My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

Is there any evidence of the political leadership needed to transform the NHS between 2015-2020?

Filed Under (Conservative party, Health Policy, Labour Party, Reform of the NHS) by Paul on 31-03-2014

There have been some interesting responses to this month’s posts. It’s encouraged me to think about perhaps resuming for a month in the autumn and then again in March 2015. It’s been especially interesting over the last week to gauge people’s response to my attempts to challenge the gloom being spread about the pressure on the NHS by too many of NHS leaders.

In this last post for the moment, I want to try and think through how the current political leadership – that which might be in charge of the NHS in the period after the May 2015 election – can help make the necessary transformation.

And in thinking through the possibilities I want to introduce the fact that from tomorrow there is a new CEO of NHS England – Simon Stevens. Between 2001 and 2004 he was a close colleague of mine, and is a friend, so I wish him well. But too much expectation is being placed on the ability of one person to make everything happen. He can and will achieve a great deal – but no-one can do this on their own.

When Pete Seeger died in January one of the many brilliant sayings that were attributed to him was, “Be wary of great leaders and hope that there are many many small leaders”. To succeed Simon will need many many small leaders.

And I don’t know about you but it seemed to me that there was something really odd in what his predecessor David Nicholson said in an interview last week. He said he would give NHS England “5 out of 10”. Given that he ran the transition body that set up the organisation, was responsible for the hubristic change of name to NHS England, and then ran it throughout its life one wonders, if the organisation is not very good, just why is that?

But the rest of this post concerns the interaction between political leadership and the NHS.

There is near universal agreement between the two major political parties who will either form the next Government alone or will form the larger part of any coalition. (Incidentally we don’t yet have UKIP’s NHS policy but I’m sure that if you visit any Home Counties’ saloon bar on a Sunday lunchtime you will hear it there first).

Both the Conservative and Labour parties agree that:-

  1. There will be standstill funding. Money won’t go up, but it won’t go down either. (But by 2020, even if the money is still the same for the NHS, most other areas of public expenditure will go down so the proportion of public expenditure being spent on the NHS will rise considerably).
  2. There will be no new structural reorganisation. (phew!)
  3. There will be many more older people with co-morbidities who will need different and better care than they are getting at the moment.
  4. There need to be many fewer emergency admissions.
  5. There needs to be a rapid development of integrated health and social care.
  6. This new model of care will have a radical impact upon the existing models of health and social care.

They also know that these changes need to happen quickly, need to happen across the whole of England, and that given the rise in demand they will need to reduce the amount of money spent on each patient.

Now of course we don’t know what the manifestos will bring but at the moment, given the pledge that there will be no more top down reorganisations, the levers that are available to bring about these radical changes are limited to what they have to hand at the moment.

The problem with this is that none of the political parties really agree with the current organisation of the NHS and the existing levers for change and so none are at all happy with what they have to hand.

Let’s start with the Conservatives. We know that the current Conservative Secretary of State Jeremy Hunt voted for the Health and Social Care Act on many occasions and supported the reforms in Cabinet. He was lucky enough to be in the job of Secretary of State when all the reforms he had consistently supported came into effect. Few politicians enjoy such a luxury.

But, as we know, a curious thing happened during the time between the passage of the Bill and his having the opportunity to enact the reforms.

Over the intervening year he came to disagree with the central idea of his legislation, that the NHS should be run by a series of arm’s length bodies – separated from the Secretary of State.

Instead of following the core principle of the reforms – to liberate the NHS from Whitehall – he instead runs the NHS from his office (in, er, Whitehall). Most of the time he ignores the legislation he supported (and, it might be said, much of a decade of earlier legislation.)

You would have to spend a long time searching through his speeches to find any reference to the changes that he wants being made by the actions of the 211 clinical commissioning groups that his legislation established.

Let’s look at an example of what he might do if he believed in the legislation for which he voted.

A few weeks ago the Times uncovered the fact that over 150,000 older patients are moved around our hospitals in the middle of the night. If he used the powers in the legislation that he voted for, he would read the Times and think hard about changing next year’s mandate to NHS England to cover this issue. He would in turn talk about how CCGs should commission care from hospitals that did not involve such nocturnal movement of older patients.

Instead the anxiety that the Times headline immediately raises in him leads him to try and ensure the NHS acts differently.  Since he won’t do that by using the levers his reforms gave him, he has to resort to shouting at the NHS as loudly as possible.

And this will be the problem for the NHS if the Conservatives are in charge of making the changes to bring about integrated care from 2015-2020. Since they don’t believe in the purchaser/provider split that is the keystone of their legislation, they have no other levers available to bring about these radical changes.

