Link, share, join, listen ...
Link, share, join, listen ...
As for anyone working in a profession providing goods or services to the NHS you’re always wondering what impact new policy will have on your business, and I wanted to offer my opinions but also invite comment from our networks of candidates in terms of what the White Paper might mean for NHS interim managers.
The BBC estimated the abolition of PCTs by 2013 could affect up to 68000 NHS managers. Many will be redeployed of course as the responsibilities of the PCTs are distributed into other areas of public services, public health professionals may find themselves working for the local authority for example, but a good percentage might decide to try their hand at interim management. Some, but not all, might be cut out for interim work but short term the influx of new candidates will depress rates, and I think it likely that that evermore price sensitive clients might prefer to appoint an ex PCT manager turned interim, who is already in their network, rather than seasoned NHS interim managers with a track record, who come at a higher headline rate (but arguably are much more likely to deliver value). Going forward you might not expect PCTs to be the target clients for recruiters, but if substantive employees start to leave early (and who could blame them) then the PCTs might opt to recruit to vacancies on an interim basis so they are covered for the remaining lifespan of the PCT. However, perhaps more likely will be the inclination for substantive employees to sit tight until 2013 and await a redundancy payout. Either way will the key skill set in demand here be HR, with the amount of TUPE, consultation and redundancy work that is on the horizon?
Chris Ham asked on BBC news on Monday night whether GPs are “motivated or competent” enough to effectively commission healthcare services in consortia. The White Paper states that “GP consortia will have the freedom to decide what commissioning activities they undertake for themselves and for what activities they may choose to buy in support from external organisations, including local authorities, private and voluntary sector bodies.” If it turns out there is not the right level of competence across GP consortia to effectively commission services then that commissioning support may well be bought in, and perhaps we will see a marketplace where providers such as ourselves can directly provide that commissioning support to consortia in the form of interims. There may even be potential for an element of performance related pay in such roles given that “consortia will receive a maximum management allowance to reflect the costs associated with commissioning, with a premium for achieving high quality outcomes and for financial performance.”
Another key theme is that of patient choice and the vision to ensure that patients have a choice of any provider will hopefully be reflected in commissioning practices. If a genuinely free market is created between providers then the increased competition should drive quality innovation, productivity and prevention in the QIPP agenda as well as potentially create demand for business development and marketing skills. In our experience trusts that are trying to achieve FT status often need interim support to help them improve standards of healthcare and meet core targets, and if all trusts now have an obligation to go through that process it should increase general demand for change and performance improvement specialists.
Ultimately though the longer term picture might show a general reduction in the demand for interim resource, given that the Government will “impose the largest reduction in administrative costs in NHS history” and the fact that “the NHS will employ fewer staff at the end of this Parliament; although rebalanced towards clinical staffing and front-line support rather than excessive administration.” The White Paper does admit there will be a cost for this transitional work and I believe that interim managers as agents of change will certainly play a part in making it happen, but ultimately if the vision is to be realised the NHS in a few years time may look like a leaner and more clinically driven service with less need for general management support.
What are your thoughts? What intelligence have you picked up from the marketplace? I would be keen to hear the thoughts of our interim management community on how the White Paper will affect demand for interim resource in the NHS in future.
Steve Melber is Senior Consultant, Health at Interim Partners.
July 14th, 2010 at 1:20 pm
The theory of this white paper is that management will be cut at all levels and that a lean, mean operation based on matching demand and capacity will result. Experienced NHS watchers know well that theory and practice are quite distinct. From the interim perspective, consider this:
1) On top of 12 major health bills from the previous administration, this just spells further change and destabilisation to the service. Each change is different and cannot be planned proactively. Acute trusts are barely more skilled in managing governance and commissioning changes than GP practices, so I would not expect their demand for interim resource to dry up unless and until the system was running smoothly, and not even then either. However, experience tells us that the “transition costs” will typically exceed assumptions by a factor of somewhere between 10 and 1000. Governments invariably underestimate these costs.
2) There are huge gaps in the knowledge of how it will be made to work, and much of the transition and adaptation will be done on the fly. Assumptions that it will be up to each GP practice to develop their own management and commissioning approach suggest that a new vision of best practice must emerge with vast opportunities for niche skills within the industry to exploit. Always assuming that GPs actually accept their share of the burden, since most will surely demand additional funding and income for taking on this extra responsibility.
3) We do have limited practice-based commissioning and indeed Choose & Book now operational. However, the system is less than efficient for two primary reasons: lack of effective triage to determine the most appropriate referrals, often resulting in time wastage as patients are referred from one consultant to another, or back to the GP; secondly, it would be unrealistic to expect GPs to commission services efficiently when they might see a given condition once in a career, where PCTs have developed procedures for commissioning on the basis of community needs. This suggests:
* New systems will spring up to fill the void, requiring requirements analysis, development and implementation etc.
