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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 »

Is there any evidence of the political leadership needed to transform the NHS between 2015-2020?

Filed Under (Conservative party, Health Policy, Labour Party, Reform of the NHS) by Paul on 31-03-2014

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There have been some interesting responses to this month’s posts. It’s encouraged me to think about perhaps resuming for a month in the autumn and then again in March 2015. It’s been especially interesting over the last week to gauge people’s response to my attempts to challenge the gloom being spread about the pressure on the NHS by too many of NHS leaders.

In this last post for the moment, I want to try and think through how the current political leadership – that which might be in charge of the NHS in the period after the May 2015 election – can help make the necessary transformation.

And in thinking through the possibilities I want to introduce the fact that from tomorrow there is a new CEO of NHS England – Simon Stevens. Between 2001 and 2004 he was a close colleague of mine, and is a friend, so I wish him well. But too much expectation is being placed on the ability of one person to make everything happen. He can and will achieve a great deal – but no-one can do this on their own.

When Pete Seeger died in January one of the many brilliant sayings that were attributed to him was, “Be wary of great leaders and hope that there are many many small leaders”. To succeed Simon will need many many small leaders.

And I don’t know about you but it seemed to me that there was something really odd in what his predecessor David Nicholson said in an interview last week. He said he would give NHS England “5 out of 10”. Given that he ran the transition body that set up the organisation, was responsible for the hubristic change of name to NHS England, and then ran it throughout its life one wonders, if the organisation is not very good, just why is that?

But the rest of this post concerns the interaction between political leadership and the NHS.

There is near universal agreement between the two major political parties who will either form the next Government alone or will form the larger part of any coalition. (Incidentally we don’t yet have UKIP’s NHS policy but I’m sure that if you visit any Home Counties’ saloon bar on a Sunday lunchtime you will hear it there first).

Both the Conservative and Labour parties agree that:-

  1. There will be standstill funding. Money won’t go up, but it won’t go down either. (But by 2020, even if the money is still the same for the NHS, most other areas of public expenditure will go down so the proportion of public expenditure being spent on the NHS will rise considerably).
  2. There will be no new structural reorganisation. (phew!)
  3. There will be many more older people with co-morbidities who will need different and better care than they are getting at the moment.
  4. There need to be many fewer emergency admissions.
  5. There needs to be a rapid development of integrated health and social care.
  6. This new model of care will have a radical impact upon the existing models of health and social care.

They also know that these changes need to happen quickly, need to happen across the whole of England, and that given the rise in demand they will need to reduce the amount of money spent on each patient.

Now of course we don’t know what the manifestos will bring but at the moment, given the pledge that there will be no more top down reorganisations, the levers that are available to bring about these radical changes are limited to what they have to hand at the moment.

The problem with this is that none of the political parties really agree with the current organisation of the NHS and the existing levers for change and so none are at all happy with what they have to hand.

Let’s start with the Conservatives. We know that the current Conservative Secretary of State Jeremy Hunt voted for the Health and Social Care Act on many occasions and supported the reforms in Cabinet. He was lucky enough to be in the job of Secretary of State when all the reforms he had consistently supported came into effect. Few politicians enjoy such a luxury.

But, as we know, a curious thing happened during the time between the passage of the Bill and his having the opportunity to enact the reforms.

Over the intervening year he came to disagree with the central idea of his legislation, that the NHS should be run by a series of arm’s length bodies – separated from the Secretary of State.

Instead of following the core principle of the reforms – to liberate the NHS from Whitehall – he instead runs the NHS from his office (in, er, Whitehall). Most of the time he ignores the legislation he supported (and, it might be said, much of a decade of earlier legislation.)

You would have to spend a long time searching through his speeches to find any reference to the changes that he wants being made by the actions of the 211 clinical commissioning groups that his legislation established.

Let’s look at an example of what he might do if he believed in the legislation for which he voted.

A few weeks ago the Times uncovered the fact that over 150,000 older patients are moved around our hospitals in the middle of the night. If he used the powers in the legislation that he voted for, he would read the Times and think hard about changing next year’s mandate to NHS England to cover this issue. He would in turn talk about how CCGs should commission care from hospitals that did not involve such nocturnal movement of older patients.

