The Health and Social Care Bill is a weighty tome. Despite strong opposition from the major health unions and MPs, it looks like a journey has begun make the NHS a radically different organisation. I hope it will lead to a better quality of care, more choice and improved outcomes for patients. I also hope that it doesn't lead to confusion, poorer services, the return of unacceptable waiting times and a greater disparity of health and care services in different parts of the country.
However, I have everything crossed when I say that – the commissioning process will be subject to competition law. The organisation which can write the slickest bid may not necessarily be the one that can deliver the best care. Carrying out a successful procurement process may not be a skill possessed by some of our best NHS organisations, so let's hope that part of the process tests their ability to deliver.
Andrew Lansley, the Health Secretary, has emphasised that the contracts will be won on quality, but there is no doubt that with the need to cut costs, price will also play a major part in decision making. An even more "unlevel" playing field emerges.
The landscape will inevitably change the NHS we know. The GP as our advocate and the specialist consultant working in the familiar surroundings of a well known hospital will be a service of the past.
Both relationships and surroundings will change and do so at a pace that will leave some patients and clients confused and disorientated.
So what can we expect from the legislation? Up to 500 GP commissioning consortia, but more likely between 250 and 300 will replace 151 existing primary care trusts (PCTs), the abolition of Strategic Health Authorities, all trusts to become foundation trusts, national tariffs to be set in some instances as maximums and the independent regulator Monitor to be first and foremost a promoter of competition.
An NHS Commissioning Board (the hub) will be created with, perhaps, local "spokes". I have no doubt that the health authorities will morph into these structures. The powers of this board negate the promise of autonomy for consortia as the Bill spells out the authority it will have to set standards, direct activity, and where necessary, fire accountable officers, abolish consortia and even to bail them out!
Despite all of this, the Bill lacks detail on the governance for the Board and the membership (no patient requirement for example), so the maxim "no decisions about me without me" was obviously used for marketing purposes only. A light touch from the government will not be the relationship described in the Bill.
To make all of this happen, and ensure that there is a minimum of confusion and disorientation, skilled and talented managers will be needed to manage the changes and devise and implement new systems that will guarantee patients are kept safe and that there is a high quality of care for all. A good manager understands the complexities within an organisation like the NHS and knows its greatest asset are the staff who work there. A good manager places a high value on maximising the potential of staff so they can deliver a good service.
However, the number 45 has not gone away when indicating the percentage of managers (bureaucracy) that will leave the service with 48,000 the average cost in redundancy packages for each person who loses their jobs in the process. The cost is no small matter either: 1.2bn. to implement the reforms in the next two years.
We need, therefore, to answer the core question – who manages and will manage the health service? Surely it's the good manager who helps the good clinician to provide better care for patients. Now is the time to redefine "manager" and bury, once and for all, the myths that perpetuate and still damage relationships between the professions.
The good manager, who may also be a clinician, will establish and maintain good working relationships with colleagues across the organisation, ensuring they understand the systems, procedures, capacities and capabilities of the organisation.
The good manager will fill the gaps that may occur: review systems with colleagues, making them better where necessary, and form consensus for changes that need to take place. They will apply the theory to practice and, most importantly, learn from those reflections in order to improve the way they work. Simply put: what have I learnt? Am I doing it right? Now what?
The cogs, however, are beginning to turn. Speaking with practice managers, they tell me that already there is pressure from their local PCTs to identify staff who will transfer into the new structure and support the commissioning process. I repeat that word – pressure. But this is also an indication of how important managers are both currently and in the future.
As the health commentator, Roy Lilley has said: "Great actors attribute their success to a great script, managers in the health and care sectors write the script that enables clinicians to do the job for which they are trained."