* Knowledge management to enable existing expertise and sources to be recycled will be essential.
* A new breed of middlemen will fill the gap left when PCTs head towards extinction in 2013, and it is unrealistic to expect “consortia” from among groups of GP practices to operate in isolation.
It’s a typical panacea to suggest that NHS management costs and the pantomime villain of public sector policy makers, “the consultants” (boo, hiss!), can be cut at a stroke, but the reality is that the NHS is one of the largest and most complex services operating anywhere in the world. Application of simplistic solutions generally gives rise to unforseen consequences, so the vast army of service support options will simply adapt to the new circumstances and feed the beast.
July 14th, 2010 at 3:50 pm
I think that, sadly to an extent, I agree with Steve’s analysis of a marketplace where prices will be pushed down and probably skill levels with it. I believe that the Local Government arena saw a similar thing a few years ago where ex staff were brought back in as consultants because they knew the ropes rather than they were any good. It is a short term solution which will always leave the customer (me, you and the rest of the general public) worse off than they were.
Equally I think that some of the points raised by Andy Millward are valid in that there is work accumulating in these organisations now which will only build up so there are short, and maybe medium, term opportunities out there in a few months I think.
July 14th, 2010 at 7:40 pm
It’s probably alright to be confused right now. There is no doubt that the transition is enormous and management capability to manage a change on this scale not high. Add to capability the capacity issues as folks begin to leave then it could all get very messy indeed. As you say many will be tempted in PCTs to hang on awaiting favourable terms for departure, if they ever come.In these circumstances I think Andy Millward’s analysis could be close to the mark.
July 15th, 2010 at 5:52 pm
Many people in the NHS have gone through these re-organisations before and survived. Currently NHS staff are in a number of camps including being; scared of losing their job, complacent, to excitement of the possibility of a good voluntary redundancy deal.
There is a view that the GP consortia will mirror the PCT structure before the mergers of 2006 i.e. 450 GP consortia rather than the current 152 PCTs.
There is no doubt that the GP consortia will need to buy in skills to meet government expectation and what worries PCTs is that for many their relationships with GPs are not positive and in some cases acromonious.
This is leading PCT personnel to think that GPs will buy in the necessary skills from the private sector rather than from current NHS pools of staff. This is a real possibility given that GP Fundholding meant some GPs settled old scores with hospitals and consultants by flexiing their new financial muscle.
If this happens then the scope for Interim consultants would be vast requiring them to skill up for the new world. However, GPs will not want to pay these consultants well (at least not in the first instance) until they realise the benefits of sourcing and paying for the best. A consultant that is able to deliver a GP a healthy profit would be a very much sought after assett.
GPs speak a different language to managers and so interims will need to understand the value drivers for GPs and translate them into successful commissioning activities. I see the White Paper as a free for all as GPs main loyalty is to themselves - so anyone able to enhance the world of a GP has a great future.
July 16th, 2010 at 6:20 am
Steve’s analysis is probably right, save for the approach that GPs may take. I have spoken to the senior partner at more than one practice, each unknown to the other and they have said they don’t know how they will find the skills to do this. They will not be looking to current PCT staff, suning phrases including the word “bargepole”. They see those individuals as requiring a large, supportive office infrastructure to get anything done, and will be looking for someone who can do this “from the off”. Two challenges for established interims _ proof of concept and rates. On the former, if you are an interim used to working at senior level, perhaps CEO or FD at an acute trust, how do you demonstrate you can do the work in a GP consortia of say 10-20 GPs? And how much will they pay? They are used to what is, at heart, a piece work system (capitation + transaction) rather than a day rate. They pay their existing staff either an hourly or annual rate. Paying for a short/medium term on a day rate will challenge them and us.
July 16th, 2010 at 8:28 am
The business skills which good interim managers and consultants provide will always be in demand. It is a question of how these skills are presented and sold to clients.
July 16th, 2010 at 9:19 am
Some managers at primary care trusts (PCTs) and strategic health authorities (SHAs) will find work with the independent commissioning boards, or with local authorities assigned responsibility for public health, but tens of thousands more will lose their jobs??. Among GPs, there can only be limited enthusiasm for pursuing a second career as a healthcare manager. The reforms will no doubt appeal to some with an entrepreneurial bent, but a large number will prefer to concentrate on delivering the care they were trained to provide.
The white paper makes it clear that, should GP consortia feel it necessary, they have the “freedom to decide what commissioning activities they may choose to buy in support from external organisations, including private sector bodies”. The reforms, may therefore, create a management void in many areas of the country ??