Instead the anxiety that the Times headline immediately raises in him leads him to try and ensure the NHS acts differently.  Since he won’t do that by using the levers his reforms gave him, he has to resort to shouting at the NHS as loudly as possible.

And this will be the problem for the NHS if the Conservatives are in charge of making the changes to bring about integrated care from 2015-2020. Since they don’t believe in the purchaser/provider split that is the keystone of their legislation, they have no other levers available to bring about these radical changes.

What they have instead is the traditional activity of shouting at the NHS to “just do it!”. Since the NHS knows that if, a week later, there is bad publicity coming from trying to create integrated care at pace, it is likely to be shouted at to do the reverse, there is little likelihood of reform taking place at the scale and pace that is necessary.

Labour of course has yet to outline the detail of its policy. But in the last month the leader of the Labour Party and the Secretary of State have both agreed that there will be no top down reorganisation of the NHS. That good news means that the levers for change contained in the current system are the only ones that will be available to a Labour Government in May 2015.

Which in turn means that commissioning at a national and local level will be the levers to bring about the move towards the integrated care outlined above. Yet the Shadow Secretary of State has made clear that the last thing he want commissioners to have at their disposal is competition. He wants to grant the existing NHS suppliers a monopoly of what health care is supplied and who supplies it.

He will therefore be asking the NHS to carry out very different integrated health and care but taking away any ability that commissioners have to challenge the monopoly of existing institutions. This reduces commissioning to an allocation mechanism with commissioners simply handing out money to existing NHS providers.

If this were to remain Labour Party policy after the next election, they too will have no levers to bring about integrated care except for the time honoured method of shouting at the NHS.

So, a year away from the next election, this is the problem.

  • We have unanimity about where the 2 main political parties think they want the NHS to get to.
  • We have agreement that there will not be a reorganisation to give the Secretary of State new levers
  • We have agreement that the current levers aren’t one they want to use.
  • They have no way of getting the NHS to move to where they want it to go.

Over the next year this may change.

I’m hoping that it has by the time I start blogging again.

People powered health and patient coordinated care

Filed Under (Health Policy, Patient centred coordinated care, Patient Choice, Patient involvement, Self Management) by Paul on 20-03-2014

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I know it doesn’t feel like it in 2014, but the dynamics of disease will move the NHS into an era which will either fully utilise patients and their carer’s capacity to better self-manage their conditions – or collapse.

The old model of healthcare will not be able to muster sufficient resources to cope with the new model of disease.

Moving from here to there will be difficult, with many fits and starts, but patients and their organisations will be the main force that will drive this change.

That’s why yesterday I posted that too much of what is at the moment called “integrated care” is simply shuffling existing services around and hoping they will fit.

They don’t.

Given the multiple morbidity of many patients it will take much more than this to create care that is properly coordinated.

Above all it will need investment in the assets that patients, their carers, families and communities have to better manage their conditions.

This process starts with a very difficult set of changes from inside the existing model of care.

At the moment many medical staff, seeing a list of sick people – some of them very sick – fairly inevitably see their patients, carers, family and communities as a set of deficits. Patients are seen as lacking average blood pressure, good breathing, the ability to be active in the world, the ability to manage their condition themselves etc. etc. Patient after patient comes in expecting some external help from the doctors and the nurse.

This experience makes it fairly likely that the tenth person who comes into the clinic will be seen as a set of needs – and not as having any assets.

Which of course becomes a self-fulfilling prophecy. The NHS sees no assets amongst the patients and the patients therefore don’t feel, when they come into contact with the NHS, that they have any.

But if we continue in this way, treating patients as if they are nothing but deficits, the health service collapses under the weight of demand from co-morbidities and an insufficient supply of medical staff kit and drugs.

Finding out what assets people have is not a straightforward process. Different people have very different assets.

Many people have family and friends who can do much more than take a prescription to a chemist. But to do more they need some investment of time and effort from the NHS. Helping people to play a bigger role in helping other people first requires the recognition that there is something there to work with and then some time and effort to help them know how to improve the patient’s capacity to self-manage.

