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 »

Given the current Secretary of State isn’t playing the role outlined for his job in the reformed structure, which NHS structure is he trying to run?

Filed Under (Coalition Government, Foundation Trusts, Health and Social Care Act, Health Policy, Jeremy Hunt, Secretary of State) by Paul on 05-03-2014

The last 10 months have made it clearer and clearer that Jeremy Hunt, as Secretary of State for Health, can only do the job the way he wants to by completely ignoring the reforms of the NHS brought in by his Government.

We have one of the most activist Secretaries of State for Health of recent years  operating within a legal system – that he helped to create – which grants him very few of the powers that he feels he needs to carry out the role.

There are hundreds of Conservative party quotes attacking targets that I could use but I’ll just take one, from their 2008 document, Renewal.

“The problem is Labour’s strategy of trying to manage the NHS through top down centralised targets. These targets focus primarily on processes and administration such as stipulating the time it should take for patients to be processed through their treatment, or for administrative procedures to be completed, rather than the actual results of patient care”

Phoning up chief execs of NHS Foundation Trusts to quiz them about their A and E performance ignores several bits of the legislation that he helped to get through parliament.

He will of course remember, as he phones the CEO of an Foundation Trust, how para 1.5 of the White Paper “Liberating the NHS” (that he agreed in Cabinet in July 2010) said

“We will legislate to establish more autonomous NHS institutions with greater freedoms, clear duties and transparency in their responsibilities to patients. We will use our powers in order to devolve them”.

I am sure the CEO of the FT will feel, as he is being called by Jeremy Hunt, that he is part of a more autonomous institution…

First let’s get one issue out of the way. There are those that say that Jeremy Hunt’s job as Secretary of State for Health is made much more difficult by the fact that he has to work within a structure created by NHS reforms that reflect the ideas of his predecessor Andrew Lansley – and that he in fact had nothing to do with the structure and the law that he now chooses to ignore.

The argument goes that Andrew Lansley had a very idiosyncratic view of how the NHS should be organised and that given just how individual that was it’s hardly surprising that Jeremy Hunt needs to do something different.

This argument depends upon Andrew Lansley having acted purely as an individual who one day simply implemented his very individual plan.

But it wasn’t like that. That’s not what happened. Andrew Lansley was a member of a Cabinet that discussed his plans on several occasions – and on each occasion the Cabinet decided to go ahead with these plans.

Andrew Lansley was a Member of Parliament who belonged to the party that formed the greater part of the Government. Jeremy Hunt is a Member of Parliament who belongs to the same political party. He voted for the Health and Social Care Act on very many occasions. He signalled his agreement with Andrew Lansley’s plans by voting for them on all those occasions.

So it may be that these reforms were odd, but they were actively supported on many occasions by the Coalition Cabinet (member Jeremy Hunt) and the Conservative Party in Parliament (member Jeremy Hunt).

And my obvious point is that Jeremy Hunt was an active part of the processes that enthusiastically agreed the plans for a new NHS structure that he now ignores.

In Cabinet in July 2010 there would have been a discussion of the White Paper that specifically argued for a much smaller role for the Secretary of State in running the health service.

In Cabinet in December 2010 there would have been a discussion of the biggest Health Bill in history where clause after clause outlined how a new architecture of independent organisations would take power away from the Secretary of State.

In 2011, given the trouble that the Bill was in, there would have been several other Cabinet discussions about the Bill. In each of these the Cabinet collectively (member Jeremy Hunt) decided to go ahead with the reforms.

Jeremy Hunt was an active member of this Cabinet. He was a part of these discussions which collectively agreed to push them forward.

These reforms – which the current Secretary of State now finds it difficult to live within – were agreed personally by him over a long period of time.

They are just as much Jeremy Hunt’s reforms as they are David Cameron’s and Andrew Lansley’s.

Jeremy Hunt’s problem is that the reforms he voted for and passed into legislation created a system which now gives him insufficient power to carry out his work in the way that he feels he needs to.

You might think that the daily spectacle of a Conservative Secretary of State trying to wield powers that he personally contributed to removing from his office, would be a matter for some derision and scorn from Her Majesty’s Opposition.

There are hundreds of quotations about not making top down decisions which could be thrown across the chamber at Jeremy Hunt and contrasted with the need to intervene he seems to feel every day.

The opposition could make him a figure of fun for doing the opposite of what his legislation signed up to.

But they don’t. No one says this is weird because the opposition think that if and when they take over the role of Secretary of State for Health they will also be looking to use as much power as possible to tell people in the NHS what to do. They relish the thought of telling CEOs what they can and cannot do and are rather pleased that they don’t really seem to need legal powers to do that.

Their failure to point this out doesn’t change the rather odd nature of what is going on though.

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.

Winding up…

Filed Under (Health and Social Care Act, Health Policy) by Paul on 25-02-2014

From next week – beginning on Monday March 3rd – the blog will be revived with a short series of posts to mark the anniversary of the major part of the implementation of the Health and Social Care Act.

One year in seems an appropriate time to take stock of progress with the implementation of the largest set of reforms to health policy since the establishment of the NHS in 1948 . It is also an appropriate time to look ahead to how health policy might affect the outcome of the next election in 2015.

And as I warned readers in my not so final remarks last year “There will be times when I just won’t be able to help myself”.

On Labour’s plans for Reorganising NHS Commissioning.

Filed Under (Health and Social Care Act, Health Policy, Labour Party) by Paul on 22-10-2012

A report in the Guardian last week explained how some Labour Party policies that were announced at the Labour Party Conference were developed.

Before the Conference I commented on the difficulties that the Party front bench had got itself into by saying it would repeal the Health and Social Care Act of 2012. On the face of it this looks like good, simple politics. (The Act is unpopular, ergo repealing the Act will be popular). Read the rest of this entry »

When is an NHS reorganisation not an NHS reorganisation?

Filed Under (Health and Social Care Act, Health Policy, Labour Party, Local Government, Localities, Reform of the NHS) by Paul on 05-10-2012

Andy Burnham made an important speech to Conference about the Labour Party’s policy on health services. In doing so demonstrated why it’s important for opposition parties not to announce policy specifics 30 months before the election. What he has discovered is that when you announce one big thing it leads to a whole host of questions about everything else. .

He announced a number of things that will now be probed in great detail. Read the rest of this entry »