The Coalition wrong-foots Labour on its (lack of) NHS policy

Labour’s plan for winning the General Election in May has a special NHSplace for the NHS. They are seeking to “weaponise” it, and promote themselves as the only party that can be trusted to run this great British institution. And yet their NHS policy has deep flaws. Now the Conservative/Liberal Democrat coalition government has come up with a plan to integrate health and social care budgets in Greater Manchester. To maintain the warlike metaphor, this looks like surgical strike on Labour. In fact the story arose from a leak in the negotiation process, and seems to be the brainchild of Simon Stevens, the politically neutral head of NHS England. But the policy poses serious questions for Labour.

The details of yesterday’s news are a little vague. The Coalition had already announced plans to devolve more powers to Greater Manchester, working through the local councils (mainly Labour, but with Conservative and Lib Dem ones too) and an elected Mayor. And integration is everybody’s favourite reform idea for the NHS. It refers to merging the health budget with that of social care (currently controlled by local authorities), so that the policies for the two can be coordinated properly. This is important because one of the main problems at NHS hospitals is that they cannot release patients to social care beds. Integration of this sort is already being piloted in such places as Torbay. This looks like a pilot on a grander scale.

As a reform idea, the Manchester proposal looks entirely sensible. Sarah Wollaston, a Conservative MP who is a doctor, and no government stooge, offered a knowledgeable and effective advocacy on Radio 4 yesterday lunchtime. Integration has been one of Labour’s big ideas. But Labour can’t bear to give the government any credit for policy on the NHS – as this undermines their weaponisation plan. So their spokesman, Andy Burham, rubbished the idea. He attacked it as undermining the “National” in the NHS, because it was a localised solution rather than being dropped from a great height from Westminster. He also suggested it would be another “top-down reform”, which the government had promised not to do.

And yet both these lines of attack expose weaknesses in Labour’s own NHS policy. In the first place, if they are serious about promoting NHS integration, how on earth are they planning to do it? The quid-pro-quo of an integration plan is surely more local devolution – otherwise you simply create a monstrous bureaucracy, and a feeding frenzy of large consultancy firms proposing over-engineered implementation plans (er, like the last Labour government’s reform of NHS commissioning). And secondly, are Labour or are they not planning a top-down reform all of their own? Their proposal to scrap the government’s Health and Social Care Act suggests just that. And if they intend to  implement integration across the whole country at once… well, that just proves it, doesn’t it?

Which highlights the real problem for Labour. Their plan is to ride the tide of anger amongst NHS insiders over the government’s record on the NHS. They headline attempts to outsource some services as an NHS “sell-off” or privatisation. This is vastly exaggerated – no major hospitals are being outsourced (private businesses would be mad to take them on) and GP surgeries, er, have always been private businesses (a fact that confused the hell out of a save-the NHS campaigner that called on me a couple of months ago). But any plan to reform the NHS in any serious way involves taking on these insiders. The idea of integration to insiders is popular probably because it is seen as a way of hitting the ball into the long grass: the setting up of some toothless committees of professionals who purr about “collaboration not competition” and achieve very little except requests for yet more money. The more serious and specific Labour gets about reforms that promote efficiency, the more dissent they will get from their core supporters, and especially the trade unions. The hard fact is that Labourare proposing to dismantle the Coalition’s health reforms at the moment they are starting to show some promising results, like this devolution initiative.

Now the public probably don’t think much of the Coalition’s record on the NHS, but they surely accept that reforms will be needed to make the organisation more efficient. And if Labour appear not to be serious about that, then their line on the NHS is undermined, and their line on tax-and-spend, already weak, gets shot through. With enough pressure this weakness will become more and more apparent – and there will be a greater and greater risk of dissent in Labour ranks. They are offering just bluster. Far from trying to avoid the NHS as a campaigning issue, the coalition parties have the opportunity of a devastating counterattack, especially if Labour persists in opposing the Greater Manchester plan.