But others – the very old and the vulnerable – may be very isolated and have lost all their organic relationships with family and friends. Here the NHS needs to find ways in which local voluntary and community groups can stand in.

Last autumn the Red Cross fundraising campaign had a picture of an isolated older lady at home in this country. This, not the health outcomes from an earthquake in another country, was ‘the crisis’ that the Red Cross was pledged to help to solve. For some years now the Red Cross have been training volunteers to spend time with isolated patients.

Of course they are not alone in this.

Organising someone to visit an otherwise isolated person is not something that a busy GP can take on board themselves. It may only rarely make sense for a doctor to find out about all the voluntary groups in their area, but it always makes sense for them to have someone who knows to whom they can refer the patient. This practice of social prescribing is gaining recognition within the NHS.

If the increase in the number of people with several long term conditions is the disease burden with which our health and social care service needs to cope, then my point is that the only way that this can be done successfully is with the very active management of patients themselves.

Changing health and social care to achieve this will not be easy.

Last year, before I suspended blogging, I posted about the work that I and others had carried out with NESTA. There are several publications on their website that flesh out how investing in better self-management can work for the NHS.

Creating patient centred coordinated health and social care isn’t just a matter of bringing existing services together.

Filed Under (Health Policy, Patient centred coordinated care, Patient Choice, Patient involvement) by Paul on 19-03-2014

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Across various parts of social care and the NHS the last year has seen a great deal of planning to create what the NHS and local Government likes to call ‘integrated care’. (I commented yesterday on how providers of care like to call it this whilst patients like to talk about ‘co-ordination’).

Across the country, there are regular meetings where teams of people are sitting down and looking at their existing services and trying to stitch them together into a different pattern.

Over a year ago I tried to understand why this was so very difficult. Staff wanted to do it; patient’s carers and the public wanted to do it; resources were demanding it. But, meeting after meeting, it kept on not happening.

My answer to this conundrum is that we underestimate the passion with which staff and services have developed their fragmented bit of the whole. More and more people come to work in health and social care with greater and greater specialisation in their work. Most careers have been developed not around better coordinated whole person care but around greater specialisation.

Two weeks ago, tucked away in John Oldham’s report on Whole Person Care was the recognition that the way in which merit awards were granted to the medical profession not only encouraged but practically enforced body part care rather than whole person care.

In the field of social work, despite several decades of argument for generic social work, specialisation is how you get ahead.

Of course staff don’t come to work with the aim of fragmenting a person’s care. They come to work with the experience of working only with diabetes; only with residential homes for residents with dementia, or only with depression. The constant in their work is the specific illness – the variable is the human being.

And it is not wrong to describe staff as ‘passionate’ about their specialisation. Hearing specialist consultants, nurses, or residential social care staff talk about their specialism is a moving experience. They really want to improve their skills but talk about more and more specialist activity.

This process has created passionate fragmentation.

And there are very many who believe that coordinated or integrated care will be created if we bring these fragmented services together. Rather like a jigsaw puzzle. So the job of the coordinated care officer is in some way to find the picture on the top of the box and fit all the pieces together.

It’s a compelling analogy – but it doesn’t work.

The jigsaw takes an existing picture – let’s call it “Whole Person Care in the Home”, cuts it into bits, and then jumbles those bits up. The coordinated care person a) knows that somewhere in all the bits there is a real coherent picture and b) that whilst it will take time and effort their job is to fit the bits together to make that picture – and given time and skill that is what they will achieve…

The problem for real coordinated care is that the fragmented services have NOT been created as a single picture and then fragmented. They have been created to only deal with bits. They have been created as fragmentations.

The big problem is that the part of the jigsaw for an 85 year old woman called “diabetes care” has not been created to fit  neatly with the part called “dementia home care”, which in turn has not been created to fit with the part called “COPD care”.

They have not been created in a way that they will fit together.

The organisations that create them have made these services as “bits” in their own right.

So a really clever coordinated care worker can shake all the pieces out of the box for Mrs Patel’s whole person care and then find that the problem is that when they try and fit them together – they won’t. They were not made that way.

