Sunday, February 20, 2011

The scale of the challenge

Over the last couple of weeks I've been blogging in detail about the strategic approach and achievements of the Equality and Diversity programme at NHS North West. I covered the theory, the underlying research, the tools and approaches we developed, and the 'EPIT' performance measurement tool which has allowed us to objectively measure the outcomes which our system of 63 NHS organisations were achieving. I also introduced our work to formalise leadership competence in this field and the importance of a communications strategy.

Yesterday, I discussed the reasons why equality and diversity work is so important within the NHS -- not simply for legal compliance.

Now, as promised, I am going to move on to talk about the approach we are taking to embed some of this into the completely new commissioning and oversight structure that is already starting to take shape.

Who stays, who goes, who comes?


The change that lies ahead for the NHS is the biggest that it has ever undergone since it was established in 1948.

Unlike any previous change we also don't have a complete roadmap as we embark on it.

The White Paper: Equity and excellence: Liberating the NHS, published on 12th July 2010, provided an outline of the biggest changes. However, it also raised as many questions as it answered.

Extra details emerge from time to time. Some of the original proposals have already changed. And, overall, the Minister (Andrew Lansley) has signalled that he wants the emergent organisations, such as GP Commissioning Consortia and local Health and Wellbeing boards, to work out crucial details for themselves.

The big picture for the purposes of this discussion is about the commissioning side of the NHS. I'm not ignoring that there are big changes too for the providers. However - for the moment at least - provider trusts (which run general and specialist hospitals, mental health services and ambulances) will still be there.

The same can't be said for the organisations who manage the present system:

  • The ten regional Strategic Health Authorities (SHAs) which oversee and performance manage the NHS system in England are due to be abolished in April 2012 - barely a year from now. Some of the functions we carry out will be absorbed back to the centre (the Department of Health) for the time being and then transferred to the new NHS Commissioning Board (NHSCB). Other functions will be migrated to a new layer of distributed management called "PCT Clusters". Think of PCT Clusters as mini SHAs. There will be 50 of them in England overall, through which the Department of Health and the NHS Commissioning Board will manage the system when we are gone.
  • The 152 local Primary Care Trusts (PCTs) which currently manage commissioning, prioritisation and a raft of detailed activities will also be abolished by April 2013 (though this date may slip). The core commissioning function of the PCTs will be replaced by a much larger number of organisations called GP Commissioning Consortia (GPCCs). The name is actually a bit misleading, as we'll discuss in future -- I prefer to think of GPCCs as rebooted PCTs, carrying out many of the same functions as before, but with a wholly different structure, ethos and accountability.

There is a lot that can be said about all these changes; however I don't want to get distracted. The important thing from the perspective of this discussion is that Equality and Diversity within commissioning currently sits in PCTs - which are going - and it is overseen and performance managed by SHAs - which are also going.

No small task

If an understanding and responsibility for Equality, Diversity and Human Rights is to continue on the commissioning side of the NHS system, we therefore have to build it all over again in the new structures as they emerge. I.e. We need to embed E&D into:

  • A vast number of GP Commissioning Consortia - the final number is expected to be around 500 consortia, replacing 152 PCTs.
  • Approximately Fifty new PCT Clusters, replacing the 10 SHAs
  • Several hundred Health and Wellbeing Boards, set up by individual local authorities or clusters of them. I estimate about 250-400 of these.
  • An equivalent number of local Health Watch organisations, reborn from existing Local Involvement Networks (LINks)
  • The NHS Commissioning Board itself and
  • The Care Quality Commission (CQC), which will be the quality regulator for the new system and the home of the national Health Watch organisation

The local challenge puts this into even clearer perspective.

David, meet goliath

The NHS North West Equality, Diversity and Human Rights team consists of just five staff -- three managers, a PA and an information and policy officer who maintains our HELP database.

There is the Associate Director of Equality, Diversity and Human Rights, Shahnaz Ali; there is an Assistant Director who manages all our communications and outreach activity, including the newsletters and our consultation work; and there is myself as the team's programme manager.

The communications manager and myself both work only 3 days a week. We are a tiny team, currently managing to oversee stable operations in 24 PCTs and 39 provider organisations.

The challenge ahead of us, before the lights go out next year, is to influence the formation of all the new GP Commissioning Consortia in our region, plus the PCT Cluster which will carry the responsibility for E&D for the 5-6 Clusters that replace us.

So far, in the North West, a total of 19 "Pathfinder Consortia" have been announced, covering about half of the population. We expect that, overall, there will eventually be about 40-50 to replace the 24 PCTs.

No prospect for top down control

A glance at these overwhelming numbers makes clear that there is no prospect for our tiny team of 3 managers to influence how Equality, Diversity and Human Rights gets embedded into 40-50 new organisations, all of which are on a mission to be lean and mean, and are at risk of assuming that E&D is a compliance issue they can tackle later.

Besides, some of these organisations won't be in any position to be approached about this aspect of their responsibilities until later this year. We have just months to achieve any effect we can have.

We also need to ensure somehow that the building and influencing work goes on after we've ceased to have any statutory power and have been disbanded.

David Nicholson, who chairs the Department of Health's Equality and Diversity Council (EDC) and is the Chief Executive of the new NHS Commissioning Board, has committed to providing one important lever - by saying that participation in the new Equality Delivery System will be a mandatory registration requirement for all GP Consortia in the new system.

There are no equivalent levers for ensuring how E&D is integrated into Health and Wellbeing boards though. And it's one thing to commit to being measured on E&D outcomes at some future date, but that doesn't guarantee the new organisations have any kind of strategy for how to achieve those outcomes.

Working smarter, not harder

In the next post I will explain the approach which the North West is taking.

It's an approach which is designed to help distribute the challenge and to preserve as much best practice as possible into the new structures. We've dubbed it, "Building the future, maintaining the best"

Like many of the things we do, it's an innovative way of addressing the big challenges we all face. We don't know whether others will follow suit. They are almost certainly facing the same challenges though.

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