What they have instead is the traditional activity of shouting at the NHS to “just do it!”. Since the NHS knows that if, a week later, there is bad publicity coming from trying to create integrated care at pace, it is likely to be shouted at to do the reverse, there is little likelihood of reform taking place at the scale and pace that is necessary.

Labour of course has yet to outline the detail of its policy. But in the last month the leader of the Labour Party and the Secretary of State have both agreed that there will be no top down reorganisation of the NHS. That good news means that the levers for change contained in the current system are the only ones that will be available to a Labour Government in May 2015.

Which in turn means that commissioning at a national and local level will be the levers to bring about the move towards the integrated care outlined above. Yet the Shadow Secretary of State has made clear that the last thing he want commissioners to have at their disposal is competition. He wants to grant the existing NHS suppliers a monopoly of what health care is supplied and who supplies it.

He will therefore be asking the NHS to carry out very different integrated health and care but taking away any ability that commissioners have to challenge the monopoly of existing institutions. This reduces commissioning to an allocation mechanism with commissioners simply handing out money to existing NHS providers.

If this were to remain Labour Party policy after the next election, they too will have no levers to bring about integrated care except for the time honoured method of shouting at the NHS.

So, a year away from the next election, this is the problem.

  • We have unanimity about where the 2 main political parties think they want the NHS to get to.
  • We have agreement that there will not be a reorganisation to give the Secretary of State new levers
  • We have agreement that the current levers aren’t one they want to use.
  • They have no way of getting the NHS to move to where they want it to go.

Over the next year this may change.

I’m hoping that it has by the time I start blogging again.

So what is this Government’s policy on the NHS?

Filed Under (Conservative party, Election campaign, Health Policy, Lynton Crosby) by Paul on 06-03-2014

I have counted three very different and opposing policies that the Government have for the NHS. Interestingly none of them represents a split between the political parties of the coalition and all of them have Conservative actors leading them.

The first, as I outlined in yesterday’s post, is Jeremy Hunt’s policy for the Secretary of State to intervene in running the NHS several times a week often using powers abolished by the Health and Social Care Act 2012. His personal NHS policy of trying to run the service as if the Health and Social Care Act 2012 hadn’t happened is backed up by other parts of the Government.

In January the Deputy Prime Minister, in arguing for more attention to be given to mental health policy, came up with the good idea of having maximum waiting times for mental health treatment. He quite rightly reflected on the experience that maximum waiting times had had a significant impact on access for physical health, and wanted the same improvement for mental health patients.

The problem for Nick Clegg is that he signed up to the July 2010 White Paper which stated that the Government should not prescribe such targets from the top. In the summer of 2010 Andrew Lansley had indeed abolished them. (And if you ever wonder why the Government has such difficulties with the 4 hour A and E target it might just be a consequence of this abolition).

The first answer to the question of what is Government policy on the NHS is therefore that they are a powerfully interventionist Government delving into the detail of NHS practice. (Notwithstanding having passed introduced a law that opposes this policy).

Incidentally I have been told third hand that the Prime Minister’s intent for his 2015 manifesto will be to proclaim that “his NHS targets are better than Labour’s targets”. (This despite having abolished top down targets some time ago)

The second – very much quieter – NHS policy is to implement the Health and Social Care Act and the consequent reforms that they pushed through in 2012. This policy stops treating the NHS as a single organisation run from the top, but instead recognises that it is a system of very different organisations that work together to create an overall system called the NHS. NHS England, Monitor and the NHS Trust Development Agency are all separate independent quangos that fit into an overall architecture. Commissioning at a local and national level will drive change and improvement.

Not many people in the Government agree with this. A bit of the No 10 Policy Unit, a bit of Norman Lamb, but for the most part they want to forget the whole reform movement in health. It’s OK to talk about the reform of welfare or education, but let’s not mention the 2 years of hard work and disruption that went into the Health and Social Care Act.

There is then a third policy on the NHS that is run by an Australian in Number 10 called Lynton Crosby. ‘Cobber’ Crosby has been put in charge of winning the election. His policy on the NHS is to say nothing about it at all.

Polling tells him that every time the NHS is mentioned it moves up the salience of issues that matter to the public. If this were allowed to continue, and if by the spring of 2015 the NHS were to be say the third most important issue that the public cares about, then the Conservatives will lose votes.

To win the election the Conservatives need voters to be concerned about issues that will win them more votes – and the NHS will not be one of those.

So Mr Crosby sits in number 10 and fumes at the hyperactive Secretary of State intervening in this and that and making speech after speech about what’s wrong with the NHS whilst Jeremy Hunt is really pleased to get headlines for his speeches and interventions.