At best they might get a few that look a bit similar to form a line, but they will not form a picture of whole person care. And when you look at that line, there are holes in between through which patients fall, and duplications where they have to do the same thing over and over again.

To build a picture of whole person care you have to fundamentally change these fragmented services so that they might just fit together.

To achieve that coordinated care staff will need much much more power to transform existing service than they are normally granted.

It won’t surprise blog readers that I think that this greater power comes from patients and tomorrow I will describe how I think that might work.

12 months ahead of the general election campaign how should we understand the politics of NHS pay?

Filed Under (Election campaign, Health Policy, Jeremy Hunt) by Paul on 17-03-2014

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Last Thursday the Secretary of State made an important announcement about NHS pay which was met with a lot of anger from NHS staff and their organisations. What is interesting is not just the announcement per se but the way that the Secretary of State chose to publicise it.

Those who felt that the way in which it was announced was deliberately designed to cause a row are almost certainly right.

Given that everyone in the NHS was either getting an increment or, if they were at the top of the scale with no more increments, getting a 1% pay rise this could have been delivered with a fanfare along the lines of “Good news everyone’s pay is going up!”.  We could have had a few paragraphs promoting that message and then something about how it’s not as much as he would have liked because of the financial crisis.

But no, that is not what was said. Instead an acutely PR conscious Secretary of State decided that a good story about everyone getting a pay rise should be turned into the bad story that a consolidated pay rise of 1% would be impossible because it was unaffordable. He headlined the curbs rather than the pay rise,

“The Pay Review Body proposals suggest a pay rise that would risk reductions in front line staff that could lead to unsafe patient care” .

This will save £200 million a year. (Remember that figure)

So why spin a story saying this is bad news when it could be spun as good news?

Because we are but 12 months away from the start of the next general election campaign. A campaign that will, so far as the government is concerned, be fought on the economic competence of the Labour Party.

So what has NHS staff pay got to do with that?

If the Labour Party say that they will implement the pay review body recommendations, it will cost £200 million. They might seek to justify this in two ways that could play into the government’s plan to attack their economic competence.

First a naïve Labour front bencher might say that this is a punitive attack upon nurses and that after all it will only cost £200 million out of an NHS budget of £110 billion. A rounding error and not a big sum of money.

How might a government spokesperson respond to someone falling into trap number 1?

“Only an economically incompetent Labour Party would say that £200 million is a small sum of money. Any responsible political party would recognise that this represents the pay of an extra 4000 nurses, not a rounding error. This shows how once again the Labour Party cannot be trusted with your money.”

A second naïve approach would be for a Labour front bencher to say they would find the £200 million from inside the NHS.

How might our spokesperson respond to that?

“The Labour Party thinks it can simply conjure money out of thin air. It can’t. NHS money is being spent on patient care. What we need to know from the Labour Party is where it will cut NHS services to find this money? Until it does we believe this could be your local hospital.”    

This Government will be looking for lots of small examples of how the economic arguments of the Labour Party don’t add up.

The politics of NHS pay is just another one.

Over the next year most announcements will need to be viewed through the lens of the election campaign in order to be understood.

But let’s return to the £200 million that Jeremy Hunt says is essential for front line services.

On the same day as the pay announcement another was made with far less fanfare. This was that government departments would make a much greater contribution to pensions for staff and that money would not be spent by the Treasury.

Next Wednesday, when George Osborne announces his budget, much will be made of a £1 billion infrastructure fund that the Treasury will pledge to spend on small infrastructure projects.

This £1 billion has been obtained by taking money from departments to pay for pensions that in the past were paid by the Treasury.

So Jeremy Hunt has agreed to give the Treasury £125 million a year that will now come out of his budget from 2015/6 onwards.

Surely, just as with the £200 million not being spent on pay rises, this £125 million can only be found by cutting front line services?

Odd that we’ve heard nothing about any cuts that might be needed to plug this £125 million gap.

Does the NHS really have to create a new business model?

