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 »
A year ago the main change happening in primary care was the move towards trying to finds ways to increase the size of the basic organisational structure.
1948 had seen Nye Bevan, for a whole range of very good reasons caused by the political reality, shy away from creating a salaried GP service. Having famously stuffed the mouths of consultants with gold, he gave GPs the right and the power to run their own businesses.
The real world of political achievement gave him little room for manoeuvre. Creating the NHS was not a matter of drafting the arrangements that you wanted. It took very hard bargaining with implacable foes running the medical trade union – the BMA. Only commentators with no feel for the reality of political achievement could criticise Bevan for the compromises that he had to make to get the NHS show on the road.
One of those was to grant to the nation’s GPs the right to organise themselves as small businesses having control over their own organisations. Unlike other small businesses however, GPs have a guaranteed state income and a guaranteed state pension. A privilege denied to small shopkeepers and painters and decorators who have to operate in a real, competitive market to make their money and their pensions.
So in 1948 hospital consultants became workers with the right to moan about the management, and GPs became small businesses with the right to run their own organisations.
This split creates all sorts of problems for integrated care (about which I will blog next week), since the problem is not just about getting generalists and specialists to work together, but the much more difficult task of getting those who work for large organisations (consultants) to work with those who run their own show (the GPs).
So the 50th and 60th anniversaries of the NHS came and went with GPs still running their own show and the vast majority of them running very small businesses while over the previous 50 years nearly all other industries had undergone a considerable increase in the size of the unit of delivery.
Customer preference had used markets to turn small grocers into supermarkets. Customer preference had used the same markets to change nearly every industry with large numbers of small outlets into bigger organisational units.
Since consumer preference was not driving primary care to change, their organisational structure stayed where it was.
The problem was that medicine needed larger organisational structures to deliver all of its potential benefits Primary care needed to be actively involved in carrying out the many more diagnoses and interventions that at the moment take place in hospitals..
I, along with many other people, cannot get a blood test at my local GP surgery. Instead I have to go to an international hospital to get something that should be available in my street from my GP.
A year ago there was a greater recognition of the problem of size in primary care than had existed in the previous 60+ years. Most parts of the country were talking about the creation of federations and building sets of relationships between GP practices and one year on this trend has if anything accelerated.
Most people see this talk of federations coming in part because of the creation of CCGs. CCGs have brought GPs together for the purpose of commissioning, not providing. However most of the activities that GP leaders of CCGs need to talk to their fellow GPs about concern variations between the way they practice as providers of care. Therefore creating larger CCGs has inevitably raised a string of questions about scaling up GPs practices.
CCG leaders have experienced what every leader in the NHS has experienced for the last 60 years – primary care is vital but very disorganised. It will only really be able to fulfil its role if it takes on much larger organisational forms.
And it is this that is behind the strong move towards federations.
However there are two real problems with this set of changes.
Firstly because it takes on some very ‘hallowed’ experiences (the right to run their own organisation), this sizing up of primary care will not happen quickly. Taking on several thousand organisational leaders and persuading them to give up a lot of the power they have to run their own organisations will not be a speedy process.
Secondly this change is voluntary. GP practices that choose not to do this will not lose their registered lists or their income. In all other industries that have scaled up the failure to grow meant that you either had to work much longer hours to make the same amount of money (small corner stores) or be taken over – often the only way you could stay in business. These drivers have not been built into this change process in primary care.
In short GPs will do this at the pace that they want to, not the pace that their patients need. This means that it is done at the pace of the producers of the service rather than the consumers.
One other change with GP practices continues apace. As I noted above Nye Bevan failed to create a salaried GP service, resting power instead in the hands of a small business structure with partners. For 50 years Bevan’s compromise created a career path which saw GPs seeking to become partners in order to run established organisations.
This is now being changed – not by fiat from Whitehall – but from the new career choices that new GPs are making. For a variety of material reasons new GPs are not choosing to tie themselves to this old organisational structure. They are now choosing to become the very people that GPs 50 years ago did not want to become – salaried staff.
