A Healthy Challenge

by | Apr 25, 2007 | Project 100: Health & social care | 0 comments

The most significant issue facing an incoming Prime Minister is that despite very significant improvements in the NHS there is a widespread belief that it is getting worse and may even be in crisis. The fact that neither of these beliefs are true is irrelevant. Worse still, there is widespread disquiet about the nature of many of the current reforms amongst many staff – particularly clinicians. This has been made worse by the frequent reorganisations, the most recent of which was particularly poorly conceived and clumsily executed.

So the first task for the new Prime Minister is to resist the urge to do any structural tinkering with front line organisations in the NHS.

But, it’s not just a case of starting to be nice to the providers and listening to staff more. Some of the reforms are rightly designed to create discomfort and therefore change services that are not sufficiently responsive. Many staff are disaffected because they believe that they are instruments of public policy in which the Department of Health, rather than patients, is the real customer. So, while the Department of Health thinks it is pursuing patient interests this is not how it appears to many front line staff.

The second task, therefore, is to change the focus from the pursuit of targets about bits of the process, such as time spent in A&E, to one that is about quality of outcomes, patient experience and safety but without the anti-professionalism that appeared to be present in earlier policy.

The third task is to challenge the hierarchy and role of the Department of Health. We know that Gordon Brown is considering how to make the NHS more independent from central government, however issues about size and hierarchy may be more important. The NHS is too large to manage as a centralised system and recent policy has made some reference to creating a more decentralised structure.

The problem is that the system has a deep habit of relying on hierarchy and decentralising often means the level immediately down the chain assumes it now has the power. The front line feels no difference. Not only is a centralised chain of command inappropriate for a highly complex organisation, it has a debilitating effect on the governance of local organisations. If local organisations are always expecting to be told what the priorities are, if the Strategic Health Authority Finance Director is constantly looking over their shoulder, then it is unsurprising if initiative and good governance is stifled. The people in hierarchies are well intentioned and genuinely think they know best. But, they see a different picture, not necessarily a better one.

Without a shift in power (but remembering that there are some central functions that make sense) independence could actually make the NHS more centralised by investing power and accountability in a central board. The focus needs to be local and the test of success is public and patient experience, health improvement and outcomes.

One concern of many health professionals is the way that a number of the reforms, and the Department of Health’s approach to them, tends to encourage fragmentation of care between providers. High quality care needs more integration, not less. As the policy conversation shifts towards looking at quality and experience the task for policy makers is to make sure that the incentives and policy design really reflects the need for integrated, well designed care that deals with the whole patient experience not just separate bits of their care.

Improving the health of the public is the responsibility of all government departments, but measures to improve it pay back in many years time. The pressure to deliver services tends to overcome the longer term need to invest in health improvement. One way to tackle this would be create incentives for long term investment in health improvement. These investments are like buildings – they are an asset with a future value. The task here is to treat health improvement as an investment for the future that is the responsibility of all agencies, not the bit left at the end when current services have had their share.

Finally, a key thing for the next Prime Minister to do in their first 100 days might be to ask ‘why’ and to keep asking it until they are sure that all the advice, good ideas and dogma they will be offered is valid or, as may well be the case, on the same intellectual and evidential level as suggestions of further restructuring.

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A Healthy Challenge

by | Apr 25, 2007 | Articles, Section: Article | 0 comments

The most significant issue facing an incoming Prime Minister is that despite very significant improvements in the NHS there is a widespread belief that it is getting worse and may even be in crisis. The fact that neither of these beliefs are true is irrelevant. Worse still, there is widespread disquiet about the nature of many of the current reforms amongst many staff – particularly clinicians. This has been made worse by the frequent reorganisations, the most recent of which was particularly poorly conceived and clumsily executed.

So the first task for the new Prime Minister is to resist the urge to do any structural tinkering with front line organisations in the NHS.

But, it’s not just a case of starting to be nice to the providers and listening to staff more. Some of the reforms are rightly designed to create discomfort and therefore change services that are not sufficiently responsive. Many staff are disaffected because they believe that they are instruments of public policy in which the Department of Health, rather than patients, is the real customer. So, while the Department of Health thinks it is pursuing patient interests this is not how it appears to many front line staff.

The second task, therefore, is to change the focus from the pursuit of targets about bits of the process, such as time spent in A&E, to one that is about quality of outcomes, patient experience and safety but without the anti-professionalism that appeared to be present in earlier policy.

The third task is to challenge the hierarchy and role of the Department of Health. We know that Gordon Brown is considering how to make the NHS more independent from central government, however issues about size and hierarchy may be more important. The NHS is too large to manage as a centralised system and recent policy has made some reference to creating a more decentralised structure.

The problem is that the system has a deep habit of relying on hierarchy and decentralising often means the level immediately down the chain assumes it now has the power. The front line feels no difference. Not only is a centralised chain of command inappropriate for a highly complex organisation, it has a debilitating effect on the governance of local organisations. If local organisations are always expecting to be told what the priorities are, if the Strategic Health Authority Finance Director is constantly looking over their shoulder, then it is unsurprising if initiative and good governance is stifled. The people in hierarchies are well intentioned and genuinely think they know best. But, they see a different picture, not necessarily a better one.

Without a shift in power (but remembering that there are some central functions that make sense) independence could actually make the NHS more centralised by investing power and accountability in a central board. The focus needs to be local and the test of success is public and patient experience, health improvement and outcomes.

One concern of many health professionals is the way that a number of the reforms, and the Department of Health’s approach to them, tends to encourage fragmentation of care between providers. High quality care needs more integration, not less. As the policy conversation shifts towards looking at quality and experience the task for policy makers is to make sure that the incentives and policy design really reflects the need for integrated, well designed care that deals with the whole patient experience not just separate bits of their care.

Improving the health of the public is the responsibility of all government departments, but measures to improve it pay back in many years time. The pressure to deliver services tends to overcome the longer term need to invest in health improvement. One way to tackle this would be create incentives for long term investment in health improvement. These investments are like buildings – they are an asset with a future value. The task here is to treat health improvement as an investment for the future that is the responsibility of all agencies, not the bit left at the end when current services have had their share.

Finally, a key thing for the next Prime Minister to do in their first 100 days might be to ask ‘why’ and to keep asking it until they are sure that all the advice, good ideas and dogma they will be offered is valid or, as may well be the case, on the same intellectual and evidential level as suggestions of further restructuring.

Submit a Comment