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 »

In March 2014 just who is responsible for the Government’s NHS reforms?

Filed Under (Accountability, Conservative party, Health and Social Care Act, Reform of the NHS, Secretary of State) by Paul on 03-03-2014

“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.

When 360 degree assessment might just become very important

Filed Under (Accountability, Clinical Commissioning Groups, National Commissioning Board) by Paul on 28-11-2012

Following on from my post on Monday about the way in which local CCGs might use the Secretary of State’s mandate to hold the NCB to account, I have had my attention drawn to some activity from the CCGs themselves. I was suggesting that since the mandate lays a number of responsibilities on the NCB to listen to the changes that the CCGs say are necessary to bring about integrated care, the CCGs could use it to hold the NCB to account. Read the rest of this entry »

Understanding how Francis might understand the world of the NHS

Filed Under (Accountability, Francis Report, Health Improvement, Health Policy) by Paul on 17-10-2012

A few weeks ago we learnt that the publication of the Francis Report on Mid Staffs will now be put off until January. In the interim there have been some concerns shared within the NHS about how the report might understand its world.

As Paul Hodgkin from Patient Opinion said at the conference I mentioned in Monday’s post, if the answer that the Francis report comes up with is ‘more regulation’, then they are probably asking the wrong question. Read the rest of this entry »

Public Health – The Government’s reforms of its reforms – the National picture

Filed Under (Accountability, Public Health, Public service reform, Secretary of State) by Paul on 23-08-2011

In July the Government published its response to its initial reforms about public health. Whilst their original reforms had failed to excite as much public interest as their plans for GP commissioning, they did contain some very radical changes to the relationship between the Department of Health and public health.

Rather oddly, at a national level the public health reforms went in the opposite direction to those proposed for the NHS. Whereas the stated aim of the NHS reforms was to remove the Secretary of State’s accountability for the NHS (something that the 2011 reforms of their 2010 reforms changed radically), their original reforms of the Department’s relationship to public health abolished the independence of the Health Protection Agency (HPA) and brought their powers under the direct control of the Secretary of State. Read the rest of this entry »

Accountability to the public for the NHS – Strengthening the role of Parliament

Filed Under (Accountability, Foundation Trusts, Health Policy, Secretary of State) by Paul on 04-05-2011

Yesterday I argued strongly that given the central fact that the NHS is paid for out of national taxation, and given this is key to the principles of the NHS that the public want to keep, the role of local government should not be to have an executive say in the commissioning of health care. NHS spending is 100% national resources from taxation and accountability should be with central and not local government. Read the rest of this entry »

Accountability to the public for the NHS

Filed Under (Accountability, Health Policy, Listening Groups, Reform of the NHS) by Paul on 03-05-2011

For the last few weeks I have been developing arguments that relate to the first two of the four listening themes that the Government set up when they had a very  belated pause for a bit of a think about their NHS reforms. I talked about choice and competition and, over Easter, blogged concerning the second group “How to ensure public accountability and patient involvement in the new system” Read the rest of this entry »

Listening Group 2 – Patient Governance and Patient Involvement

Filed Under (Accountability, Health Improvement, Health Policy, Listening Groups) by Paul on 18-04-2011

I am running through the four different groups that the Government have set up to organise listening during their 2 month gap.

As I did with the previous listening group, the way in which I would like to frame this policy discussion is controversial. Read the rest of this entry »

What does it look like when a Government loses control of its health policy?

Filed Under (Accountability, Health and Social Care Bill, Reform of the NHS, Secretary of State) by Paul on 05-04-2011

Yesterday morning the Chair of the Health Select Committee, Stephen Dorrell, said that the Government had ‘lost control of its health policy’.

Even to someone like me this seemed a pretty stark accusation. A Government with a large majority was forcing its health bill through the Commons – so in what sense could it be said to have ‘lost control’? Read the rest of this entry »

Before the Health Select Committee

Filed Under (Accountability, GP Commissioning) by Paul on 07-03-2011

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Never quite sure about writing anything about the House of Commons in case I get done for contempt but on March 1st I gave evidence to the House of Commons Health Select Committee. They are carrying out an in depth enquiry into how the Bill will ensure Commissioning works in particular looking at the role of the NHS Commissioning Board. They had asked me to give evidence – so it was pretty relaxed. Read the rest of this entry »

Next Steps – Local Democratic legitimacy,how can the NHS work with the public locally to give them the power to say anything but “NO”?

Filed Under (Accountability, Coalition Government, Next Steps, Reform of the NHS, White Paper) by Paul on 23-12-2010

There are several really important issues in the chapter of Next steps that deals with local government. But the ones that will matter most to the survival of the NHS are seemingly technical paragraphs 5.39- 5.45.

These concern local authorities’ right for significant changes to designated NHS services, to be referred to the Secretary of State.  This is important to local authorities. Read the rest of this entry »