So, that Total Defence plan. Not long after blogging about the weird way becoming an NHS Foundation Trust member is mostly about the staff discounts, my Google Alert tail-warning receiver lit up. Specifically, it caught the fact that the Haringey Clinical Commissioning Group was going to have a public meeting, so off I went with a little notebook of talking points.
My first impression (as I was on time) was the usual depressing one - they're all 117 years old, there's four of them, and Christ, they're odd, and one of them's reading something called God's Word Made Plain. Why did I volunteer again? But the room filled up, and then filled up some more, and eventually we counted up 53 MOPs who turned out.
The original agenda was all about "how the CCG can communicate with the public", but when it got communicating, the message from the public was that the public wanted no part of that. It turned out that the local "Patients Panel" hadn't met for years. An effort was made to explain the new NHS structure, and at this point, astonishment and disbelief set in as the CCG vice chair and the (existing) NHS finance director tried to draw the organisation on a flipchart. (It reminded me of the enchanted PowerPoint presentation in one of Charlie Stross's novels.) So, GPs were meant to commission everything, and the PCT and SHA had been shut down, with 54% cuts imposed on their staff, but to keep the wheels turning, they were reorganising as a cluster in the meantime. Then, the GPs would take over, but the GPs themselves couldn't be in a position to commission their own work, so they would be commissioned nationally, while some other services would be carved out of local commissioning.
One of the CCG doctors said of the re-org that "in terms of human pain it's quite remarkable - managers are people too, you know". Before the CCG took over, it would be allowed to have a "shadow budget" but no actual money, because it didn't have an accountable finance function. And before it did, everyone would be sacked again. The national commissioning board would replace the SHAs, but would have four or possibly more regional branches that might be quite a lot like them.
The questions kept coming and eventually they abandoned the agenda in favour of just standing there fielding. It turned out that there was a 93 page national test that the CCG would have to apply, but nobody had seen a copy and nobody was clear about who set the test or how. There was a Joint Strategic Needs Assessment, carried out by the cluster and the local authority, but how that fed into this process was a mystery.
On the question of specialist services that would be carved-out of local commissioning and reserved to the national level, the chair had to be told that it wasn't right and it wasn't OK to say that "normal people" wouldn't need to know about it because a lot of them are psychiatric in nature. It turned out that they represent 40% of the budget. The service-user activists got angry. As well as a Health and Wellbeing Board, whose makeup a Lib Dem councillor told me was still being debated, there is a Mental Health & Wellbeing Board, but the GPs have yet to deign to meet them because after all they're only nutters (I paraphrase, but not much).
It turned out that the NHS organisations being butchered have a variety of huge databases of information vital to the commissioning process. Nobody seems to know what will happen to this.
The specialist/local interface seems to be enormously crucial, and a completely undemarcated frontier. The GPs are hugely keen on "continuous follow-up", but it's far from obvious why anyone would want follow-up by someone who has no specialist knowledge of their condition.
The FD confirmed the following figures in my talking points: the Government has budgeted £25 per head per year for the CCGs and the Commissioning Support Organisations. Of this, the NHS North Central London cluster says it can do the CSO job for £15/head/year, which leaves £10*225 kilocitizens in Haringey or £2.25m a year in funds flowing to the CCG as such. The CCG plans to have CSO staff co-located with it, and in fact to rely on the CSO for pretty much all its day-to-day functions.
Apparently the Government arrived at the figure of £25 by halving the existing Londonwide figure and dividing by the population.
Anyway, my take-home points: CSOs are crucial (although we knew that). Status of staff - are they civil servants? Who has responsibility for the public money flowing through them? What happens to this database? Further, the frontier problem between central and local is important. And I've got to get on to some of these assorted boards.
I was really pleased by the turnout, and the degree to which the crowd were intelligently angry. A surprising number of people had evidently taken the time to brief themselves in advance.