Mr Crosby considers Jeremy Hunt’s hyperactivity a very strange way of winning votes for a Conservative Government.

So there you are. 3 very different policies for us to watch will wend their way over the next 14 months until the election.

In March 2014 just who is responsible for the Government’s NHS reforms?

Filed Under (Accountability, Conservative party, Health and Social Care Act, Reform of the NHS, Secretary of State) by Paul on 03-03-2014

“Victory has a thousand fathers but defeat is an orphan.” – John F Kennedy

A year ago, when I paused in my blogging, the bulk of the Health and Social Care Act was about to be implemented (on 1/04/2013). So it’s inevitable that much of the next few weeks’ posts will revolve around what has happened to the biggest set of NHS reforms since 1948. The detail of those reforms is a fascinating topic but stepping back from the minutiae, what is really interesting is how the Government takes no ownership at all for this enormous set of changes.

In reviewing their work over the last 4 years government ministers have established a litany to describe what the Coalition has achieved. Three things are mentioned again and again.

“We have succeeded in getting on top of the deficit, and have successfully reformed education and welfare.” 

But there is no mention of NHS reform.

That enormous Bill, the famous pause in the legislative timetable, the subsequent reworking of the Bill, the many, many changes in the Lords, and all of the political capital spent ramming it through against a high level of opposition.

All of that effort has resulted in …………………silence.

As we will see in subsequent posts this silence on reform is reflected in the way in which the current Secretary of State does his job, but today I want to explore the implications of no-one taking responsibility for the implementation of the actual implementation.

Of course it is wrong to say no-one takes responsibility for implementation. The Department of Health has a timetable of things it needs to do to keep the new show on the road – and of course the technical implementation continues.

But the problem is that the impetus for these reforms did not come from a set of technical problems. They were created from a new vision for the organisation of the NHS.

Andrew Lansley began work as the new Secretary of State in late May 2010 and within a month had abolished the 4 hour waiting target for A and E. (Incidentally those seeking to understand why the NHS is having difficulty meeting this target will find at least part of the answer in a letter sent out by the Conservative Secretary of State abolishing it).

Then within 8 weeks of taking up his post he published a White Paper intent upon “liberating” the NHS from the control of an overbearing centre. Within a few months the largest Health Bill ever was published and as it progressed through Parliament it became clear that it was intended to change everything.

The legislation was passed (as all legislation is) through a process of ruthless party political whipping. Again and again the two Government parties voted for radical change and presumably did so with some kind of vision of what they wanted to achieve.

Of course that Secretary of State moved on, but the vision of the cabinet, several hundred peers, and MPs was realised in this enormous piece of legislation.

And all of that politics has led to…………………..silence.

A process of change that was essentially political now has no political champion to explain what was being attempted and why any of this happened.

The only explanations we hear are the technical ones from the civil servants whose job it is to implement it.

Up until the passing of the legislation if you asked the question “why is all of this happening?” Andrew Lansley would give some sort of reply about decentralising power to clinicians in localities.

Now if you ask the question you get the reply that “we are carrying out the will of Parliament and these are technical implementation issues”.

The problem is that the implementation of technical issues actually needs an overall vision to make sense of them. And no-one is owning that at all.

We had 27 months of intense political noise and row, but since the passing of Andrew Lansley we have had 18 months of prolonged silence about why all this is happening.

In part this can be explained by my opening aphorism from John F Kennedy. The Government was successful in passing its legislation, but the moment it was passed this success was recognised as being a failure. Andrew Lansley was moved partly because he kept on banging on about it as if it were a success. But given that it’s a failure no-one wants to own it.

This is not just a political matter – it goes into the depths of all of the detail of the implementation of the reform.

Take one example – the detail of what organisational form a Commissioning Support Unit should take is a technical issue. But it would be best if that technical issue should in some way fit within the overall architecture of the NHS. If no-one is looking after that larger vision, then the answer to what happens to each bit of the structure is only answered in relationship to those bits….. The overall architecture then gets dragged apart by the answers to each small technical question.

One of the main real cries of anguish you will hear within the NHS in March 2014 is that no-one really knows how all these bits fit together. It looks as if each bit is plying its own trade with little relationship to the whole.

And my point is that there is not a single politician looking after the overall architecture.

For me this is something I can’t forgive.

Throwing the whole of the NHS up in the air has caused everyone a lot of difficulty.

Walking very quietly away from the results and pretending “it’s nothing to do with me guv” is much, much more irresponsible.

