As David Cameron, Nick Clegg and Andrew Lansley strutted their stuff at Guy’s Hospital today, arguing that lots of detail had altered over their NHS plans but that the fundamentals remained the same, who quietly re-emerged as the most powerful man in the NHS?
Answer: Someone who wasn’t there – Sir David Nicholson, the NHS chief executive. Up until the “pause”, Sir David had been the most powerful since his appointment as chief executive designate of the commissioning board was forced on Andrew Lansley back in December in the first sign that the government was panicking about the health secretary’s NHS reforms.
Now that the pause is over, he is right back in the driving seat. It will be Sir David who decides how many of the newly named Clinical Commissioning Groups – GP consortiums as was – are ready to take over their budgets in April 2013. It will be Sir David who decides how fast the others are ready to do so. And despite all the talk of transferring power to front line clinicians, it will be Sir David who controls the great bulk of NHS spending in 2013.
The commissioning board will anyway control some £25bn to £30bn of NHS spending on more specialised services. And if only, say, half the commissioning groups are ready by 2013, at that point he will be controlling around £60bn of the budget - his own £30bn plus half the £60bn that was to be transferred to the renamed and redesigned GP consortiums from 2013.
So in 2013, Britain’s biggest unelected quango – the commissioning board – will be running perhaps £50bn to £60bn of NHS spending. Of course, over time as the commissioning groups mature, that should change. But it is unlikely to be precisely what the prime minister had in mind when he said today that under the coalition’s plans ”the bureaucrats will work for the doctors, rather than the doctor working for the bureaucrats”.