Let’s not shed any real tears for the passing of Strategic Health Authorities
Filed Under (Failure regime, National Commissioning Board, Strategic Health Authorities) by Paul on 25-02-2013
In the last few weeks I have been fortunate enough to have been involved in a simulation about how the new NHS architecture will work rolling forward. I don’t know if you have ever been a part of a simulation but they gained traction in the early 1990s when the famous Rubber Windmill (pioneered by Alasdair Liddell) took place. This rolled forward the new architecture of the time and gave people playing the simulation the opportunity to see not only how the architecture would work but much more importantly what they would actually do in this new world.
Since then the method has been used many times to understand how a policy works its way through giving real clinicians and managers the opportunity to work and behave within the new architecture.
What is interesting about such simulations is how both the small and the big changes work. If we role play from the year 2013 to 2014 we quickly see the big decisions looming for the local NHS.
Inevitably, given the coming demise of SHAs, there are some that feel that the tier of management that developed strategy is going and that the capacity to make strategy will go with it.
But that is to confuse titles with reality. Just because an organisation is called a Strategic Health Authority does not mean that it created strategy. What SHAs mainly did was to pass down actions that were expected by the centre. So given the stock management culture of the NHS this meant that the NHS Management Board raised its voice a little on a Tuesday, the SHAs shouted at the PCTs on a Wednesday and at the NHS providers left – who did not have FT status – on the Thursday.
Whatever this was we should not mistake it for strategy.
And it is at this time of year – towards the end of year closing of accounts – when what passed as strategy took place at highest volume in the NHS. For it is at this time of year that the DH expects the SHAs to ensure that as few NHS organisations as possible end up in deficit.
It was therefore at this time of year that PCTs and their local NHS providers were summoned by the SHA to gather in darkened rooms where the PCTs would be leant on to cough up a few million pounds to providers to make sure that they weren’t in deficit. Never mind the fact that they were in deficit and had economically failed that year. The role of the SHA was to lean on the PCT to cough up a bit more money to make the books balance.
The role of the Strategic Health Authority is effectively to make the PCT steal money from organisations that are succeeding to pay for organisations that are failing.
Again you can call this process whatever you like – ‘bungs’ is quite a good name – but it is definitely not a strategic approach to developing the NHS.
And as I have travelled the country over the last few weeks I have heard this traditional bullying of PCTs to deliver bungs going on as normal. With only 6 weeks to go learnt SHA behaviours are still being carried out to the end.
So who will do this next year? Certainly there are elements in the NCB who think it is still their job. (This is hardly surprising since so many NCB staff have a track record both of running NHS providers and holding senior management positions in the NHS).
But the big difference next year will be that the organisation that needs to organise the bungs – the NHS Trust Development Agency – will be separate from the organisation that can lean on the CCGs – the National Commissioning Board. I am sure there will be elements of the NCB who will see this as their job, but the bungs won’t be able to flow from one part of a single organisation to another.
I am sure the NCB will, over the year, build what they will see as a failed NHS hospital emergency fund but their crisis, the one that matters to their organisation, will be the problems within CCGs. The NCB will be judged over 2013/4 on the success of CCGs and not by the size of the deficits in the remaining non-FT NHS trusts. That will be a separate problem for a completely different organisation.
So the passing of the SHAs will not mean the passing of strategy, but it will mean the passing of a single organisation that could, in the last 6 weeks of every year, move money around to hide those NHS organisations that are failing.
Not sure if that is worth a tear or a cheer?
There’s a bit of a cycle here- the NHS saying it’s going to be rigorous and not hide failure, then a rapid U turn when the consequences of this become apparent and too difficult to deal with. Paul has noted the absence, still, of an effective failure regime. The people running the new system are the same people who ran the old system. It’s always a mistake to say things can’t change, but a full blooded market system may be too scary for the politicians when they realise what it means.