Filed Under (Clinical Commissioning Groups, Health Policy, NHS England, NHS Providers, Nicholson Challenge) by Paul on 12-03-2014

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One of the remarkable experiences of my last year has been to witness near universal agreement that the NHS needs to change fundamentally. Nearly all of the various bits of the NHS agree with this.

Most of their speeches and papers usually agree that the need for fundamental change exists in terms of both quality and finance.

If you look at speeches from…

  • The Secretary of State
  • The Chief Executive of NHS England
  • The Chief Executive of Monitor and
  • The Chief Executive of the NHS Trust Development Agency

…they continually say that there needs to be change which touches on the fundamental.

Many talk about the next 2 years being the defining moment for the NHS with a warning that a failure to change dramatically will put the institution in peril.

So much so universal.

I am sure these four individuals (one Jeremy and three Davids) really believe in the necessity of large changes, and given that they all run big organisations with, between them, thousands of staff responsible for parts of the NHS, one might expect that their organisations would all be beavering away at the forefront of radical change.

You might expect that if you met a civil servant from the DH, or an employee of NHS England, Monitor, or the TDA they would all be raising questions about how, in order to save the NHS, you were developing your new business model. Given that the leaders of these large organisations are preaching very radical change, then you might expect their staff to be an active part of a massive engine of change.

But you would be wrong.

Whilst the leaders talk about the need for radical change, their staff enforce the old business model that their leaders say is finished.

This can be a bit bewildering for, say, a CCG. They will read NHS England’s call to action and may well start to develop some commissioning intentions and activity that will radically challenge the existing providers of healthcare to change their business model.

They will then discover that their Local Area Team, as a part of NHS England, will sharply question why they are doing something that will ‘destabilise local providers’. A wise CCG will then quote David Nicholson’s letter as a defence of such radical plans back at the NHS England employee.

Usually, and without hesitation, said employee will tell the CCG to pay no heed to that because all that matters is that the health economy breaks even financially – and that if you ask your failing local District General Hospital to do something different, they will financially fall over.

So stop it.

The leadership of Monitor and the NHS TDA both recognise that, for many of the NHS’ acute and mental health trusts for which they are responsible, the current business model is running out of time (and money). There is even encouragement for Trusts Boards to think about radically different business models and models of care.

But woe betide any board, in thinking through those new business models of care, that might opt to forgo any of the finances that come from within the existing model of care. If that happens Monitor and TDA staff will very quickly threaten them with lower ratings if they fail to squeeze every financial drop out of the existing business model.

So these important organisations have a policy of radical change in the NHS…

…and a practice of not allowing that radical change to happen.

On many Trust and CCGs boards there are one or two senior staff who think about going through the difficult process of radical change. But the difference between policy and practice within the major organisations running the NHS makes arguing for the necessary change within the NHS very hard indeed. Those against change argue that the practice of the main performance managers in fact penalises change by enforcing the status quo.

If the necessary changes in the NHS care model don’t happen this will in part be the fault of the very organisations whose leadership appear to be arguing for them.

Practice beats policy every time.

“Unless you bring the consumer into the heart of these changes you won’t get the change.”

Filed Under (Ed Miliband, Health Policy, Patient Choice, Private Sector, Public service reform) by Paul on 10-03-2014

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 (Ed Miliband on the Marr programme)

When Ed Miliband said this in January he was talking about the energy industry. One of the major planks of his policy for developing a new economy is to encourage and enable much more active consumers.

Active consumers challenge provider bad practice in two ways.

First they make a fuss about their existing supplier. Increasingly they may join a range of campaigns about how badly they are treated – and social media is making those campaigns more powerful every day.  The political scientists (and Ed Miliband) call this ‘voice’. Increasingly consumers let the world know when they get bad treatment and they say it ever more loudly and in greater numbers. The reputational costs for providers of services that have campaigns run against them can be immense. So providers worry about consumer voice.

Second, where there is competition consumers have the right to take their business somewhere else. Political scientists call this ‘choice’. In the energy industry Ed Miliband makes the important point that exercising choice is difficult. He is committed to making it a lot easier for consumers to move their business. And where there are monopolies he will develop policies to break them up and provide the consumer with more choice.

