What of the bill?

First published on Oct 11th 2011

As the Health Bill returns to the House of Lords for its second reading, what are peers expected to make of the increasingly vociferous messages directed at them?

I have written before about how most of the reporting sits at one or other end of a polarised debate, often showing limited understanding of either the NHS or this entire sector of our economy.

Andy Burnham, the new shadow secretary, says scrap the bill and we will work with you.  But this is to deny the fact that the fabric of decision-making structures has already been dismantled beyond the point of no return.  Going back is not an option.  Too much has already changed for that to happen.  Stopping mid change, leaving a vacuum within which confusion and indecision reigns is arguably even worse – possibly the surest way to seal the very demise of the NHS that people are clamouring to avoid.

It is therefore incumbent on the Lords to avoid the temptation for filibustering, scoring points from each other, and other parliamentary devices, so that the debate can be shifted onto a more worthy plane.  Such a debate would pivot around what it takes to secure a sustainable future for health services:

  • that are better at adopting innovation,
  • in which all elements of the system drive together towards best possible outcomes for available resources,
  • that ensure we continue to drive up the health of the nation, whilst also reducing the unacceptable inequity – both in terms of health (mortality /morbidity), but also in access to quality care when needed.

Many improvements have been made to the Bill through its previous readings, the Pause and revision, but uncertainty remains.  The Bill continues to focus too heavily on structural issues, leaving unanswered those more important questions dealing with roles, responsibilities and effective governance.  Such ambiguities include:

  • detail of how Clinical Commissioning Groups (CCG) will be held to account;
  • how Monitor will promote the integration of services whilst deterring anti-competitive behaviours;
  • how the NHS Commissioning Board (NCB) process will work to evaluate and strengthen CCG Boards.

Current indications are that the NCB will continue conflating its important role to determine what needs to be done, with interference in how things should be done.  If CCGs are to drive innovation, improvement and best possible outcomes, then they must feel a real sense of ownership.

Much commentary focuses on these individual issues, but the real risk lies in the unknown cumulative effect of how these interact.  Current debates tend towards passionate defence of both ingrained vested interests and the proliferation of silo working.  These have proven time and again to prevent progress, always keeping internal issues in the spotlight, instead of giving real attention to transforming the way customers (patients, carers, relatives, service users) are meaningfully engaged.  “No decision about me, without me” will never become more than a collection of words until these internal issues are relegated to the back seat.  What we need is an open-minded focus on how to achieve successful transition to a new shape.  The health system is too big and complex, to be susceptible to management by central diktat.  We need more emphasis on applying the best management science to understand how such a complex beast can be steered to achieve the desired outcomes, by using the right incentives.

We welcome the increased attention on integration, but success in tackling quality and efficiency, requires incentives to be aligned with outcomes throughout the whole system.  GPs manage 90% of patient encounters, and need to retain identity as primary care providers, properly integrated with all other aspects of community and hospital care.  There is a real danger that concentrating on developing their role as commissioners will prevent opportunity for better integration of provision.  That GPs will be subject to conflicts is clear in recent stories, and the solution to place commissioning responsibility for primary care in the NCB makes a mockery of localism – surely primary care is the area which most needs and deserves to be given a local commissioning flavour.

Achieving the right balance here demands that Health and Wellbeing Boards are strong enough to direct the NCB and robust enough to hold them to account.  Health and Wellbeing Boards bring the different cultures of NHS and local authorities directly together.  Success of these boards is pivotal to the future.  It is essential that they are rapidly gain maturity to deal with difficult issues robustly, demanding significant organisational development to face up to and overcome these often ingrained cultural differences and tensions.  We see no attempts being made to nurture the new relationships on which success can be assured.

The Lord’s second reading has much to discuss and shape, but its biggest challenge will be to avoid the polarisation and misunderstanding which has shaped debate to date.  There are important matters to be understood, which will make a real and important difference.

The middle way

First published 31 Aug 2011

The latest controversy surrounding the Coalition’s health and social care bill stems from the legal advice obtained by the campaign group, 38 degrees, that the revisions allow the health secretary to wash his hands of the duty to provide a national health service.

This report has brought the expected response from many quarters, demanding that the health secretary retains full controlling influence over the NHS.  But for many years, when senior health leaders have been asked to cast their vote for the single most important change required for the NHS, the overwhelming demand has been to remove the whimsical hand of politicians from the tiller.  So clear has been this demand, that in 2007, the Nuffield Trust published a thought piece exploring various models which would indeed sever direct political influence.

This is just the latest example of the complete polarisation of debate whenever the NHS is discussed.  We seem destined to end up at loggerheads between the two ideological extremes of “preserve the NHS ownership in public hands at all costs”, and “the NHS needs to be subject to market forces before it will get the best from efficiency, innovation and quality”.

Where and how is the middle ground to be found?  Certainly not in the ill-informed rhetoric and the knee-jerk reactions which dominate.  As we have argued elsewhere, the NHS provides only a small fraction of the overall care, and much of that is already in the private hands of small businesses.

What we need is an enlarged vision of a care ecosystem, in which the existing diversity of contributions from all manner of providers is properly recognised, whether they go under the name of social services, NHS, volunteer carers, social enterprises, or private for-profit companies.  The most compelling and urgent case for reform, is that we stop the partisan fighting over organisational form, and start concentrating on setting out precisely how “free at the point of need” translates into a nationally consistent and coherent entitlement, delivered in a locally relevant context.  The only question relevant to the Health Minister is What?, not How? or When? or Which? or Who?  I could perhaps sit on the fence when it comes to Why?

The listening exercise

first published 18th August 2011

Welcome to this, my first posting from the Centre for Better Managed Health and Social Care.

David Cameron has announced the addition of Integration as a fourth strand to the continuation of the  listening exercise and the work of the Future Forum.  Much of the Centre’s work to date has focused on the need to reduce the artificial boundaries which exist throughout the care system.

Our emphasis on the Interdisciplinary aspects of care demands that the professional boundaries be peeled away – there is so much evidence that diversity in its widest sense yields better solutions to problems, with stronger engagement and ownership of the solutions when there has been clear consideration of different perspectives.

Our emphasis on treating health and social care, not as different domains, but as different contributors within a whole care ecosystem demands that sectoral boundaries are overcome, so that the process of care is not fragmented, and the journey of care is seamless.

Our emphasis on new styles of leadership and governance demands that there is a renewed sense of clarity of purpose, constructive partnerships and greater transparency.  Only with these in place can incentives be properly aligned throughout the system, instead of pulling in opposite directions and reinforcing individual fiefdoms.  Only when freedoms and accountabilities are held clearly in balance with each other, will appropriately judged risk-taking foster the combination of innovation and quality by which most other industries have been shaped.

Let us now invest serious energies in nurturing meaningful integration, not because it is declared as policy, but because it is owned and understood to be the best way to ensure that each service user is placed at the centre of the entire care ecosystem at their moment of need.  When these social principles of putting the needs of each service user first are partnered with the entrepreneurial spirit which simply won’t accept that today’s solution is good enough, then we might be able to forge ahead, sweeping aside much of the polemic which currently polarises debate and stagnates progress.