If the answer is David Nicholson – what was the question Andrew Lansley was asking?
Filed Under (Culture of the NHS, Reform of the NHS, Secretary of State) by Paul on 07-01-2011
One of the main issues for Andrew Lansley in 2011, during what is meant to be his first year of implementing his “revolutionary” reforms, is why he has appointed as his main ally in this difficult daily struggle for reform someone who so fundamentally disagrees with him. This disagreement is not intellectual (despite all the attempts at bluster David Nicholson has a very fine intellectual capacity even if he would hate that to be recognised), but is, as we will see, a very significant cultural difference. Culture is “the way in which we do things around here”. And David Nicholson is very much not the way that Andrew Lansley “does things around here”.
How did this happen?
It happened because of a large political and analytical error that the Tories made about reform and the NHS. Indeed it’s a mistake they have made about reform in others areas too, probably in education and in welfare reform, but it’s in health where it has taken just 7 months to come home and bite them.
They came to power in May 2010 with a firm analysis that NHS reform had not happened and that they had to get it going. Their analysis in health was a simple one. Reform had not happened. The NHS was being run “top down” as a single organisation by the people at the top telling the people at the bottom what to do. One of the main reforms they would bring in were market based reforms that would insert a set of price incentives into the system – with a clear distinction between those who purchase health care and those that provide it – and that these reforms would stop NHS bosses from telling people what to do.
The rhetoric from May to December was clear. The problem was the “top down” NHS bosses who were to be swept away over the next few years and replaced with empowered clinical commissioners and an economically regulated market place.
They could have come in with a different analysis. In 2000-2007 Tony Blair started to carry out a set or reforms. 2007-2010 Gordon Brown, and in particular Andy Burnham, had been at best ambivalent about them and had tried to slow them down. But in many places they were churning away, developing aspects of the market that the new Government wanted to move further.
A wise Government would have looked at what was going on in the summer of 2010 and found some elements with which they wished to press forward and some elements where the old NHS was getting in the way. They would have carried out a quick analysis of what was going in their chosen direction and found ways of giving it more power, combined with an analysis of what was stopping them and removed those barriers with increased vigour.
Of course the July White Paper would have been their policy and their direction but they would have developed that direction on a terrain where they recognised things were moving in their direction. This would not just have been a hypothetical analysis but would have been one where they looked for allies who were perhaps part of the dreaded NHS bosses but were pro-market and pro-reform.
That analysis would have led to actions which saw some PCT Directors and CEOs being brought into the centre of the DH to use their skills to develop the National Commissioning Board. To work out with Monitor how prices were working and how they could be made to work better.
And a recognition that the old style of the NHS – where nearly every CEO still did not have the experience of actually buying health care would have been infiltrated by people who had commissioned health care and knew what a market was when it was working.
Instead the analysis was that NHS bosses were all bad and represented the old way. GPs are good and represent the new way. The new way will take over the old – all will be fine. It is this sort of analysis that has led the Government to be called Maoist where it sees that everything has to change at once and May 2010 is a sort of year zero where no real change had happened before Chairman Lansley took over.
In December 2010 the childish simplicity of this analysis came to grief. No 10 frightened by its own Maoism said that these long term reforms are all well and good but how is the NHS going to save money in the short term? I know, let’s appoint someone who clearly doesn’t agree with the reforms but can save money and keep the show on the road whilst the changes happen.
Given that the analysis of NHS bosses is that they are all the same, all part of the problem and not part of the solution, let’s appoint the biggest boss of them all to hold everything still.
A different analysis in the summer could have created a cadre of people from the past to organise the future that at least has some experience of commissioning health care. They could have had people who had been actively getting what there was of the market to work to develop the next step in that market. Those with the experience of that market could show how a number of small but significant changes to the contract will help that change happen.
But the analysis was they were all the same. Nothing before May 2010 had changed and therefore there was no real experience of change.
David Nicholson along with most others that run SHAs has run hospitals. They treat the NHS as if it is one big organisation like a hospital. They tell it what to do just like they tell one big organisation like a hospital what to do.
The operating framework makes it clear that over the next two years the DH and the SHA will have much increased top down powers of the NHS. As the SHAs disappear in 20011/12 David Nicholson can make them reappear within the regional offices of the National Commissioning Board. The NHSCB will have a leadership which has no experience of commissioning, very few beliefs in the power of markets, and hundreds of years experience in telling people what to do.