Newer GPs, instead of yearning for the long term relationship with a locality that partnership gives, are opting for the greater freedom provided by being salaried staff. This is partly caused by the change in gender of new GPs, with the larger number of women wanting to be able to shift their work patterns around prospective family responsibilities and partly because the relationship between place and security that was behind the creation and continuity of this model 60 years ago has changed radically. Professionals want to be able to move around and being tied to a locality through a particular organisational relationship does not give the freedom of movement that being salaried provides.
This means that the organisational structure of NHS GP service provision is primarily being changed by the wants of the new workforce.
The problem for patients is that they need larger scale primary care now and not in the 20 years it will take to work these changes through.
Truthful answer?…. not very far. In two parts of London various bits of the failure regime have sounded a death knell for the old model of the local hospital, but I wouldn’t say we are a year further on in being able to explain to the public what any new model will look like.
It’s a good 18 months since the administrator argued for the breakup of South London Healthcare offering different possible solutions for different parts of the old Trust. One part was to be taken over by Kings College Hospital FT whilst another was to become a different model of local hospital.
And in October 2013 the Secretary of State (mainly) agreed to the reconfiguration proposals in North West London which amongst other changes agreed that there needed to be a new model for local hospital care in Ealing and a part of Imperial hospital.
The main thing to say about both these developments is that progress doesn’t happen quickly. My feeling is that in both locations the local trust is trying to construct its own model of the future. Of course such local ownership is a good thing, but it’s asking a lot of failing institutions to construct their own future.
And the NHS has been discussing new models of care for local hospitals for a good 15 years. This problem is not new to the NHS, nor is it something that will happen in only three or four locations.
In September 2012, in a pamphlet called The hospital is dead, long live the hospital, I suggested that there were between 20 and 30 locations where a new model would need to be created. 18 months later I would say this was an underestimate – the number is nearer 40.
The NHS has known for some time that this is going to be a sizeable problem and whilst the main performance management organisations of the NHS are concerning themselves with very many different aspects of the organisations they manage, there is no systemic, organised development of a new hospital model.
Given these organisations are spending time and effort looking into the future, the only reason such powerful bodies are not specifically developing new models of hospital must be fear.
Developing a new model of local hospital would mean publicly entering into a debate with the public about what hospitals should look like. Generally the way in which the NHS does this is pretty awful. I have read tens of documents making a case for change that begin by saying that because there is a remorseless increase in demand for healthcare there must be radical change, and when you get to the nature of the radical changes proposed they all look like cutting hospital services.
At the bare bones level the argument seems to say “The increasing demand for services is causing us some problems, so that is why we are closing your hospital.”
This is not reassuring.
The public recognise that there is rising demand for healthcare and they need some reassurance that there will be services there to meet it. They would really like these to be run by their local hospital. But the building is just an icon for them which the NHS seems obsessed with changing.
The public really do think the reasoning is strange. “Because there is much more business for the NHS we are going to close the place that does the business.”
Why not start by saying that because there is so much more business for the NHS we will be providing more services? I would think it very likely that demand and the need for healthcare will go on growing for some time and therefore we could probably start by saying that the locations where healthcare is being provided at the moment will be providing healthcare in the future. It’s just that the nature of the healthcare being provided will change.
From the point of view of the local hospital the number of patients going through their new model of care is likely to increase. But the numbers of people going through their building may decrease.
It starts with an interesting reworking of the label ‘outpatient’. At the moment outpatients have to go into the hospital for diagnosis and treatment. It’s actually quite curious that they are referred to as “out” patients.
The new model is reworked by the idea of moving outpatients to… er… outside the hospital. For this to work of course the consultants have to recognise that the bulk of their work will be outside the hospital. And this is the rub for the real change for a new model of local hospital.
Most hospital doctors (and nurses) choose to work in a hospital and not just for it. The major change in any new hospital model is to move the bulk of their work away from the fixed building that contains a load of in-patient beds. This is a radical change in the working practices of staff and will take a lot of managing.
But in financial terms the hospital can do much more business outside of the walls of the building.
That of course brings us to what is seen as the central issue – the buildings. It’s a pity that most of the people who manage hospitals seem to end up in the real estate rather than the health business. It would appear that the rate limiting factor in terms of change in the NHS has little to do with healthcare and everything to do with the fixed costs of the buildings.