All of which shows how fatally bad is Ed Miliband’s leadership. He has valued party unity over making serious political choices. He has chosen sound and fury over policy substance. He hoped to craft clever policy positions that cover the cracks in his own party while providing credible ideas for saving the country. Alas serious policies mean taking on vested interests in your own ranks, not just the usual villains. The unity of silence in Labour ranks  is not a token of assent – it is a token of denial. Labour’s most vocal supporters, and the providers of the bulk of their funding, do not think that Labour is serious about public sector reform and austerity. As Labour is pressured by the coalition parties the greater it is in danger of falling apart just when unity is most important. It is a political strategy put together by policy wonks and campaign tacticians – and not those with serious nous about taking on political responsibility.

The Coalition parties have their own weaknesses of course. These may yet save Labour. But a meltdown for Labour cannot be ruled out on this form.

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9 thoughts on “The Coalition wrong-foots Labour on its (lack of) NHS policy”

  1. umm, Freudian slip? ” policy wanks”, which about sums them up for the most part.
    The lack of imagination over the NHS is breathtaking. The Manchester initiative is most interesting (do you remember when we had the DHSS?); but it is announced by the Treasury. The Treasury! Not the DoH or even Eric Pickles; and therein lies the major problem, i.e. money, by increase or withdrawal will solve the problem.
    Think on this. Real demand for health and social services has NOT gone up. Demand has been confused with activity, not with real need. What has gone up, thanks to New Labour and the current witless Coalition (especially the LibDems) is the amount of corrective and non-value added activity most often caused by government tampering with the institutions, e.g. setting up CCGs, compliance demands that have nothing to do with patient care, and corrective activity without causal analysis. All these create rework in one form or another, which is both very expensive (adding up to 50% to the costs) and bad for your and the NHS staff’s health.
    So you are quite right in saying we must make the NHS more efficient. Could you define efficient please.

    1. Thanks John. I have corrected the typo, though I agree the original word conveys my meaning rather better. Incidentally I think the main initiative comes from NHS England, which is not meant to be directly a part of the government at all – and the story leaked. That may be why the Treasury decided to pick the story up and run with it.

      I’m not sure I entirely follow you on your claim that real demand for health and social has not gone up – perhaps because I am looking at it from a different angle.

      Demand, in my sense, is rising rather rapidly for two main reasons. The first is demographics. There are more older people and older people are the main source of demand for both health and care services. The second is an apparently insatiable demand to reduce pain and prolong life, and to deploy ever more new technology to this end. We may sneer at this, but it does make a bit more sense than buying ever higher piles of consumer goods that we really don’t need or 4-wheel drive vehicles to take the kids round the corner to school, etc. By “efficiency” I am thinking about dealing with this volume of work with fewer resources – and I think this is how most voters will view it. And as for the volume of management activity, I’m not sure the coalition has made things any worse. At least they abolished “World Class Commissioning”, a work creation scheme for consultants and bureaucrats of breathtaking proportions.

      Of course, if we managed ourselves better, and resisted the temptation to medicalise everything, and lived in more cooperative and caring communities – the demand for the things that we ask NHS and care services to do would fall. I suspect this is what you mean. Alas too little creative thought is put into how we might achieve this – we haven’t got further than rather bossy directives from public health officials and their statistical evidence bases…

  2. “The more serious and specific Labour gets about reforms that promote efficiency, the more dissent they will get from their core supporters, and especially the trade unions.”

    Trade unions and efficiency don’t go well together. The unions’ objectives are to get the best deal they can for their members – that doesn’t sit well with the idea of increased efficiency which might cost some union members their jobs.

  3. Nonconformistradical
    Trade unions and efficiency don’t go well together. If that were generally true, and it is not, I would add that management and efficiency don’t go well together even more. Put the lunatic banks to one side: cost-cutting by the NHS management drove costs up; managers skimp on maintenance (outsource, usually) so production costs go up as more machines go down; UK IR department lays off senior staff, complaints shoot up, tax avoidance increases so they hire them back as consultants at double the cost; then they have a merger with Customs! And on it goes. Unions could not wreak half the damage that British management does – daily.