So imagine you are a GP Commissioning Consortia and you go to the shadow NHS Commissioning Board and you raise an issue that is quite near the front of the concerns of most GP Commissioning Consortia. You say that we would really like to come and have an early discussion with you about the nature of the contract we have been given to manage with hospital providers. GPCCs may well feel that these contracts have been written, not with an eye to empowering the purchasers of health care, but to empowering the providers of health care. So you come down to London and search out the new CEO of your commissioning board and you raise this as a complaint.
What do you see? You meet someone who has spent their life working for providers of health care. Who has been responsible for the development of the very contracts that you feel represent the provider against the purchaser. What is he going to say? “You are quite right dear GP. We have, until this moment, got these things wrong and we will put it right.”
Or is he going to act as he has before? And say “Look at the operating framework. Your job over the next two years is to hold everything still – not to go around being disruptive with talk of change.“
It’s a strange place for a Government that came in wanting change only 7 months ago to get to.
One of the reasons this will go awry is that the culture of the past that ran the NHS for most of 60 years has been wrongly called a “Command and control Culture” It should in fact be called a Command Culture with very little control. There has been (and now there will continue to be) a lot of shouting but in fact not a lot of control.
A Tory Government has put its immediate future into the hands of ineffectual Stalinism
I agree with most of what you have written and waiting to see the Health Select Committee’s second report into Commissioning.The question I would like someone to answer as a patient/carer is (How many of the Acute Trusts in England have issues Capacity notices in area like general Surgery? and how will any of the new policys address this?also what does this do for Choose & Book.
The private sector under the leadership of Nr Nicholsons policys have creamed off a lot of the easy case load leaving the difficult cases for the Acute NHS sector.
“Ineffectual stalinsism” is a pretty harsh assessment of some important improvements in NHS services over recent years – minimal waiting lists, major improvements in stroke, cancer and heart disease pathways, etc. Yes, there is still much more to do but these have generally been pretty uniform improvemens across the (English) NHS.
The “full throttle” marketeers however (and does this include yourself, Paul?), have yet to explain how such uniform progress will be consistently secured under these reforms. The new outcomes frameworks, for example, look at some of the right things but are toothless, and set no benchmarks for improvement.
Look at the growing list of NHS communities restricting treatments, likely to worsen in 2011 with QIPP undermined by the chaos of reform.
The NHS may stay free at the point of use but its boundaries will narrow, just like in social care. Then we may be into top-ups, and nostalgia for a lost era.
Uniform progress I like,yes how does this work?not by recruiting staff without due process.Otherwise you get people who whatever the cost to the NHS,do what thay are told!!!!!!I think that was what Paul was highlighting the gang bang!!!!
Dear Trevor
I would not characterise the organisational politics of the last 10 years of the NHS as Stalinism because there have been consistent reform levers put into the system to help bring about the improvments that you mention. There has been a growing battle between the Stalinism of the past and the reform levers of the present and the future.
The problem is that this Government, in a panic over the disruption caused by their transition, haved decided that during that transition they will hand over the risk of the transition to Stalinism. They have created a pact with the past which says – if you, the past, can get us through to 2013 in a good position, between now and 2013 we will construct an authority position for you at the centre which will mean you can tell PCTs what to do. We will make that easy for you by stealing 2% from the PCTs allocations and giving it to you and the centre to construct a large “bung” fund with which you can reward failure. And we will cluster the 152 PCTs into, at the most 50, so that you can get them all in a room and shout at them. This is not reform.
But as I say it is a Faustian pact where Andrew Lansley says “I completely disagree with top down NHS bosses. But if top down control can get me to my reform paradise in one piece then for the next two years I am giving control of the the NHS to the thing that I believe is wrong”
This wont work as a transition.
And inter alia. A centrally controlled NHS or other public service does not get rid of variation. In fact through the attempts by the centre of the NHS to control the organisation those variations have been enormous. Attempting to run 1.4 million people as a single organsiation does not stop variation, it encourages it, because the parts of the organsiation that are not good do not have the mechanism for improvment and change that differntiation brings.
Best, Paul