A wiser man than me noted that every NHS reorganisation over the last 20 years promised to decentralise power to the front line but actually resulted in more centralisation than existed before.  So, will the newly announced changes to NHS England and ICBs result in the same?

When the government explained its decision to scrap NHS England it said, “The changes will crucially also give more power and autonomy to local leaders and systems – instead of weighing them down in increasing mountains of red tape, they will be given the tools and trust they need to deliver health services for the local communities they serve with more freedom to tailor provision to meet local needs.”

It is a pretty stark promise of more local autonomy, but one that sets off alarm bells in those concerned that yet again this will result in even more centralised control.

The first articulator of this concern was, surprisingly, former Health Secretary of State Patricia Hewitt, who also announced that she was stepping down from her current role as ICB Chair for health reasons.  She said, in an interview with the HSJ, “The real problem is combining the abolition of NHSE with hugely increased micromanagement from the centre”, concluding “it’s one more tightening of the screw, I fear”.

In response a DHSC spokesperson said, “We aren’t going to replace micromanagement from NHSE with micromanagement from DHSC”, which is a pretty firm rebuttal, but not enough to reassure sceptics (like me).  Instead, these words need to translate into action.

It is into this context that the Advice and Guidance Operational Delivery Framework for ICBs has just been published.  This is of material interest to general practice, who at the same time have received their own Enhanced Service specification for advice and guidance.

Unsurprisingly, the framework does not give any of the promised freedom for local areas.  Instead, it provides a list of more than 20 indicators and over 70 minimum standards that ICBs need to achieve. These are not outcomes, but rather a huge list of process actions that are very specific, such as “complete clinically led audits quarterly at specialty level” and “agree and develop a peer learning programme to address identified learning needs”.

Not only is it disempowering, but it is hugely time consuming.  ICBs are “required to review the key indicator and related minimum standards and assess the level of implementation within their system for the quarter being completed”.  Just think of the work involved in trying to complete the template against the 70+ minimum standards every quarter.  All effort shifts from making advice and guidance actually work locally to complying with the demands of the centre and reporting upwards.

The document also contains what it terms “guiding principles of accountability”.  These state that general practice has responsibility to “reduce unwarranted variation in the use of Advice and Guidance”, and that GP Partners are accountable for this(!).  However, a quick cross check to the DES and there is no mention of “unwarranted variation”.  Indeed, there the focus is solely on when advice and guidance is actually being used, with zero on an expectation of overall usage.

As a result, many practices will end up being questioned about their rate of usage of advice and guidance, which is not included in any contract they have signed up to.  I doubt it would take much of this type of inappropriate pushing for many practices to turn their back on the DES altogether.

It could, of course, be totally different.  If the national teams had resisted the urge to micromanage, then local teams could have brought primary and secondary care clinicians together to have productive conversations that could move the whole process away from box ticking into one with an education focus to improve the service for local patients.  But, sadly, we are where we are.

This is material for general practice.  While practices can ultimately ignore their ICB and focus on delivering the contract they have signed up to, there is wider talk (including from new NHS CEO Jim Mackey) about integrating general practice into the NHS via local care organisations and the like.  Should this happen, while the current system remains, there would be no escaping the top down NHS pressure, and practices would undoubtedly face constant questions not just about their usage of advice and guidance but also about their access times, e-consultation rates, rate of A&E attendances etc etc.

The message for general practice must surely be that unless there is a demonstrable commitment to devolve decision-making (particularly about how to do things like advice and guidance) to local providers then the independent contractor status, and the protection it affords from this NHS madness, must remain sacrosanct.