Whilst voice can raise problems of reputation for businesses, it is the loss of customers through choice that is the direct driver for companies to improve service. If there is no choice the impact of putting consumers at the heart of change is diminished.  Thousands of active consumers combining voice and choice will have an impact on bad providers – or they will lose a lot of business.

The important political point for Ed Miliband here is that given his committtment to stand up for consumers against monopolistic power in the private economy where does he stand on the issue for consumers of public services.?

On February 10 he made a speech addressing the problem for consumers of public services. In this speech he clearly said that he was as committed to tackling the abuses of power of public services as he was of private services. This is a new dimension to the recent post-2010 politics of the Labour Party and of course will have a big impact on the politics of the NHS.

If you are to win votes from voters outside your tribe then good politics is all about developing positions that are a bit different from those that the tribe expected. A traditional Labour position attacks the power of private companies over consumers but has not attacked the power of public organisations over citizens.

So when his Feb 10 speech talks about understanding that that there are people feeling powerless because of state institutions and not only private sector companies, he is making an important and not completely expected point.

The speech went on to talk about enhancing the power of the citizen in developing their voice in gaining more power in public services. There were important promises for parents (and in the future patients) on developing their public voice to have a greater say. In particular a part of the speech that could have a big impact on the NHS was the promise of helping individual patients organise themselves with similar patients. This blog has often spoken about the importance of patient organisations developing a more powerful collective voice for individual patients. This is potentially an important and practical policy.

He was talking about people powered public services.

But when it came to choice he said that this was different for public services because parents don’t choose a school in the same way that they choose a café. That’s true. A café choice is made every day, and a school choice once every few years. That makes them very different choices – but they are still choices.

And parent choice of schools informed by information from Ofsted has had and is having a big impact on driving up standards. Just as for a private company if you don’t listen to the voice of parents about your school then parent choice will have a direct impact on your bottom line. Head teachers who don’t care how parents use their ability to choose schools don’t last long.

To allow consumers in private industry to use the power of choice is a vital way of empowering consumers.

Not to allow citizens who use public services to use the power of choice will limit their empowerment.

If you want to improve public services people need all the power they can get, choice as well as voice.

So what is this Government’s policy on the NHS?

Filed Under (Conservative party, Election campaign, Health Policy, Lynton Crosby) by Paul on 06-03-2014

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I have counted three very different and opposing policies that the Government have for the NHS. Interestingly none of them represents a split between the political parties of the coalition and all of them have Conservative actors leading them.

The first, as I outlined in yesterday’s post, is Jeremy Hunt’s policy for the Secretary of State to intervene in running the NHS several times a week often using powers abolished by the Health and Social Care Act 2012. His personal NHS policy of trying to run the service as if the Health and Social Care Act 2012 hadn’t happened is backed up by other parts of the Government.

In January the Deputy Prime Minister, in arguing for more attention to be given to mental health policy, came up with the good idea of having maximum waiting times for mental health treatment. He quite rightly reflected on the experience that maximum waiting times had had a significant impact on access for physical health, and wanted the same improvement for mental health patients.

The problem for Nick Clegg is that he signed up to the July 2010 White Paper which stated that the Government should not prescribe such targets from the top. In the summer of 2010 Andrew Lansley had indeed abolished them. (And if you ever wonder why the Government has such difficulties with the 4 hour A and E target it might just be a consequence of this abolition).

The first answer to the question of what is Government policy on the NHS is therefore that they are a powerfully interventionist Government delving into the detail of NHS practice. (Notwithstanding having passed introduced a law that opposes this policy).

Incidentally I have been told third hand that the Prime Minister’s intent for his 2015 manifesto will be to proclaim that “his NHS targets are better than Labour’s targets”. (This despite having abolished top down targets some time ago)

The second – very much quieter – NHS policy is to implement the Health and Social Care Act and the consequent reforms that they pushed through in 2012. This policy stops treating the NHS as a single organisation run from the top, but instead recognises that it is a system of very different organisations that work together to create an overall system called the NHS. NHS England, Monitor and the NHS Trust Development Agency are all separate independent quangos that fit into an overall architecture. Commissioning at a local and national level will drive change and improvement.