And this is where leading NHS organisations could help local hospitals change their models of care.
In terms of change most other industries are more agile than the NHS because they have moved their proportion of fixed costs into the column called variable costs. In the NHS the idea of fixed costs is treated as … well… fixed. In other industries one of the main aims of policy is to gain more flexibility by moving costs into the variable column.
Individual trusts will find this hard. But collectively the NHS could tackle this by changing policy and rules.
The NHS is often disappointed when the public become fixated on the hospital building and seem less interested in services outside of that building. Yet by failing to tackle the issue of fixed costs for local hospitals, the NHS ensures that they remain fixated on buildings and not services.
So my main point is that over the last year not a lot has happened in terms of developing a new model of local hospital for the 30-40 hospitals that need to develop one. It would be good, if this blog were to report back in another year from now, for some progress to have been made.
One of the remarkable experiences of my last year has been to witness near universal agreement that the NHS needs to change fundamentally. Nearly all of the various bits of the NHS agree with this.
Most of their speeches and papers usually agree that the need for fundamental change exists in terms of both quality and finance.
If you look at speeches from…
- The Secretary of State
- The Chief Executive of NHS England
- The Chief Executive of Monitor and
- The Chief Executive of the NHS Trust Development Agency
…they continually say that there needs to be change which touches on the fundamental.
Many talk about the next 2 years being the defining moment for the NHS with a warning that a failure to change dramatically will put the institution in peril.
So much so universal.
I am sure these four individuals (one Jeremy and three Davids) really believe in the necessity of large changes, and given that they all run big organisations with, between them, thousands of staff responsible for parts of the NHS, one might expect that their organisations would all be beavering away at the forefront of radical change.
You might expect that if you met a civil servant from the DH, or an employee of NHS England, Monitor, or the TDA they would all be raising questions about how, in order to save the NHS, you were developing your new business model. Given that the leaders of these large organisations are preaching very radical change, then you might expect their staff to be an active part of a massive engine of change.
But you would be wrong.
Whilst the leaders talk about the need for radical change, their staff enforce the old business model that their leaders say is finished.
This can be a bit bewildering for, say, a CCG. They will read NHS England’s call to action and may well start to develop some commissioning intentions and activity that will radically challenge the existing providers of healthcare to change their business model.
They will then discover that their Local Area Team, as a part of NHS England, will sharply question why they are doing something that will ‘destabilise local providers’. A wise CCG will then quote David Nicholson’s letter as a defence of such radical plans back at the NHS England employee.
Usually, and without hesitation, said employee will tell the CCG to pay no heed to that because all that matters is that the health economy breaks even financially – and that if you ask your failing local District General Hospital to do something different, they will financially fall over.
So stop it.
The leadership of Monitor and the NHS TDA both recognise that, for many of the NHS’ acute and mental health trusts for which they are responsible, the current business model is running out of time (and money). There is even encouragement for Trusts Boards to think about radically different business models and models of care.
But woe betide any board, in thinking through those new business models of care, that might opt to forgo any of the finances that come from within the existing model of care. If that happens Monitor and TDA staff will very quickly threaten them with lower ratings if they fail to squeeze every financial drop out of the existing business model.
So these important organisations have a policy of radical change in the NHS…
…and a practice of not allowing that radical change to happen.
On many Trust and CCGs boards there are one or two senior staff who think about going through the difficult process of radical change. But the difference between policy and practice within the major organisations running the NHS makes arguing for the necessary change within the NHS very hard indeed. Those against change argue that the practice of the main performance managers in fact penalises change by enforcing the status quo.
If the necessary changes in the NHS care model don’t happen this will in part be the fault of the very organisations whose leadership appear to be arguing for them.
Practice beats policy every time.
Having posted about last year’s developments in the politics of NHS reform, I would now like to look at what is happening to reform within the NHS itself.
I stopped blogging just before the Health and Social Care Act began to be implemented in April 2013. If it seems as if the Act has been around for a lot longer than 11 months that’s partly because most of the new architecture was up and running before last April.
How does it seem a year on?
