Like a hurricane

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.