Not many people in the Government agree with this. A bit of the No 10 Policy Unit, a bit of Norman Lamb, but for the most part they want to forget the whole reform movement in health. It’s OK to talk about the reform of welfare or education, but let’s not mention the 2 years of hard work and disruption that went into the Health and Social Care Act.

There is then a third policy on the NHS that is run by an Australian in Number 10 called Lynton Crosby. ‘Cobber’ Crosby has been put in charge of winning the election. His policy on the NHS is to say nothing about it at all.

Polling tells him that every time the NHS is mentioned it moves up the salience of issues that matter to the public. If this were allowed to continue, and if by the spring of 2015 the NHS were to be say the third most important issue that the public cares about, then the Conservatives will lose votes.

To win the election the Conservatives need voters to be concerned about issues that will win them more votes – and the NHS will not be one of those.

So Mr Crosby sits in number 10 and fumes at the hyperactive Secretary of State intervening in this and that and making speech after speech about what’s wrong with the NHS whilst Jeremy Hunt is really pleased to get headlines for his speeches and interventions.

Mr Crosby considers Jeremy Hunt’s hyperactivity a very strange way of winning votes for a Conservative Government.

So there you are. 3 very different policies for us to watch will wend their way over the next 14 months until the election.

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

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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.

Something is stirring in the Labour Party…

Filed Under (Andy Burnham, Ed Miliband, Health Policy, Shadow Secretary of State) by Paul on 04-03-2014

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…on NHS and social care policy.

Today sees the launch of a report by John Oldham’s Independent Commission for the Labour Party into health and social care policy, and to declare an interest up front, John is a close friend of mine.

Those that know him will recognise that his report “One Person, One Team, One System” is very much his own (and his colleagues on the commission). By which I mean that it is not owned by the Labour Party and some of it will make difficult reading for the Shadow Secretary of State.

That is why it’s interesting that today’s report will be publicly received with a speech by the leader of the opposition Ed Milliband. One of the reasons that he is playing such a big role in receiving the report is because it does not support the line taken by some of his Shadow Secretary of State’s speeches. It therefore provides the Leader of the Opposition with an opportunity to drop some of the things his Shadow Secretary of state has said he wanted to do.

Again, those that know John Oldham will not be surprised that his report is based upon a radical critique of the current delivery of health and social care for NHS patients and social care service users.

The press release begins:

In 2014 the NHS and social care work very hard to deliver a model of care that was created for a different population with different diseases. It mainly provides a wide range of good episodes of care aimed at improving the health of parts of the body but this does not meet the needs of our current ageing population. At the moment 70% of the health and social care budget is spent on older people with long term conditions and much of considerable resource is not well spent.  The crisis for the NHS and social care is that in order to meet the needs of our new ageing population needs to radically change its model of care. It finds it very hard to do this”

In truth none of this is news to any of the leadership in the NHS. But the case for change in John’s report goes a few steps further because it is most strongly voiced by the people themselves. People receiving fragmented care need a radical new approach over the next parliament to rework the health and social care system to meet these new needs.

And one of the things that is most needed to bring about this radical change is for the next Labour Secretary of State NOT to launch a reorganisation of the health service.

We do not need a new Health and Social Care Reform Act.

We do not need to change the local commissioning structure for NHS care by giving it to local government.

We do not need a new reorganisation of NHS structures.

As the press release for the report continues:-

“It is vital that the next Government leads this change and does so without a complete reorganisation of the structures of NHS and social care. The recent reorganisation has left the NHS and social care demoralised and not able to understand the system within which it is meant to be working. A further reorganisation in 2015/2017 would place the whole system in very great peril.   

The next Government must dedicate itself to improving health and social care outcomes for patients and service users defined by them. Government leadership is needed to change how the organisations that provide care actually behave with people It should not spend time passing legislation to change structures.”

How the Labour leader and his Secretary of State for Health respond to this challenge will be an important part of the politics of health over the next few years.

Winding up…

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

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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”.

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