The most significant impression I have is that very few people within the NHS actually understand how their organi
sation fits into the system. One of the main reasons for this, which I reflected on last week, is that the politicians who were responsible for the reforms have not taken the time and effort to explain how they should work. So no one has explained to the people who have to make the system work how each bit of it interacts with another.
This political failure was compounded by the fact that one of the main parts of the new architecture, the NHS Commissioning Board, was allowed to change its name to NHS England from April 2013. This change of name was deliberate in that it gave everyone in the NHS the impression that one organisation was in charge of everything.
If an organisation is called “NHS England” then it seems reasonable that the average person in the NHS – working in England – would believe that this is in fact the organisation in control of the NHS in England.
Once the name sticks the legal fact that it isn’t in charge of the NHS seems a bit contrary. The law becomes secondary to the organisational title.
This leads to many happy hours of explaining to people that whilst the label “NHS England” may appear to put that organisation in charge of the NHS in England that is not in fact the case.
Consider the important example of an NHS local hospital trying to develop a new model of care. This is a really important issue for the future of the NHS and tens of local hospitals are trying to do just this.
Since NHS England is a commissioning organisation of specialist and GP services it has a role in these areas – deciding what care it wants to commission.
But it has no role in deciding what new model of care an NHS provider should develop.
Locally that task falls to the Board of the hospital itself. It is the Board that has to work through the possible future offer of health services and to work out with local commissioners what they might want to commission.
Nationally, if the local hospital is a Foundation Trust, then the board needs to work with Monitor to think through how they will assist with that development.
If they are not an FT that task is carried out by the NHS Trust Development Agency.
Both of these organisations have the legal responsibility to help Boards develop their models of care.
NHS England – at a national and local level – has no power over provider’s boards.
But that does not of course stop them from claiming it.
They do so because NHS England, at a local and national level, has a lot of staff who previously worked for Strategic Health Authorities (SHAs) and, when they worked for the SHAs, they were used to telling providers what to do. For non FTs SHAs had the responsibility to performance manage such organisations.
The fact that they now work for an organisation that has no such role does not stop them from exercising it.
However, as I said last week, you can hardly blame staff in NHS England when the Secretary of State himself regularly ignores the law, that he voted for, enshrined in the Health and Social Care Act.
Many commentators seem to wish for the SHAs to be recreated sometime soon. In fact I am told that many of the staff of NHS England see this as inevitable. They are imminently expecting another reorganisation to give them back their powers to run the system.
So having created a title that gives them the appearance of running everything, all they need now is a law to back that up.
(Ed Miliband on the Marr programme)
When Ed Miliband said this in January he was talking about the energy industry. One of the major planks of his policy for developing a new economy is to encourage and enable much more active consumers.
Active consumers challenge provider bad practice in two ways.
First they make a fuss about their existing supplier. Increasingly they may join a range of campaigns about how badly they are treated – and social media is making those campaigns more powerful every day. The political scientists (and Ed Miliband) call this ‘voice’. Increasingly consumers let the world know when they get bad treatment and they say it ever more loudly and in greater numbers. The reputational costs for providers of services that have campaigns run against them can be immense. So providers worry about consumer voice.
Second, where there is competition consumers have the right to take their business somewhere else. Political scientists call this ‘choice’. In the energy industry Ed Miliband makes the important point that exercising choice is difficult. He is committed to making it a lot easier for consumers to move their business. And where there are monopolies he will develop policies to break them up and provide the consumer with more choice.
Whilst voice can raise problems of reputation for businesses, it is the loss of customers through choice that is the direct driver for companies to improve service. If there is no choice the impact of putting consumers at the heart of change is diminished. Thousands of active consumers combining voice and choice will have an impact on bad providers – or they will lose a lot of business.
The important political point for Ed Miliband here is that given his committtment to stand up for consumers against monopolistic power in the private economy where does he stand on the issue for consumers of public services.?
On February 10 he made a speech addressing the problem for consumers of public services. In this speech he clearly said that he was as committed to tackling the abuses of power of public services as he was of private services. This is a new dimension to the recent post-2010 politics of the Labour Party and of course will have a big impact on the politics of the NHS.
If you are to win votes from voters outside your tribe then good politics is all about developing positions that are a bit different from those that the tribe expected. A traditional Labour position attacks the power of private companies over consumers but has not attacked the power of public organisations over citizens.
