Congratulations to Mark Britnell of KPMG, who in the best tradition of all things world-class, has now gone global. He is to be the management consultancy's Global Head of Healthcare, and oversee the company's global healthcare strategy.

This will include setting up three regional centres of excellence Americas, Europe and Asia and the South Pacific. KPMG also plans to appoint up to 15 new partners in the next year to join its growing global health team.

The press release quotes Mark as saying, “Our new global strategy reflects the fact that healthcare systems around the world are facing similar challenges – offering better quality of services at lower costs. We are convinced that healthcare systems around the world can rise to the challenge by sharing new and innovative approaches. By aligning our services and propositions globally we will be better able to help our clients in that task”.

All good stuff. Time will tell whether anyone in an NHS of 45% lower management costs will be able to afford the KPMG offer. The new NAO report on consultancy use by government departments showed DH spending £108 million in 2009-10 - a £97 million reduction on 2008-9. In a straight lift from the litany of Things That Are Not Surprising, the report's top-line conclusion is that "government is not getting value for money from its use of consultants because it often lacks the information, skills and strategies to manage them effectively".

The Macbeth Alliance
One maxim for NHS Alliance's response to the White Paper could be Macbeth's lines, "If it were done when 'tis done, 'twere well it were done quickly". Another would be thinking on a late M. Lautrec - 'no time Toulouse'.

The NHS Alliance (COI dec - I have done paid work for them in the past) is a long-standing suoporter of clinically-led commissioning, and tis relatively unambiguous support is unsurprising. Their response argues that "GP practices and PCTs should start working together immediately to accelerate the pace and implement the changes sooner rather than later. This will not only minimise the risk of valuable NHS staff going elsewhere, but it will also allow those who are ahead of the game to become fully-fledged GP Commissioning Consortia (GPCC)".

“In some parts of the country putative GPCC will be ready to assume responsibility for commissioning now and in the very near future; ... others will require more development support and time to be in that position. The NHS Alliance believes that there should be sufficient flexibility within the proposed timetable to accommodate both the fast movers and those who require a more considered timescale”.

Twin-track, then - and Alliance CE Michael Sobanja warned, "concerns around the details of implementation and timescale need to be carefully considered. The pace of change may be daunting but we must ensure we get it right. For that to happen, flexibility and a focus on culture, behaviour and outcomes, at all levels in the system, will be paramount”. Elsewhere, the document calls for "a flexible and negotiated organisational development programme, not inflexible nationally prescribed change management for its own sake".

Their response on the relationship between the National Commissioning Board and GP commissioning consortia suggests, probably more in hope than expectation, that "propose that the Board is formally constituted to include both non-executive members and members drawn from GPCC themselves. There may also be a case for introducing, with minimum bureaucracy, a lean 'NHS Trustees' organisation which overseas the NHSCB and holds it to account". Intuitively, one would think that this is startlingly unlikely to happen, but you never can tell.

Alliance also call for "a statutory duty on both GPCC and local authorities (LAs) to collaborate, but also that there should be specific mechanisms for GPCCs to be involved in the development of local “public health action plans” and agree them formally, with a right of reference to a third party should it prove impossible to reach local agreement. This arbitration role should not be exercised by the NHSCB alone. Similarly, LAs should have a reciprocal role in the agreement of local commissioning plans, which, once agreed should be binding".

The document is outspoken on the cause behind the failure to achieve the oft-stated intention of moving services out of acutes and into the community where safe: commissioners failed to achieve this because "the system has conspired against them by the over-protection of providers, particularly in secondary care, from the consequences of robust commissioning undertaken on behalf of local communities".

It also notes, "System redesign will be painful to implement, particularly when coupled with a more constrained economic environment".

Also unsurprising is Alliance's call for the Board to "delegate the power to hold providers to account, but retain the responsibility for contractual performance ... GPCCs should be collectives in the true sense of the word, and not used as local enforcers".

On the role for CQC and Monitor, the document hopes for "regulation to be “light touch” and not replace local decision-making with national regulation. The regulators therefore will require the input of GPCC to inform their activities and the standards they set for providers. For instance, it should be for GPCC to set affordable standards locally, and not have artificially imposed standards set by CQC.

"This could be achieved in part by both regulators being required to establish commissioning stakeholder boards which would be the key means by which they would be required to reflect commissioning priorities and needs".

DH RTT figures show small increase in waits
It is early days indeed to see the impact of the abolition of central performance management of waiting time targets, but the DH is to be commended warmly for continuing to publish the RTT data.

The figures for August 2010 show a small median increase to 4.4 weeks media wait for non-admitted patients (the figure was 4.3 in July 2010). They also reveal a minor fall in the non-admitted number treated within 18 weeks to 989.0% (98.1% July 2010). The biggest increase is in incomplete patients, which rises to a 6.2 week median wait (up from 5.8 weeks in July 2010).

These are all small, mostly close to margins of measurement error or random scatter. But trends have to start somewhere.