July 16th, 2010 at 10:31 am
As someone who has worked in all NHS sectors I believe that the comments of Sue Munday are the most accurate. GP community often have good links with acute colleagues and many GP’s have a poor view of exisiting PCT’s, especially senior mgmt. I can see acute trusts providing mgmt support to GP commnunities in terms of contracts, commissioning and data intelligence but then charging this cost back globally to GP community as a mgmt charge - this would aid both sectors. I also think that this change of financial direction is an opening up the sector to private suppliers on a major scale, especially data/information mgmt. Start reading declaration on interests !
July 16th, 2010 at 1:52 pm
Did anyone notice that David Nicholson has reserved a fund of £1.7bn to enact changes which, according to Andrew Lansley will cut bureaucracy permanently? I have severe doubts that this change will break even in the short term, even if it does curb the worst excesses of PCT commissioning behaviours. At worst it may duplicate many fold and end up costing more to manage.
At a political level, the cliche is always to slash management costs, as if the health service was populated by a vast tribe of managers who sat around and twiddled their thumbs all day. In practice, the 3% of NHS budgets spent on management is below the European average and certainly not excessive. Yes, it could be reduced by simplifying targets and procedures, but beware distortions in the system from losing one set of practices but gaining another.
The secret for interims is to adapt faster than the service. As Benjamyn correctly states, we have to provide evidence that our service offering can fulfil a need consortia cannot readily fill through any other means, and in so doing consortia will need to build their bureaucracy and change practices in order to survive.
July 16th, 2010 at 7:30 pm
It is quite easy to make the case that the market for interims will shrink and especially for the next year. Factors such as the present uncertainty on the new commissioning model, and anticipating a period whilst consortia organisational plans are formed, provide good reason for expecting a hiatus in the interim market.
In your blog, you talk about existing NHS staff and the impact their career decisions will have on the demand for interims. Given that the consortia are intended to be formed and start operating in shadow form during 2011-12, I think that many NHS staff will need to decide whether they want a career move to the consortia during 2011-12, and therefore there will be fewer chances of just waiting out a redundancy package until 2013. The main staffing consortia modus operandi and the key staffing for the consortia will need to be addressed by 2011-12.
There are presently circa 500-600 consortia in England. It can be argued that this is will be inefficient, and that there will have to be far fewer to achieve economies of scale and hold sufficient purchasing power with providers. However, the white paper is quite clear that GPs will have the deciding vote on how they structure, and GPs may very well see the priorities differently. They may place more emphasis on localisation and forming small, more manageable groups of GPs.
In this scenario, the interim commissioning opportunities increase because the NHS will need 500-600 commissioning groups (contract management, performance management, information, finance, procurement etc etc). The permanent staffing for this volume does not exist today and some of the existing staff will want to move on. Other than the the Dirs Commissioning and the ADs Commissioning in the existing PCTs, I cannot see that the other existing staff (in general) have the skill base to set up and run a new commissioning operation alongside GPs.
Whilst DH is promising to empower the GPs (via consortia), there will also have to be very strong governance to hold the consortia to account for both performance (experience, quality, outcomes etc) and budget. To achieve this, there will have to be top down definition of how this will work, and that in turn will tell us to what extent existing senior commissioners will have to lead the GPs to organise as effective consortia, versus GPs taking the lead themselves. I see a real opportunity for interims taking on roles in the short term working with GPs and leading or programme managing the consortia formation and set up.
The promised paper from DH on the GP Consortia model should reduce some of these variables.
July 22nd, 2010 at 12:27 pm
As an interim with a track record, admittedly mostly private sector, I see the NHS as a future opportunity. I have done some work in the NHS and have a number of colleagues working there. I believe the short term opportunity to be far less attractive than the medium term.
Although there is clearly tremendous support for promoting from within, aka jobs for the boys, that is also true in the private sector. How many clients are far sighted enough to admit interims can transfer their skills across sectors? Very few. However if the NHS continue not to challenge the status quo and to hire their own, many of whom are ex-employees who have miraculaously morphed themselves into contractors/interims, the phrase “doctor heal thyself” springs to mind and medium term it is not a solution.
imho the more broad minded within the NHS realise they need to introduce private sector skill, but are not close enough to the cliff edge to turn this into action. Again this is not so different from private sector employers. They forget problems do not heal themselves with ageing!!
I do not believe day rates to be a big issue. Consultants have crawled over the NHS for years and taken many millions of pounds for providing reports. Hopefully the NHS will realise sooner than later the benefits of interims and actually take a little more risk. They certainly take medical risks often enough, why not business risks. There are apparently far too few people with commercial knowledge in the NHS - profit and loss, cost per patient/action taken, waste removal, cost cutting and performance management need to become their new lexicon.
Change in the way the NHS introduce it equals, and has equalled for years, disorganised intiative driven chaos. Similar to change being introduced into the private sector a decade ago before a process for change was identified and practiced by professional interims and their provider associates.
So short term patients - sorry patience - medium term opportunities…………….
July 23rd, 2010 at 12:30 pm
The new coalition government has delivered a White Paper that seems to pose more questions than it answers.
