented: “This is good news for patients – for whom historically there have been few treatment options available – and also for the patients’ families.”

Zytiga may potentially extend the lives of patients by more than three months. It is now recommended in combination with prednisone or prednisolone as a treatment option for castration-resistant metastatic prostate cancer that has progressed on or after one docetaxel-containing therapy.

The calm expression of Malcolm Grant, Chair of the NHS Commissioning Board, betrays that he is at the eye of the NHS reform storm. Maxine Vaccine considers what this quiet man has to tell us about UK healthcare.

As everyone knows, the NHS Commissioning Board is the engine-room of NHS reform. Charged with running the NHS for the next three years after April 2013, it’s already (in its shadow form) restructuring the healthcare landscape at such a pace that any still image of the process is a blur.

As PCTs and SHAs fade into the dawn, and CCGs progress towards authorisation with CSSs trailing them like hopeful fluffers, and thousands of dedicated clinicians wait to find out whether they still have a livelihood, there’s no question that the man of the moment is the quiet academic entrusted by Andrew Lansley with running the show.

Whereas Lansley is a demagogic politician out of his depth among people who expect more than a soundbite, and Nicholson is a sturdy bureaucrat with no trace of charisma, Grant is something else. He combines a feline precision with a diplomat’s charm and a surgeon’s presence of mind. The camera loves him, and Chuck Norris goes pale at the mention of his name. He’s like a cross between James Bond and Garfield.

During his speech to the NHS Confederation, the audience hardly breathed. In twenty minutes he said more about how the NHS is changing than Lansley could have expressed in a month. There were soundbites – describing the limiting factor of healthcare systems as “stagnant economies” was a good opening strike, while “the top-down approach is dead” was a killer blow. But above and beyond his neat turns of phrase, he delivered an incisive and unforgettable analysis of what the Board is up to.

The essence of which is: the Board is delivering control of the NHS to local commissioners and providers in a way that could not happen without central governance. To break down a monolithic system into autonomous fragments that stand any chance of individual success, you can’t just pitch it into the world of competition like a cow being fed to piranha fish. The market needs the hidden hand of government.

And so the NHS CB is there to orchestrate the decentralisation of the NHS: not just to make fundamental changes, but to ensure the system goes on changing as the patterns of clinical outcomes and profit play out at local and national level. Nothing will look like a public sector service provider any more: not Foundation Trusts, not CCGs, not CSSs, and certainly not commercial providers like Serco. This is a business plan for the NHS, and Grant delivers it with all the authority of a seasoned corporate CEO – but without the pomposity or the bad jokes.

The keynote of his presentation was “local autonomy”: by finding their own solutions, the CCGs – with their partners and providers – will reshape the national character of healthcare in England. The task of the CB is to provide “stability and continuity” as the national becomes the local, services become businesses, and austerity bites deeper.

Another of Grant’s elegant turns of phrase was the statement that the CB would define outcomes for CCGs, but not processes. A few days later, the CB announced that it would define commissioning processes for CCGs. While there are U-turn features in this shift, it’s probably more accurate to see it as another subtle twist in the dialectic of policy and rhetoric. The new NHS is a flagship experiment in free-market economics. As such, like a supermodel, it needs a high level of off-screen maintenance to keep that ‘natural’ glow intact.

Grant has admitted that when things go wrong, the person most likely to be facing the music on Newsnight is him. But where politicians are all fake swagger and bluster, Grant radiates a steely nervous energy that says “Bring it on.” He forecasts a future of community-based healthcare in which outcomes and cost-cutting are held in a dynamic balance. He says the CB’s draft mandate, due to be published in July, is “completely about the future”. And the future is now.

Maxine’s views are not necessarily those of Pharmaceutical Field.