I don't want to be unkind to whoever wrote the DH's PCT cluster implementation guidance.

Or at least, not more unkind than is strictly necessary.

They did not write this dog of a policy; they are merely having to try to operationalise it.

So I shall tread gently(ish) in my interventions on this plan, which brings to mind NHS Supreme Soviet Chair Sir David Nicholson's comments to the NHS Confederation conference a few years back, about how managers "huddled together for warmth and swapped stories about clinicians".

Below are some key extracts, and a few thoughts: Health Policy Insight readers likely to be affected should of course read the whole thing. And then probably get legal advice. And then send me an email to editorial AT healthpolicyinsight.com

Extracts from PCT cluster implementation guidance
(Comments in bold)

"The creation of clusters is intended to:
- Sustain management capacity, and a clear line of accountability, providing greater security for the delivery of current PCT functions in terms of statutory duties, quality, finance, performance, QIPP and NHS Constitution requirements through to March 2013;
- Provide space for developing GP Commissioning Consortia to operate effectively;
- Provide a basis for the development of commissioning support arrangements, allowing current commissioners and new entrants to develop a range of commissioning support solutions from which consortia and the NHS Commissioning Board can secure expert support;
- Similarly, provide space for new arrangements with Local Authorities, and particularly Health and Wellbeing Boards to develop;
- Provide a mechanism to enable high quality NHS staff to move to new roles in consortia, commissioning support arrangements and the NHS Commissioning Board, including minimising unnecessary redundancy costs;
- Support the provider reform element of the transition particularly in terms of ensuring progress with the FT pipeline through commissioning plans".

"Sensible clusters of PCTs exist which have the following features:
- A single Chief Executive, accountable for quality, finance, performance, QIPP and the development of commissioning functions across the whole of the cluster area;
- Supported by a single executive team for the cluster. This must include a Director of Finance to ensure effective financial management, a director with responsibility for the full range of commissioning development and medical and nurse directors to ensure clinical engagement and leadership. From these and any other cluster director posts, there should be clarity about personal leadership for in year performance and medium term QIPP delivery, service quality and safety, communications, and informatics. Local Directors of Public Health will not be consolidated at cluster level, in order to support the transfer of this function to upper tier local authorities. Further detail of the transitional processes associated with creating the new Public Health landscape will be published separately;
- Be sustainable until the proposed abolition of PCTs at the end of March 2013"

So these are really significant tasks - maintaining the all-important financial and service delivery grip working at three times any previously-accustomed scale, while also creating the new system and finding which staff should stay and which go.

Okay. What a great time for manager-bashing to be near the top of the political agenda. That will motivate these people nicely.

"SHAs will ensure that there is a transparent and appropriate appointment process for cluster Chief Executives and executive teams. There will be national oversight of this process."

If you've annoyed your SHA leaders or Sir David Nicholson, then put your head between your legs and kiss your arse goodbye.

"Current information received from SHAs suggests there will be around 50 clusters nationally."

"SHAs will ensure that clusters are able, at the earliest opportunity, to be involved in and take on responsibility for integrated plans for 2011/12, QIPP plan implementation, consortia development and support and commissioning issues associated with the FT pipeline.

"Critically, SHAs will also ensure that clusters are able to take on the requirements for securing quality through change that will be set shortly by the National Quality Board and for promoting the Equality Delivery System as developed by the National Equality and Diversity Council. SHAs and clusters should also ensure that all statutory duties, including for example safeguarding, equality and diversity and information governance, are handled clearly, explicitly and effectively through the new arrangements. This includes paying due regard to the provisions of the Equality Act 2010, which aims to ensure that all public bodies within the health service comply with principles of equality."

SHAs. Not gone yet, and certainly not to be forgotten. Fear us (for now).

"Following appointment, the cluster Chief Executive will be confirmed as the Accountable Officer for each of the constituent PCTs by the Boards concerned. He or she will be expected to exercise the full range of responsibilities associated with being the Accountable Officer.

