The NHS, probably rightly, is one of the main controversies in current British, or rather English, politics. The Coalition government has put it there after Labour, by dint of a massive increase in spending, had managed to take most of the heat out of the debate, bar a few controversial hospital closures. Personally I am a bit perplexed. From one side I am being constantly lobbied by the Social Liberal Forum, a Lib Dem pressure group, to express disapproval of what looks like almost the entire reform process. On the other side is 18 years experience as a business services manager, reinforced by my regular reading of the Health Service Journal (HSJ), the weekly magazine aimed at NHS managers. This takes the need for reform pretty much as read, almost on a continuous basis – and gives me an inbuilt suspicion of people who resist change. Partly because I have been trying to get a management job there, I am better informed than most on the NHS; but I have found it very difficult to make up my mind. Will writing a blog post help me?
First, let’s understand that there is something of a crisis in the NHS. The figure of £20 billion of savings required by 2015 is widely accepted as a fact. This is quite interesting. The figure first emerged a couple of years ago from a leaked McKinsey report, which the government tried to deny. But it is a now central theme of NHS Chief Executive Sir David Nicholson’s management. But the NHS’s budget isn’t being cut: the Coalition is protecting it in real terms. In response we get some rather airy stuff about the increased demands on the NHS from an ageing population, medical inflation and suchlike. But if we are cutting £20bn, we must be adding the same sum back somewhere – but we aren’t being told where. I have a dark suspicion that a lot of it is about large PFI rents coming back to haunt us from all the capital investment of the last decade, though I’m not sure if that quite adds up either. I find it strange that so little is being said about this. It has the signs of a manufactured crisis to inject a sense of urgency across the organisation.
If so, then I don’t particularly disapprove. There is a massive inertia about the organisation, with almost any change proposal meeting outraged resistance. When I reflect on my career as a manager in the private sector, we were in an almost continuous state of crisis. As a result we pushed through change after change, so that after 18 years the business had been transformed out of recognition both in efficiency and business model. This was the result of simple competitive pressure. Such competitive pressure is largely absent from the NHS, so Sir David’s success in stoking up a comparable level of crisis is to be commended. It is clearly helping him deal with the resisters and rally supporters of change.
There seem to be two main challenges to the government’s reform strategy. First is along the lines of “we don’t need this” – it will disrupt the process of making the £20bn worth of savings. The second is that the reforms themselves are wrong, because they will “privatise” the NHS. The answer to the first depends to a great extent on how convinced you are that the previous government’s infrastructure was up to the job. This rested on three levels of organisation to commission services from a series of notionally independent providers, in turn answerable to various parts of the bureaucracy. It is easy to think that this was over-complicated, but the three levels (national, regional and district) have a resilience about them; the NHS seems to revert back to such a structure every time people try to cut a layer out. A more valid criticism is that the system is accountable only upwards, to the Secretary of State, meaning that managers spend too much time managing their chain of command, and not enough on the patients. Another criticism, which may follow from this, is the sheer volume of management blather that the system generated. Heaps of guidance, toolkits, methodologies, procedures, silly names, acronyms, and such. The commissioning framework was called “World Class Commissioning” and involved developing eleven competences, progress on which had to be reported up the system. This sort of thing is a charter for mediocre management. People who manufacture millions of words that somehow don’t get to the point. A particular worry is the lack of management with any clinical experience, and a failure to integrate clinicians into management generally.
To many this management structure was incapable of driving through the change needed, except in a few lucky pockets. The blather merchants would succeed in populating scorecards with green spots and burying their peers and seniors in verbiage, but be unable to deal effectively with entrenched resistance from clinicians, and politicians nervous about reactions to reconfigurations. To these critics it was essential to tear this structure up, while trying to salvage some of the best bits. I wasn’t so sure. I would have opted for keeping most of the infrastructure intact but bringing local political accountability into the picture, while trying to cut back on some of the thickets of blather.
But it’s too late now. Many managers have lost their jobs; many more face the prospect of their job disappearing an uncertain future. The damage has been done. Far reaching reform may not have been the best idea, but we must capitalise on the current fluid situation to create something that works better than the previous version. This may well slow down the march towards the £20bn savings in the short term – but maybe these savings aren’t quite as urgent as it suits many to claim.
But are the reforms going in the right direction? I’m nearly up to 1,000 words already. this is a topic for another day.