We live in such cynical times……

Filed Under (Conservative party, Health Policy, Secretary of State) by Paul on 10-10-2012

I, along with what I thought were most people, assumed that last Saturday morning Jeremy Hunt made a big mistake. The main item on the news and the front page of the Times’ magazine were full of the reporting of his belief that abortions should be restricted to 12 weeks after conception. Read the rest of this entry »

What might the Conservatives say about NHS policy at their Conference?

Filed Under (Conservative party, Health Policy, Reform of the NHS) by Paul on 08-10-2012

In two years time the Conservative Party conference of 2014 will take place just a few months from the General Election. The Conservatives will not want to go into that Conference with their opinion poll placing on the NHS as far behind the Labour Party as it is now. Read the rest of this entry »

Having rewritten everything else about the NHS the Coalition Government has now rewritten the meaning of the word ‘independent’.

Filed Under (Conservative party, Health Policy, Hospitals, Independent Reconfiguration Panel) by Paul on 26-07-2012

On July 2nd the new chair of the Independent Reconfiguration Panel took up their post. Lord Ribeiro, who was between 2005 and 2008 President of the Royal College of Surgeons, is, as a top doctor, an obvious appointment. If you want someone to do something ‘independent’ then it’s obviously totally within the meaning of that word to go to a top doctor.

But look again. This is the same Lord Ribeiro who became a member of the House of Lords in December 2010 and has, since then, taken the Conservative Whip. Whether he was one before he took up his seat in the Lords on 21 December 2010, he has, since that date, been a publicly committed Conservative.

But, you might say, are not these doctors who sit in the Lords an independent bunch? Don’t they vote with their conscience and not with a Party? Isn’t he an independent first, and a Conservative second?

Luckily an organisation called “The Public Whip” keeps a record of the balance between Lord Ribiero’s independent votes against the Government and his adherence to the Conservative Whip. They have computed that there have been 157 whipped votes since he took up his seat.

The noble independent Lord has only once voted against the Conservative whip. Or to put it another way he has demonstrated his independence over party loyalty on 0.6% of the occasions when he could have done so.

Let’s not forget that during this period of time a contentious Health and Social Care Bill has gone through the House of Lords. During this period there were many pressures on doctors to vote against the Government whip in favour of a different approach to NHS reform.

But again, perhaps like many members of the House of Lords, he has been a part time politician. Perhaps these voting record figures are those of a reluctant politician who only occasionally turns up?

Another organisation called “Theyworkforyou.com” computes the number of times that Lord Ribiero has voted with his political affiliation as a % of all of the occasions upon which he was eligible to vote. They calculate this figure at 73.02% – being the percentage of occasions on which he elected to vote with the Conservative whip. They comment that “This is well above average amongst Lords”

We have the evidence that the new chair of the Independent Reconfiguration Panel has been an active Conservative.

Does this matter?

It does. For two reasons.

First you will remember that the Coalition Government has wanted to take politics out of the NHS. “We want to free NHS staff from political micro-management” said the coalition agreement in May 2010. Over and over again the Government have said that the aim of their reforms has been to remove politics from the NHS. It is therefore, at the very least, strange to appoint a person with a clear track record of party political belief to a part of the NHS that has been, up until now, independent and free from political micro-management.

So the small point is that – as in a number of areas – the Government are doing the very opposite of what they said they would do. Rather than removing politics from the NHS, this is a clear example of the way in which they are putting people with a track record of active Conservative party politics into positions of power within the NHS.

The second issue is the specific work of the Independent Reconfiguration Panel within the NHS.  Hospital reconfiguration is a profoundly political issue. At both local and national levels there are campaigns against hospital reconfiguration.

The current Secretary of State was engaged in these campaigns in the run up to the last election. Within days of his coming to power he made reconfiguration even more party political by making statements in front of hospitals – opening up parts of them. These were all in Conservative constituencies and were all opening parts of hospitals where clinicians had supported their closure.

Over the next few years everyone agrees that the pace of hospital reconfiguration must quicken. The NHS will need a larger number of radical changes to develop sustainable and safer hospital services.

For the NHS to thrive the reconfiguration process will have to be seen to work well and work cleanly.

By appointing someone with a public record of Conservative affiliation the Secretary of State has made that process much harder.

In political terms it must be the case that following the appointment of the new Chair of the Independent Reconfiguration Panel the Labour Party in the localities and nationally will be looking very closely at all of the decisions that they make.

With this chair every contentious decision becomes more contentious.      .

A very strange way for the Government to remove politics from the day-to-day running of the NHS.

“We will scrap politically motivated targets…”

Filed Under (Coalition Government, Conservative party, Health Policy, Manifestos, Targets) by Paul on 16-05-2012

(Conservative Manifesto 2010)

It was always going to be interesting to see how the Coalition government would live with this pledge.