It outlines probably the most radical shift in the way the NHS works for over a decade, mostly driven by the change in commissioning responsiblity from PCT’s to GP’s through collaborative “consortia”.
For me the challenge is threefold.
1. How can patient pathways be redesigned to drive value, outcome and single accountability.
2. How will information be gathered and harnessed across the three dimensions of Outcome, Quality and Experience.
3. The management of the critical transition period.
GP consortia will need resources and guidance to deliver what’s required from these challenges. To be honest, that experience does not lie consistenly through the NHS. GP’s have a mixed appetite for commissioning and traditionally have been excluded from the process by PCT’s. Managers with key skills, but more importantly vision for how to execute, will be valuable both during the transition and early stage implementation.
July 24th, 2010 at 8:03 pm
I’m an interim with 7 years continuous NHS experience and currently a Director of Commissioning charged with making this all work!
The 3 big challenges are:
1. Cut 10% of clinical activity - nationally £15-20bn
2. Keep the business going
3. Help set up GP commissioning
And do this with 45% less staff!! But that’s what we interims bring - radical ideas, can do attitude and delivery.
Some thoughts to ponder:
1. Likely management cost envelope per commissioning consortium = 0.85% (deduced from White Paper numbers)
2. Lack of expertise and willingness amongst GPs - burnt by ending of Fundholding and PbC
3. No organisational future for current PCT/SHA staff
Smart staff starting to think about setting up social enterprises (under right to request)to provide services to consortia locally - and maybe further afield. Pick yoiur bets and brightest colleagues - get PCT help to form SE - start working with GPs now as part of the day job. By the time “guidance” has been issued you’ve got on with helping set up consortia and started to define the offer based on inside knowledge of what the GPs want. Food for thought!!
Many GPs are anti-private sector health organisations. How much commissioning will be done in the new world? Maybe a lot of de-commissioning? GPs won’t have to worry about the future viability of local Trusts (that’s for Monitor). Lots of local procurements.
So I suspect there will be work for good interims who know what they’re doing. Rates will be under pressure but what’s new in downturns. Need to understand the local situation and get in with key players.
July 26th, 2010 at 1:29 pm
What immediately comes across after reading the White Paper and the associated Draft Structural Reform Plan is the magnitude of this change, which will have an enormous impact, White Knight or Red Light/, probably in the very short term, say this year less assignments, in the medium term 2011 and on I believe that there will be an increase in opportunities, increasing as we move forward from the consultation to the transition period and then to operating under the new structure. Such a huge Change Management Programme, and the planned speed of implementation brings huge risks.
Many GP practices will not willingly embrace becoming part of a Consortia, and taking on these new managerial and financial responsibilities, few have any depth in terms of resources and management expertise, so the process involves the setting up effectively from scratch new organizations, shadowing (PCTs) in 2011/2012 (I wonder how that will work).
Whilst there are many good Commissioners and Managers within the PCTs (I read a comment recently in the HSJ that suggests the best SHA and PCT managerial staff are already lining up top jobs with GP consortia), however my experience is that presents relationship PCts and GPs are often adversarial, as they are with SHA’s . It seems likely to me that the new Consortia will buy in private sector expertise including Interims of all disciplines using this opportunity to build lean responsive organizations without baggage. This will probably not happen until the first quarter of 2011.
Regardless of where Commissioning is carried out, within the PCTs as now, or the new GP Consortia, it has be done, and the volume of work, the complexities of contracting for service provision, with more private sector providers and every Acute having foundation status are immense, so I not see the NHS dispensing with Interims, there use is likely to grow in the medium, long term.
July 27th, 2010 at 9:16 am
From a historical perspective, it seems to me that the coalition government is returning to the Conservative policies of the early 1990s of an internal market and GP fundholders, only this time they are saying that all GPs will become fundholders.
As a previous corrspondent has said, there will be those GPs who will welcome the change but there will be others who see this as an extra administrative burden. In the 90s this led to tensions between GP practices on the strategies to be followed, and obtaining consensus was difficult and time-consuming. I do not imagine that it will be any different this time, as GPs try to form themselves into consortia, and then consortia endeavour to co-operate in order to improve their purchasing power.
One of the reasons why the internal market collapsed in the 90s was the possibility that acute hospitals may lose sufficient work that they became financially unviable and would have to close. The politicians took fright at the possibility of them having to explain to their electorate as to why their district general hospital was going to close. Are the current crop of politicians prepared to face up to that possibility this time? I think not.
No matter who does the commissioning, I shall take a bet that the amount of bureaucracy will not diminish. NHS Head office and the DH civil servants will still insist on receiving a raft of reports, so that they have the information to hand, just in case a minister has to answer a Parliamentary question.
Will this lead to a reduction in the number of interims? Personally I think not.