"Whilst allocations, and accounts will remain at PCT level, with critical roles for the individual PCT Boards, the managerial processes for monitoring and holding to account will be exercised through the cluster Chief Executive.

"Boards will retain their full range of statutory accountabilities and will have a clear agreement, adopted by the Board, of which of those are being exercised through the cluster arrangements, and which are being retained at PCT level.

We can't abolish boards as that would take valuable legislative time. Stay on for ornamental purposes - or to be sacked when money goes wrong.

"Through to 31st March 2012 these clear lines of accountability will be exercised by SHAs through clusters. For 2012/13 it will be exercised by the NHS Commissioning Board through clusters."

"Where established cluster arrangements and substantive appointments already exist in parts of the country, appointments will not be revisited as part of this national process, unless the SHA, in agreement with the NHS Chief Executive, deems that further change is required."

And what is to happen to PCT CEs? Well, the document makes it clear that they can apply to the cluster CE job, and then to cluster director jobs. Thereafter, “It is not the intention of this process to cause the redundancy of current PCT Chief Executives and Directors above and beyond what may be required to achieve running costs reductions … Alternative work could include senior roles in GP Commissioning Consortia (subject to their agreement), development of Commissioning Support, support to the development of the NHS Commissioning Board or oversight of key quality and statutory responsibilities".

"The appointment of cluster Chief Executives needs particularly careful handling where jointly appointed PCT Chief Executives / Local Authority Directors exist. Again we do not intend that either the appointment or non-appointment of such a person to a cluster Chief Executive position should automatically lead to the dismantling of effective joint PCT/LA appointments prior to 2013. The SHA, cluster, PCT and Local Authority should work together to identify how best to sustain joint working arrangements, and the development of new joint working structures, including, as appropriate, the retention of such jointly appointed posts. Equivalent considerations should be given to joint appointments at PCT Director Level."

Don't. Get. This. Dragged. Into. An. Employment. Tribunal.

"Cluster arrangements are temporary and clusters are not statutory organisations in their own right. It is envisaged, therefore, that Directors will continue to be employed by their current organisation."

"Once the functions and posts in the single executive team have been identified and the consultation commences, all affected CEs and Directors should be declared “at risk” and they will form part of the pooling arrangements described in this guidance."

"it is important to set out the context in which all leaders are expected to work to support SHA and PCT staff in the change processes which lead up to their abolitions in 2012 and 2013 respectively.

"One of the purposes of clusters is to offer a bridging structure to allow the change to be managed more effectively. Clusters will:
- Be actively supporting the development of GP Commissioning Consortia. This will include developing appropriate staff, those whose functions will move from PCTs to GP Consortia, eventually under TUPE provisions, so that they can best meet Consortia’s future requirements;. Whilst staff cannot be directly employed by consortia until they are authorised and become statutory bodies, consortia may choose to have certain staff assigned to them to help and support them during the transition;
- Be directly charged with sustaining commissioning expertise through the transition and enabling it to be formed into effective commissioning support arrangements from which consortia can choose. This is likely to include the creation of social enterprises and joint ventures with the independent and voluntary sector. Again this will enable clusters to support appropriate staff in developing opportunities with these new bodies;
- Be working with the emerging NHS Commissioning Board on how it might structure its local interfaces for primary care commissioning, oversight and support of GP Commissioning and regional and national specialist commissioning. Whilst it is not yet possible to be precise about what form these will take it provides a further opportunity for clusters to support existing staff in potential moves to the new landscape."

The third point above is your opportunity to rebuild the intermediate tier in a way SOS Lansley will not notice.

"The role of the statutory boards of PCTs remains key. In making the change to cluster executive teams the right balance needs to be struck to retaining the statutory roles, challenge and oversight from individual boards with having streamlined arrangements that enable effective executive action."

And in being sacked when the money goes wrong.

"Whilst there has already been significant local change in many parts of the country on the function and composition of PECs, and this will continue, the creation of clusters should not lead to the unnecessary loss of local structures for clinical engagement and leadership."

Keep having token meetings, but no biscuits.