So when his Feb 10 speech talks about understanding that that there are people feeling powerless because of state institutions and not only private sector companies, he is making an important and not completely expected point.
The speech went on to talk about enhancing the power of the citizen in developing their voice in gaining more power in public services. There were important promises for parents (and in the future patients) on developing their public voice to have a greater say. In particular a part of the speech that could have a big impact on the NHS was the promise of helping individual patients organise themselves with similar patients. This blog has often spoken about the importance of patient organisations developing a more powerful collective voice for individual patients. This is potentially an important and practical policy.
He was talking about people powered public services.
But when it came to choice he said that this was different for public services because parents don’t choose a school in the same way that they choose a café. That’s true. A café choice is made every day, and a school choice once every few years. That makes them very different choices – but they are still choices.
And parent choice of schools informed by information from Ofsted has had and is having a big impact on driving up standards. Just as for a private company if you don’t listen to the voice of parents about your school then parent choice will have a direct impact on your bottom line. Head teachers who don’t care how parents use their ability to choose schools don’t last long.
To allow consumers in private industry to use the power of choice is a vital way of empowering consumers.
Not to allow citizens who use public services to use the power of choice will limit their empowerment.
If you want to improve public services people need all the power they can get, choice as well as voice.
Over the last year the idea of outcome based commissioning within the NHS has evolved from being a policy to establishing real contracts. In a little while a completely new provision for musculoskeletal (MSK) services will begin in Bedfordshire organised by a partnership of a local Foundation Trust (FT), an existing GP led MSK service, a private sector hospital group and patient charities. This partnership will replace a plethora of very different and fragmented contracts that are currently held by different organisations, each of which was contracted to provide fragmented care inputs.
It’s a big change, and the journey to establish outcome based contracts has been characterised by long periods of universal agreement punctuated by periods of intense conflict. Why has this happened?
Those with experience of working to change policy in the NHS will recognise that dangerous moment when everyone agrees that the new policy you are trying to create is correct.
It is the moment when you prepare… for nothing to happen. All sorts of people agree with a change in policy – because in the end no one cares about changes in NHS policy. What matters are the changes in NHS practice that will take place if a policy is implemented.
Unsurprisingly this has been true of the recent development of outcome based and integrated care contracts in the NHS. From 2010, with the development of the NHS outcomes framework followed by the Secretary of State’s mandates for NHS England, most policy has argued that the NHS should start judging itself on patient outcomes and not inputs.
At the level of policy few can disagree with that. Intellectually we know that money spent on a hip replacement operation only creates real value if the patient can resume work – or walk to visit their daughter without pain. The policy of paying for outcomes and not inputs must be correct at an individual, social and economic level.
Equally most policy makers are quite rightly concerned about the current fragmented care for the elderly. So it’s interesting that when you ask older people and their organisations what would count as a positive outcome for their care the answer is very simple.
“Since you spend so much money on our health and social care, what we would like is that every time we come into contact with the health or social care system, we are more independent at the end of an intervention than we are at the beginning”.
The individual social and economic outcome of greater independence must be a good thing and, if we could achieve it, surely worth the money that is spent on the service. As a goal it’s difficult to argue against.
But current provider practice is all about fragmented inputs. Moving to new, patient based, outcomes is very disruptive of current practice. The problem is that a great deal of existing practice produces the opposite outcome for older people in that it creates greater dependence. If the long term condition of an older person becomes exacerbated – resulting in a 12 day emergency admission to hospital – this hospitalisation will normally leave the patient with a higher level of dependence. If they move wards several time during their stay, they may even have increased experience of dementia and therefore substantially increased dependence.
A contract based on paying a provider only if they achieve greater independence for this older person would therefore need a very radical shift in practice. And it is here, at the point of implementing a policy of outcome based contracts, that the near universal agreement with the policy disappears. Providers recognise that in order to maintain financial sustainability they will need to radically change the way in which they operate.
It is at this stage that we are told that working to patient outcomes will destabilise the NHS.
