Tag Archives: Sir David Nicholson

The NHS crisis: while politicians look the other way, what should we do?

The NHS is deep in a long term crisis. Last Thursday NHS England published a “call to action” outlining the emerging crisis. This attracted a day or so of news coverage, focusing mainly on a £30 billion funding gap. But there was no political debate, and the story quickly died. It was replaced yesterday by a story on the NHS’s abuse of the “Liverpool Care Pathway” for end of life care, and today by an investigation on struggling hospitals. Both stories are backwash form the continuing struggle of NHS management and staff with financial pressures. But where are the politicians? Labour are waiting to pounce on stories of struggling accident & emergency services to promote a general air of government incompetence on the NHS; the government try to play things down, blaming any problems on long standing issues not tackled by the previous government. A debate about the long-term options for the service it is not. So what should they be talking about?

The dimensions of the crisis are quite clear. Britain’s NHS is almost entirely funded from tax. But after the economic crisis of 2007-09 the tax base has shrunk. Furthermore a number of trends, not least the increasing proportion of older people, point to a slowing down of the overall rate of growth in the economy and hence taxes. And yet some of those same trends will create growing demand on the NHS. The government has promised to protect the NHS budget in real terms, much to the chagrin of right wing critics, but this will not solve the problem of rising demand. The NHS England report settled on a headline gap figure of £30 billion by 2021  – after toying with £60 billion by 2025, the number used by Health Service Journal (HSJ) in its preview.

The strategy is to buy time through efficiency savings. As a large, monolithic organisation, with weak accountability, inefficiency is rife. NHS top management has been ratcheting up pressure on the component services by progressively squeezing the available funding, , in a process known as “the Nicholson challenge” after NHS England’s chief executive, Sir David Nicholson. The NHS England report claims that this is on track to deliver its target of £20 billion efficiency savings by 2015, but there is plenty of reason to doubt its efficacy, as the number of crises with a financial root seems to grow.

But the strategic point is that efficiency is not a long term answer to the pressures. The NHS paper calls for fresh thinking, but seems to rule out most radical ideas, like charging for, or heavily restricting services, although in doing so it is only holding to the current political near-consensus (the far right does not go along with this, but everybody else does). Let’s take a step back and look at this.

The first point to make is that increased demand for health services in the economy will be met by increased supply. Occasionally you hear people suggesting that the economy can’t bear an increase. But there is no fundamental economic reason why the proportion of the economy taken up by health care cannot increase substantially. It does not depend overly on imports, and there are plenty of things the public can give up to make way (own fewer or cheaper cars or clothes, go out less, and so on and on). Healthcare offers the prospect of a longer life and less pain; it is a consumer proposition, as I have pointed out in an earlier blog, to die for. If there is demand, there will be supply. The only question is how that supply will be met.

There are broadly four ways the NHS will meet this crisis:

  1. Taxes will be progressively increased so that taxpayer funded services maintain their current profile overall. This is clearly what is favoured by most NHS insiders, and left wing policy types who like the paternalist structure of the current NHS.
  2. It will stratify into a class-based service, where only poorer people will use it, while richer people go private. This will happen because the NHS service will be considered dangerous, shoddy, and accessible only after an intolerable wait. This is largely what has happened to NHS dentistry, and it is what will happen if the NHS is allowed to muddle on with its current level of funding (or if funding is cut).
  3. The NHS will concentrate on excellence in a smaller core of services, while letting people go private for others. However healthcare has few neat boundaries, and it is difficult to see how this would work in practice.
  4. The NHS will start charging for more services, and accepting co-payments for cosmetic and other add-ons. This may be done with increased collaboration with the private sector, rather like NHS optometric services. This is the direction of travel favoured by the right, apart from those who secretly favour option 2.

These solutions are not mutually exclusive, and indeed option 3 is probably only viable in conjunction with 4.

The first strategic question is how far new taxpayer funding will be forthcoming. Many seem to assume that it will be. John Appleby, economist at the health think tank the King’s Fund,  assumes this will be so: the economy will be growing again by 2025, and public demand for increases to real spending will return. I’m not so sure: the headwinds on the economy are severe, and I don’t see any return to the growth rates we have previously seen for more than a two or three years in a row. Meanwhile demand from other areas of public expenditure has been suppressed and could bounce back. And I think public attitudes to higher taxes have changed, after the general squeeze that has been put on living standards. Some left-wingers assume there is large pot of money available from taxing rich individuals and businesses. This is open to doubt, however, and it has proved a volatile source of tax revenue both Britain in the past, and to other economies, like California’s, whose public funding depends heavily on taxes on the rich.

Besides, I do not think that taxpayer funding is particularly efficient. It means that resources tend to be allocated top down according to political objectives, and not where it is really needed. And difficult problems tend to be left unsolved rather than confronted. My guess is that we will end up with option 4, after having given options 2 and 3 a try. It will continue to be a very bruising time for the NHS.

