Professor Alan Maynard sees covert entrepreneurialism emerging and wonders about the opportunity costs of Mr Lansley’s liberation

Despite the efforts of the Department of Health and strategic health authorities, it is possible that the Lansley reforms will create a nice element of chaos in the NHS. Out of chaos comes opportunity for swift local deals to rationalise capacity and work practices.

The performance of SHAs and PCTs is remarkably variable. SHAs vary from the invisible to the high -profile - e.g. Mike Farrar in the North West SHA introduced PROMs before the slow, old Department of Health hitched itself to this bandwagon in its usual lethargic way, and he has also introduced the US Medicare Premier programme in an effort to get clinicians across the patch to adhere to evidence-based guidelines.

The other nine SHAs, reflecting the styles and skills of their chief executives and their teams vary from the quietly efficient to the apparently vacuous. They are all losing staff, but they all still have important roles to play in the periods before they fall on their swords in 2012. They have to keep folk in budget; ensure they do not kill and maim too many patients publicly; and drive forward a long-needed innovation regime.

’Managers are inevitably incentivised by this hasty and ill-organised staff cutting to quit early rather than late ‘

PCTs also exhibit great variability and they too are losing staff due to the attractions of early pensions and early redundancy when new job in GP consortia and hospitals are few.

Managers are inevitably incentivised by this hasty and ill-organised staff cutting to quit early rather than late. Why stick around and go down with the ship in 2012, when the nineteenth hole of the golf course is there now and offers the bliss of watching rather than participating in the death of organisations for which you have loyally worked for years?

The nice issue in this haemorrhaging of staff is the fate of all those excellent managers in SHAs and PCTs who do not want to quit. Some of the most able, it is rumoured, are getting jobs in hospitals. Is this true? Where is the data?

If it is true, we will have the nice 1991 effect all over again i.e. the reinforcement of the comparative skills advantage being in the provider rather than the commissioner. As this happens, government is trying to improve commissioning. Another own goal, comrades?

While SHAs and PCTs are being savaged, what is happening down “sleepy provider-ville” as it emerges from the Blair-Brown largesse? Are there any signs of them do daring things?

The new NHS entrepreneurs
The sparky amongst these guys (male and female!) are beginning to realise this is the time to cut deals and implement changes previously inhibited by SHA and PCT bureaucracy.

For instance: with community services largely being vertically integrated with provider trusts, deals have to be done with nascent GP commissioners. Both parties are realising that the PCTs are becoming rather comatose, and unlikely to interfere with bargains which previous they would have put out to tender and wittered about for decades!

By keeping under the radar of “public consultations” and the efforts of the Co-operation and Competition Panel to avoid evil alliances which concentrate power and improve patient services, some nice and nasty deals may emerge.
Is government, explicitly or implicitly, turning a blind eye to all this “entrepreneurialism”? With SHA monitoring disappearing, how can it possibly keep up with all this “churning” to determine whether it is to the advantage or disadvantage of taxpayers and patients?

Does it care? Or is this part of “local autonomy”?

Opportunity cost of liberation
If we lived in a democracy and had an efficient system of government in the land, we might expect quarterly audit of the costs of these reforms and an estimate of their benefit. As it is, the system races on - with the many NHS entrepreneurs having fun and an absence of data about how much the reforms will cost (two billion pounds?) and what if any benefits are accruing to patients and taxpayers.

This is very reminiscent of Mao Tse-Tung’s Cultural Revolution in China, when a “thousand flowers” of revolution bloomed: the chaos it created led to Mao’s “gang of four” accomplices disappearing in an “air accident”!

Hopefully the Con-Dem Coalition version of Mao’s revolutionary ardour will not lead to the elimination of “comrades”; but will have some demonstrable benefits to a system of healthcare in need of speedy and systematic reform.