And if we take that last sentence literally it is true. The current stability of much of the existing model of care from providers has evolved from the experience of fragmented care that many patients regard as normal. Integrated, outcome based, health and social care will destabilise these existing models of care – and that will be a good thing. .
Because policies really don’t matter if they aren’t implemented, and over this calendar year we will see whether the NHS and social care can bring about the change that comes from working towards outcomes.
In recent weeks Oxfordshire Clinical Commissioning Group (CCG) passed proposals for the CCG to work with existing providers to develop outcome based contracts for older people and mental health services. The CCG have now reached the point where they have to negotiate with existing providers the radical changes that working to outcomes will being.
By deciding to work with existing providers the CCG have demonstrated that the development of outcome based contracts does not have to involve market based procurements. The CCG recognises that existing providers may have the capability to radically reorder their priorities. But they have the option to hold an open market procurement for the roll-out of 2014-15 contracts should dialogue at the point of contract agreement not be successful.
As in Bedfordshire outcomes based contracts will necessitate new ways of working which will need new forms of provider partnership.
Elsewhere the movement is gaining widespread support with CCGs backing prime and alliance models of contracting, to change and challenge the commissioner/provider relationship where existing models simply don’t work. Along with Oxfordshire, other CCGs leading the way include Cambridgeshire, Bedfordshire, Bexley, Northumberland, Croydon, and Staffordshire.
In all of these locations and more, the crunch will come when the idea moves from being a policy to making the necessary changes in the practice of provision.
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.
The last 10 months have made it clearer and clearer that Jeremy Hunt, as Secretary of State for Health, can only do the job the way he wants to by completely ignoring the reforms of the NHS brought in by his Government.
We have one of the most activist Secretaries of State for Health of recent years operating within a legal system – that he helped to create – which grants him very few of the powers that he feels he needs to carry out the role.
There are hundreds of Conservative party quotes attacking targets that I could use but I’ll just take one, from their 2008 document, Renewal.
“The problem is Labour’s strategy of trying to manage the NHS through top down centralised targets. These targets focus primarily on processes and administration such as stipulating the time it should take for patients to be processed through their treatment, or for administrative procedures to be completed, rather than the actual results of patient care”
Phoning up chief execs of NHS Foundation Trusts to quiz them about their A and E performance ignores several bits of the legislation that he helped to get through parliament.
He will of course remember, as he phones the CEO of an Foundation Trust, how para 1.5 of the White Paper “Liberating the NHS” (that he agreed in Cabinet in July 2010) said
“We will legislate to establish more autonomous NHS institutions with greater freedoms, clear duties and transparency in their responsibilities to patients. We will use our powers in order to devolve them”.
I am sure the CEO of the FT will feel, as he is being called by Jeremy Hunt, that he is part of a more autonomous institution…
First let’s get one issue out of the way. There are those that say that Jeremy Hunt’s job as Secretary of State for Health is made much more difficult by the fact that he has to work within a structure created by NHS reforms that reflect the ideas of his predecessor Andrew Lansley – and that he in fact had nothing to do with the structure and the law that he now chooses to ignore.
The argument goes that Andrew Lansley had a very idiosyncratic view of how the NHS should be organised and that given just how individual that was it’s hardly surprising that Jeremy Hunt needs to do something different.
This argument depends upon Andrew Lansley having acted purely as an individual who one day simply implemented his very individual plan.
But it wasn’t like that. That’s not what happened. Andrew Lansley was a member of a Cabinet that discussed his plans on several occasions – and on each occasion the Cabinet decided to go ahead with these plans.
Andrew Lansley was a Member of Parliament who belonged to the party that formed the greater part of the Government. Jeremy Hunt is a Member of Parliament who belongs to the same political party. He voted for the Health and Social Care Act on very many occasions. He signalled his agreement with Andrew Lansley’s plans by voting for them on all those occasions.
So it may be that these reforms were odd, but they were actively supported on many occasions by the Coalition Cabinet (member Jeremy Hunt) and the Conservative Party in Parliament (member Jeremy Hunt).
And my obvious point is that Jeremy Hunt was an active part of the processes that enthusiastically agreed the plans for a new NHS structure that he now ignores.
In Cabinet in July 2010 there would have been a discussion of the White Paper that specifically argued for a much smaller role for the Secretary of State in running the health service.