Over the last weekend, just prior to its conference, the Royal College of Nurses published a survey of its members reflecting their experience of patient waits in A and E. Their President was on the airwaves saying that the progress that had been made on speedier and better working with A and E patients was being lost as more were being treated on trolleys. Read the rest of this entry »

We know the Prime Minister was in favour of unnecessary changes to the NHS – but is he in favour of the necessary changes?

Filed Under (Conservative party, Hospitals, Prime Minister, Reform of the NHS) by Paul on 04-04-2012

The Health and Social Care Bill has become an Act. This was only possible because the Prime Minister supported changes from the moment he put his name to the White Paper, through to the moment he changed his mind in April 2010, and all the way to the end of the process. It all adds up to the simple political truth that Prime Ministers get the legislation that they want through Parliament.

I suspect that if he were asked what the Bill was for he could give the ‘top line’ answer – that it gives more power to doctors and nurses. But if, over a kitchen supper, you asked him to explain how Monitor would both set prices and performance manage existing FTs, I suspect he couldn’t really give you an answer.

That wouldn’t matter so much if someone else could give an answer, but never mind – for the moment the Bill is an Act.  We know that he was in favour of something that didn’t really matter.

But what I am not clear on is where the Prime Minister stands on change in the NHS that really does matter.

Across the country there is a growing recognition that most hospitals are going to have to change the way that they deliver services, and how they are organised. The best ones are going to have to take over the worst, and as a consequence nearly all of them are going to have to change.

For example, last Friday the London Evening Standard published a page full of likely changes that will be necessary in west London over the next year or two. It involved closing A&Es and many other departments. Some local politicians were shocked at the level of these changes, but what was even more significant was an editorial supporting the changes.

This is going on all over the country.

Long term readers of my blog will remember that when the Coalition Government was formed I said that I suspected that what had been one of the major tensions within modern conservatism would play a role in the development of NHS policy. Since 1979 modern conservatism has believed both in the power of markets to improve efficiency and outcomes, and the importance of conserving institutions.

Of course these two drivers are in tension. In the Conservative-led Government of 1979-1997 markets ran through British society bringing substantial change. Whilst not many Conservatives noticed the closure of the steel and mining industries in their towns and villages, they did notice the closure of the local offices of banks, post offices and shops. All of these closures were the result of market decisions for efficiency that were at the core of the Government’s drive to change society.

Then these same Conservatives would launch campaigns against the closure of these local facilities, because not only do they believe in markets – but yes they believe in conserving as their name suggests. In the 1980s and 90s most of these campaigns, launched against the impact of their own policies, failed. Their market ‘side’ beat their conservative ‘side’.

How does this relate to the Prime Minister and his current policy toward the NHS?

At various stages in the last 18 months the Prime Minister has argued strongly that the NHS needs to change radically and that bits of markets might help bring this about. He will probably see clinically-led commissioning as something that will drive greater efficiency in the health service than the previous PCTs. He recognises that the NHS needs new drivers for efficiency.

But I wonder if he understands how that efficiency is going to hit the way the local district general hospital operates? After all as we saw in the 1980s and 90s driving efficiencies into organisations brings about changes and in many parts of the country those efficiencies meant that services were changed forever.

The consequence of greater efficiency in the NHS will be radical changes to the District General Hospital (DGH).

I think this may mean that the first half of this Parliament will see the Government arguing for greater efficiency in the NHS and the second half will see them defending the DGH against it.

But if he doesn’t make these efficiency savings, the Prime Minister will have to find more billions for the NHS to fund the inefficiency that his conservatism demands.

Why is the Government so pleased with itself now that it has passed its Health and Social Care Bill?

Filed Under (Coalition Government, Conservative party, Health and Social Care Bill, Health Policy, Prime Minister) by Paul on 21-03-2012

Since the autumn of last year I have blogged several times about the rather odd truth that the Government really doesn’t seem to care much about the detail of their Health and Social Care Bill. Since June last year they have been agreeing amendments to almost every part of the Bill (and then amendments to these amendments) with a reckless disregard for whether the Bill still makes any sense at all. Read the rest of this entry »

Would 50+ doctors standing for Parliament at the next election have any impact?

Filed Under (Conservative party, Election campaign, Liberal Democrat Party) by Paul on 20-03-2012

Last Sunday’s story in the Independent concerning at least 50 doctors standing at the next general election against members of Parliament from the Lib Dem leadership and Conservative marginals was an interesting one. Once again – as much of the campaign against the Bill has shown – it demonstrates the gap that exists between the detailed experienced of party politics and the detailed experience of medicine. Read the rest of this entry »