    1. That’s not management, that’s bad management. Large, centrally managed (and especially nationalised) organisations are particularly prone to it. And I agree it’s rife in the current NHS – witness the huge amounts being spent on agency staff in order to maintain a top-down pay policy. But in many organisations (disclosure: it used to be my job) management may make mistakes but drives improved efficiency and allows organisations to adapt to changed circumstances. But it only works if you have true accountability and managers have the power to change more than small number of things. Which is why a more devolved structure in the NHS is the way to go, even if you get Andy Burnham’s Swiss cheese.

  4. Matthew
    Unfortunately it is not “bad management” in general thinking, it is common management practice, i.e. a system of management that is commonly accepted, but one that creates a management prison in Dr Deming’s parlance designed by top managers. It is underpinned by a mindset that sees employees as unable to to good work unless bribed or threatened by (arbitrary) targets and PRP, that has shunted shareholders into primacy of the company performance so that the directors can align their benefits with those of increasing shareholder value. In this way they can justify their undeserved bonuses – at the expense of the real company performance, viz the Co-op Bank.
    Our intellectually effete politicians bought into this model wholesale, led by Tony Blair, and stuck it into the NHS et al. This has caused the ruination of the NHS, the demoralisation of teachers and your bloated civil servants, and brought about justifiable contempt for politicians and the large corporates.
    Ask yourself, why is John Lewis, the most successful retailer, an exception in its management style?

    1. John. I do agree with much of what you say. There has been a fashion to obsess about incentives – for which conventional microeconomics has much to blame. And politicians, Blair as well as many Tories (and perhaps a few Lib Dems) rather swallowed it. But I can assure you that managers in both public and private sectors that know about management disregard it. And the whole thing about shareholder value (which started to be a fad when I was a manager) has been woefully corrupted into clever wheezes to engineer hikes in the share price and reward senior management with fabulous riches.
      But, but, but. There’s much more to it than that. Before Blair came along management in the state services (mostly) was appalling – habitually gobbling up money without anything to show for it. Tolerating fragmented processes because they had always done it that way, or to maintain some antiquated form of professional etiquette. Much of what New Labour did didn’t really work. But it wasn’t all bad. At the school where I am a governor I have seen levels of achievement raised massively – and with teachers of higher professional standards who evidently enjoy their work (much more so than 10 years ago). Plenty of good things have happened in the NHS too – stroke services for example. And the progress made in cardiac services (for which I have real reason to be grateful) has been enormous. I don’t think you give NHS staff and managers the credit they are due when you describe their work as “the ruination” of the service. What we have is an enormous challenge – what we need to do is learn and move forward. Not tear everything up and try to start again. The Coalition should have been much more evolutionary in its approach. and now I fear Labour are going to make the same mistake.

  5. Matthew, I did not include the staff in the ruination of the NHS, just the management. The staff succeed despite the management, at great personal cost. In the latest Kings Fund report the greatest risk seen by the finance directors in the trusts is staff morale – overworked and over-managed. 6 in 10 trusts rely on financial support from the DoH; the target for the proportion of outpatients waiting longer than 18 weeks has missed the target for the first time since 2008; there has been a 47% increase this quarter of patients spending longer than 4 hours in A&E this quarter, i.e. 414,000. Most worrying of all is that there are now 5000 late discharges a day. This is the key causal factor behind increasing costs, ill-health and low staff morale, and is due solely to bad management who are now paying regard to the whole system of healthcare and too much to obeying the government’s cost-saving edicts, which actually push aggregate costs up.
    Where there are examples of good practice brought about by improving, for example, diagnostic, admission and discharge processes through well mapped care pathways that, in the case of Plymouth’s Derriford hospital halved the cost of treating stroke patients, increased the success rate dramatically and released a third of the beds. But this is ignored because the management mentality induced by the politicians is one of command and control, and cost-cutting.

    1. There are quite a few competent, dedicated managers in the NHS too. I think it is more constructive to condemn bad management than all managers. But the top-down command and control model is not helping – and crude target s set by the Nicholson Challenge. What’s needed is to move the politicians away from managing the service, get more clinicians involved in management, and promote devolution and integration. Which boils down to the intent of the Coalition’s policy, funnily enough – even if the implementation doesn’t live up to it.

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