In Cabinet in December 2010 there would have been a discussion of the biggest Health Bill in history where clause after clause outlined how a new architecture of independent organisations would take power away from the Secretary of State.
In 2011, given the trouble that the Bill was in, there would have been several other Cabinet discussions about the Bill. In each of these the Cabinet collectively (member Jeremy Hunt) decided to go ahead with the reforms.
Jeremy Hunt was an active member of this Cabinet. He was a part of these discussions which collectively agreed to push them forward.
These reforms – which the current Secretary of State now finds it difficult to live within – were agreed personally by him over a long period of time.
They are just as much Jeremy Hunt’s reforms as they are David Cameron’s and Andrew Lansley’s.
Jeremy Hunt’s problem is that the reforms he voted for and passed into legislation created a system which now gives him insufficient power to carry out his work in the way that he feels he needs to.
You might think that the daily spectacle of a Conservative Secretary of State trying to wield powers that he personally contributed to removing from his office, would be a matter for some derision and scorn from Her Majesty’s Opposition.
There are hundreds of quotations about not making top down decisions which could be thrown across the chamber at Jeremy Hunt and contrasted with the need to intervene he seems to feel every day.
The opposition could make him a figure of fun for doing the opposite of what his legislation signed up to.
But they don’t. No one says this is weird because the opposition think that if and when they take over the role of Secretary of State for Health they will also be looking to use as much power as possible to tell people in the NHS what to do. They relish the thought of telling CEOs what they can and cannot do and are rather pleased that they don’t really seem to need legal powers to do that.
Their failure to point this out doesn’t change the rather odd nature of what is going on though.
…on NHS and social care policy.
Today sees the launch of a report by John Oldham’s Independent Commission for the Labour Party into health and social care policy, and to declare an interest up front, John is a close friend of mine.
Those that know him will recognise that his report “One Person, One Team, One System” is very much his own (and his colleagues on the commission). By which I mean that it is not owned by the Labour Party and some of it will make difficult reading for the Shadow Secretary of State.
That is why it’s interesting that today’s report will be publicly received with a speech by the leader of the opposition Ed Milliband. One of the reasons that he is playing such a big role in receiving the report is because it does not support the line taken by some of his Shadow Secretary of State’s speeches. It therefore provides the Leader of the Opposition with an opportunity to drop some of the things his Shadow Secretary of state has said he wanted to do.
Again, those that know John Oldham will not be surprised that his report is based upon a radical critique of the current delivery of health and social care for NHS patients and social care service users.
The press release begins:
In 2014 the NHS and social care work very hard to deliver a model of care that was created for a different population with different diseases. It mainly provides a wide range of good episodes of care aimed at improving the health of parts of the body but this does not meet the needs of our current ageing population. At the moment 70% of the health and social care budget is spent on older people with long term conditions and much of considerable resource is not well spent. The crisis for the NHS and social care is that in order to meet the needs of our new ageing population needs to radically change its model of care. It finds it very hard to do this”
In truth none of this is news to any of the leadership in the NHS. But the case for change in John’s report goes a few steps further because it is most strongly voiced by the people themselves. People receiving fragmented care need a radical new approach over the next parliament to rework the health and social care system to meet these new needs.
And one of the things that is most needed to bring about this radical change is for the next Labour Secretary of State NOT to launch a reorganisation of the health service.
We do not need a new Health and Social Care Reform Act.
We do not need to change the local commissioning structure for NHS care by giving it to local government.
We do not need a new reorganisation of NHS structures.
As the press release for the report continues:-
“It is vital that the next Government leads this change and does so without a complete reorganisation of the structures of NHS and social care. The recent reorganisation has left the NHS and social care demoralised and not able to understand the system within which it is meant to be working. A further reorganisation in 2015/2017 would place the whole system in very great peril.
The next Government must dedicate itself to improving health and social care outcomes for patients and service users defined by them. Government leadership is needed to change how the organisations that provide care actually behave with people It should not spend time passing legislation to change structures.”
How the Labour leader and his Secretary of State for Health respond to this challenge will be an important part of the politics of health over the next few years.
“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.