For those that want to avoid this, I think the most promising way forward is to bring health services into a complete rethink of public services to make them more integrated with each other, and centred on people rather than symptoms. And in case you think that sounds like motherhood and apple pie, its practical consequence means dismantling current power structures, and pushing towards democratically accountable local control. That will not be popular amongst NHS professionals, and we know how much noise they can make. Some on the left are starting to think this way, and while I don’t trust the left, with their penchant for paternalism, this may be the basis for a useful political coalition. One interesting aspect of this is that the other services (personal care, housing) with which the NHS would be integrated are not “free at the point of use”, considered so sacred in the NHS, which may allow the whole question of charging and co-payments to be fudged in a constructive way. Here’s hoping that something can be achieved along these lines.

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NHS reform – the politics is a smokescreen

Ever since the NHS was formed over 60 years ago, politicians have struggled to manage it.  Assorted ministers and policy wonks have dreamed up elegant reform plans, while the NHS’s insiders have undermined them in a bid to carry on much as before.  The NHS does change, but never quite along the path that the politicians have in mind.  That is as true now as ever.  The difference is that NHS management is promoting reform rather than resisting it; but they are going about it in their own way.  The fire and fury of the current political debate is mostly irrelevant.

I have already posted some thoughts on the NHS.  I considered the question of the timing of the reforms, alongside the £20bn cost-saving challenge posed by NHS Chief Executive Sir David Nicholson (referred to alternatively as “the Nicholson challenge” or “the QIPP*programme”).  My conclusion was that the main organisational damage has already been done, so we do not have much choice but to follow through.  I left aside the question of whether the reforms are wrong-headed.  I would like to consider this, before coming to an equally pragmatic conclusion.

What is being proposed?  A continuation of the big idea of the last 20 years or so: to create a purchaser/provider split, and to use this to introduce market mechanisms, under the banner of improving choice, to help ensure that the NHS is effective and efficient.  The problem that these reforms are supposed to solve is that the NHS is too dominated by hospitals, and the doctors who run them, who do not have enough incentive to change to meet new needs or to become more efficient.

In this latest incarnation, the purchaser element (now usually referred to as commissioners) of this set-up will be a combination of consortia of general practitioners (GPs), and an arms-length NHS Commissioning Board operating at national level (i.e. for England – the reforms don’t cover the other parts of the UK).  The intermediate commissioners under the current system, regional Strategic Health Authorities (SHAs) and district Primary Care Trusts (PCTs), are to be phased out.  On the provider side (i.e. the hospitals and other facilities), the idea is that all NHS facilities should be run by more or less independent Foundation Trusts, but that the commissioners will be allowed to secure services from “any qualified provider”, which will not be restricted to these trusts.

These reforms are a natural, if rather accelerated, continuation of the previous government’s NHS reforms.  Commissioning by GPs was already being piloted, and the idea of moving all hospitals to Foundation Trusts was the previous government’s idea too.  What is newer, and perhaps more radical, is the proposed regime of accountability that is being imposed on this.  Previously the NHS was run by the Secretary of State for Health, with very little restraint or accountability.  Now a complex framework of powers and accountabilities is being imposed, giving both parliament and local authorities a greater role.

The government argues that this is just evolutionary change.  But there has been vehement opposition from people who think that the new regime will end the NHS as we know it.  One problem is the commendable desire by the government to establish much of the framework in parliamentary law, rather than simply letting the minister rearrange things by fiat.  People now have the opportunity to project all their worst fears into the legislation on the basis that it does not specifically ban them.  In fact we are still being asked to trust ministers to do the right thing, only with more accountability.

Two lines of criticism that I can see have some kind of traction.  First is that the framework will open up the health market to competition law (and specifically European law) in the same way as for gas and electricity.  This means that the NHS trusts and the private sector would have to compete on a level playing field – and this might literally drive some NHS trusts out of business.  A lot of what NHS hospitals do is a natural monopoly (accident and emergency work, complex surgery, etc) , like the railways.  The fixed costs are so high that the market cannot sustain competition in most localities.  However, so the argument goes, these fixed costs also support activities where private sector competitors could undercut the NHS; if these are competed away then many hospitals would cease to be viable, and so the service on core activities would deteriorate.

Frankly I’m not stressed by this.  If a train wreck is on the way, it will be in very slow motion, giving time to take corrective action if need be.  More to the point, NHS professionals are masters at keeping the private sector at bay (except for NHS doctors doing private work on the side…), and they will only be seriously vulnerable in places were the service offered is ludicrously bad.  And as for European competition law, judging by its impact (not) on the French and German energy markets, there shouldn’t be anything that the politicians can’t handle.

The second criticism is more cogent.  It is that the rules for setting up GP commissioning consortia are a bit vague.  They could be set up in such a way that makes them very difficult to hold to account, or to act in partnership with other agencies.  For example, they may not be geographically coherent, cross local authority boundaries, and so on.  This does need some more thought – though again the worry is the direction reforms could take, rather than what is actually likely.

