So, let's start with the likes of me and you: the electorate. We go to the polling booths
and elect a government to be in charge of this country and make decisions on our behalf.
The government forms a cabinet in which loads of different spending departments are represented.
Let's look at the Department of Health. Between the Department of Health and the Prime Minister
there is a Secretary of State for Health. The one you've probably heard of most in connection
with the NHS reforms is Andrew Lansley. He was in post until September 2012, and he was
the architect of the health reforms we are currently living with, although we'll see
they're quite different from what he originally intended.
Lansley's view was that there was a whole load of unnecessary red tape in the NHS that
was stifling clinicians' ability to deliver high-quality care. What really needed to happen
was for the money for NHS services to go directly from the Department of Health into the hands of GPs.
Why GPs? Well because a lot of NHS spend is determined by what they do, and because
they're the people that see patients on a day-to-day basis and arguably have the greatest
understanding of what those patients need.
However, giving £80 billion to a group of people who have never dealt with that size
of budget did not go down well with a number of different people. So what we've actually
ended up with is something a little bit different from what Lansley originally intended.
About £65 billion of the NHS £100 billion budget is going to organisations called clinical
commissioning groups, or CCGs. They're made up of GPs, but there's also representatives
from nursing, the public and hospital doctors. Their job is to try to improve the health
of their bit of the population.
How do they do that? Well part of the way they do it is by commissioning - choosing
and buying - services for their population.
They can commission services from a range of different organisations including hospitals,
community health services, and the private and voluntary sectors. All of these have to
be registered with the health care regulators, the Care Quality Commission and Monitor.
So in CCGs we've got people who are largely medical professionals, who may have had some
experience of commissioning, but they need quite a lot of support to fulfil this role.
There's two different bodies that support them.
The first one is commissioning support units. There's about 20 of these; they're set up
to provide technical support to CCGs. They crunch data, they can do contract negotiations
and some technical contract management. They are there as a resource for CCGs to draw on
if they want to.
Another body that provides support is clinical senates. When Lansley issued his vision to
give all the money to GPs, there was an outcry in various areas, including from hospital
doctors saying, "Actually, the complexity of some of our patients is far beyond the
knowledge of GPs, so it's going to be difficult for them to commission services they don't
really understand".
So, the idea of clinical senates is to bring together a whole range of medical professions
to offer advice to CCGs on particular patient groups or conditions. For example, if you're
a CCG trying to commission services for people with heart disease, you might want to get
the view of a cardiologist, well you can go to a clinical senate for that. They are there
to offer advice; CCGs don't have to listen to it.
So we've got this collection of around 200 CCGs in England, commissioning services locally.
But, the NHS is a national system, and is really high in the minds of the electorate,
so there needs to be something that looks at the system from a wider perspective.
So we've got an organisation called NHS England, it was originally conceived as a "small and
lithe organisation". If anyone's got problems sleeping, I'd recommend that, rather than
counting sheep, they list off all the activities that this "small and lithe organisation" is
going to undertake. You'll find that it stretches to a number of pages.
What's NHS England there to do? It's there to do specialist commissioning, so it buys
services for conditions that affect relatively small number of people. To make sure there
is access across the country to these services, it makes sense to commission them regionally
or nationally.
NHS England also commissions GP services. CCGs don't do this because that would mean
commissioning services from themselves, which would make for some interesting contract negotiations
- although they do have some responsibility for improving the quality of primary care
There's more than 4,000 people who are employed by NHS England, Some of them are at a central
office in Leeds and we've got four regional offices too, as well as around 25 area teams
who are playing the NHS England role at a local level.
So, the original plan was to have a devolved system, but a lot of power will actually be
held centrally by NHS England. Another part of the vision was that politicians should
be less able to interfere in the day-to-day running of the NHS. The law's changed to give
the Secretary of State a lot less power to get involved, although most people are quite
cynical about how much this will happen.
Let's get back to the likes of you and I, going to the polls back in 2010. We had a
number of choices on offer to us, one of which was not the coalition government we ended
up with. Like all coalition policy, current health policy is a compromise between parties.
And there's some interesting things when you look at this policy. One is the influence
of the Liberal Democrats.
We know that the Liberal Democrats are really interested in localism and local democracy.
If Lansley saw GPs as a way of understanding what people need, the Liberal Democrats see
local government as their way in.
Public health, or how we keep the public healthy, has long been the territory of the NHS, with
things like healthy eating and smoking cessation campaigns. What the health reforms have done
is move public health and their budgets over to local government and another new national
body, Public Health England.
Another role that local governments have got is to establish health and wellbeing boards.
These bring together key players in the health and social care system including local councillors
to improve care in a joined-up way across health, social care and other public services.
They'll be talking to CCGs and, really crucially, to their electorate.
We shouldn't forget Healthwatch, which will exist at a national and local level where
it's the responsibility of local government to set it up. It's there to represent the
views of patients and for people to engage in how services are planned. In reality, that's
quite difficult and previous attempts to do this by the NHS haven't been successful.
There are loads of organisations that we haven't even mentioned yet that also have an important
role to play in this health and social care system. What we've got in front of us is a
picture of considerable complexity, and whether you're a health professional working in this
structure, or a patient trying to navigate your way through, it can be quite challenging.