Today's announcement about the future of the Vanguards is probably a defining moment in the history of the NHS. The days of the all singing, all dancing, stand-alone district general hospital are over. The full details are here.
Destined for the misty-eyed history of the NHS, along with Dr Findlay's Case Book, the DGH will give way to a new beginning.
Quite frankly, the model we've got is knackered. It's over. With a third of Trusts that have no one, permanent, to run them, two thirds in debt and all of them beleaguered by impossible regulatory demands, the game is up. But for a few, austerity, complexity and regulation has crushed them.
Thirteen Vanguards have been selected to morph into groups or chains or whatever you want to call them.
The rest will be 'franchising' their specialist expertise and running departments in hospitals elsewhere; accountable clinical networks.
I think we need to take a pace back, a cuppa-builders and have a bit of a think. I see there are three layers to this story.
First...
If we can't run the hospitals we've got, what makes us think we can run groups of them? Marking out the Trusts that are successful (increasingly difficult to do), the common theme is they have a chief executive who has been in post for a long time. Bosses that are marinated in their tasks and entrenched in their organisations.
Is running a hospital a skill that means you can run two? You'd have to say no. It is the intimacy of leadership, entwined with the organisation, the attention to detail that creates success.
If Trusts are to be become branches, run by a branch manager, we still need to find the talented branch managers. If the branch managers are to be overseen by a super boss, we have to find the super bosses.
My guess is, successful Trust bosses will be reluctant to leave the ranch to go out mending someone else's fences. And, 'out' they will have to go. This is not a time for a boss with a big desk to think it can be accomplished with a bigger desk.
Flattery, hubris, a misplaced belief they can be in two places at once, may drive an optimistic few but it is a huge risk to stability and careers. Failure is but a drive down the motorway.
Franchising success, devolving blue prints of care to be used elsewhere? It is closer to being doable. Clinicians are collegiate and in recent years, many have lost the knack.
Second...
As these innovations take hold, the window of choice will narrow and the door to competition will close. The law precludes that either is the case. The reassurance Monitor is in joint venture with the Carbuncle, to deliver these transformational models, cuts no ice. The law is the law and the plans open to costly challenge.
There will be nothing for commissioners to commission. They are the fastest ever to achieve management dinosaur status. Born in 2012, extinct by 2015. The money flows will evolve into population based, capitated budgets; the CCGs redundant.
The CQC is deteriorating in its task, its dysfunctional Board in chaos; measured by its own metrics, it is a failing organisation. It can't do what it sets out to do now. It will never cope with a service in one place, run by an organisation in another place and bossed by a person someplace else.
Third...
This Vanguard experiment will bring chaos, disruption, commotion and risk. They will create challenge; bring out the daredevils and the show-offs. They will overturn the law, guidance and common practice and d'ya know what?
...I couldn't be more pleased.
We have to scrape Andrew Lansley off our boots, walk a new path and be daring. Creative disruption; throw the whole lot in the air.
Our options are; manage the decline of the NHS, or circle the waggons... collect-up the best and show the rest what it looks like and how to do it.
We can chose between the bravado of pretending that fiddling with a broken system will fix it or the bravery of actually fixing it.
Have a good weekend.