Personally, I don’t place a huge amount of faith in the purchaser/provider split and the marvels of choice anyway in this context.  There are two big problems: that the buyers (you and me) don’t know enough about what they are buying, and have to rely on intermediaries, whose incentives distort the picture.  The second is that so many providers are natural monopolies.  After decades of reform, the NHS does not remotely resemble a market economy.  It reminds me of a large company trying to introduce market-style rules for internal transactions; these systems never achieve as much as their proposers hope, since everything is trumped by politics in the end.  There have been two big achievements of the NHS reform process.  First is that hospitals are gradually being forced to be more efficient and accountable; this has mainly been achieved by good old-fashioned management, of which the “Nicholson Challenge” is but the latest example.  The second is that commissioning processes have forced NHS managers to address the question of what society actually needs, and then try to reorganise the service to meet these needs.  This last development is the more recent, and the the reorganisation of PCTs has interrupted it – but the new arrangements will probably be more effective in the long run.

The big prize to be won from the current reforms is hardly spoken of at all.  It is that GPs will start to come under the same sort scrutiny as hospitals have.  The consortia themselves will do some of this; the NHS Commissioning Board, which must authorise the consortia, will also be on the case.  The PCTs were supposed to be doing this, but were mostly pretty ineffectual.  The important point is that we should be in no hurry to authorise the consortia, to allow this scrutiny process to have real bite.  This seems to be exactly what Sir David Nicholson (who will chair the NHS Commissioning Board) has in mind.

Meanwhile the over-large number of PCTs has been reorganised into a more manageable number of “clusters”; these and the SHAs will no doubt live on as embodiments of the Commissioning Board.  The NHS will become much more centralised in the short term.  With some very sharp minds at the centre, including Sir David, this doesn’t have to end badly.  But the politcal arguments are mostly a smokescreen.

*QIPP stands for Quality, Innovation, Productivity, Prevention

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NHS: the net is tighteneing around hospitals

September 11, 2001 was a good day to bury bad news, a government spin doctor famously emailed on the day.  What about a royal wedding day?  Sure enough, via the Department of Health (DH) there was this announcement, saying that hospitals are expected to make an even higher rate of “efficiency” savings than before: from 4% per annum up to 6-7%.  This press release seems to have come out so late yesterday that neither the DH website nor that of Monitor (the regulatory body that made the announcement) have published it.  So I have been unable to access the details.  But make no mistake, this is a highly significant development.

What on earth is going on?  So far almost all the heat has been around the Coalition’s health reforms, and the dramatic changes to the commissioning side of the NHS, which are already in rapid progress, regardless of what is happening in Parliament.  This is the side beloved of politicians and policy wonks.  The idea is that the NHS will be shaped by more or less local organisations assessing their needs and then “commissioning” it from the supply side – mainly hospitals.  Hospitals, formerly in the driving seat of the NHS, would be put in their place.  It is a chaotic, market driven vision of change.  Under Labour commissioning was being led by the primary care trusts (PCTs); the coalition is moving this towards consortia of general practitioners (GPs).  This is all very well, but there is something else going on, and this is much more Stalinist, and which pre-dates the Coalition.

Or rather the model might be the Chinese leader Deng Xiaoping, who masterminded China’s recent astonishing growth.  Deng ensured the process was centrally directed, with no challenge to the Party’s authority; he worked by manipulating the incentives open to his underlings.  The centrepiece of this dynamic in the NHS is the £20bn of savings that I described in my last post.  This money isn’t being cut from the NHS budget; it is being “redeployed”, spent somewhere else, although it is very unclear where.  What today’s story suggests is that most of this pressure will be felt by hospitals.  The drive is to take 25% out of their budget over a mere four years.  Wow.

Regardless of where the chaotic process of commissioning takes us, the central leadership of the NHS (and it is not difficult to identify Sir David Nicholson as the driving force) has decided that hospitals are going to play a smaller role.  This is pretty conventional thinking in the medical field.  Hospitals are old-fashioned places where people are as likely to catch an illness as be cured.  The idea is to reduce them to a smaller number of centres of excellence, with the very best professionals supported by the very best technology.  Meanwhile more illnesses will be treated “in the community”.  I can’t express an opinion on how valid this view is, though I instinctively feel that it is missing something.

Never mind.  What it means is that many of the country’s hospitals will be closed.  Regardless of the chaos that has hit the commissioning side, the NHS bosses are turning up the heat.  I don’t know how ready our politicians are for it.  It has Labour’s fingerprints all over it, but it is the Coalition that will be in the firing line.  The only upside is that it should release money that can be spent on other things.  That and the knowledge that the government is doing the right thing.  Probably.

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NHS reform: we’ve started so we’ll finish

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.

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