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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 »

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.

Why NHS England is not in fact in charge of the NHS in England. (or an SHA by any other name would smell as sweet)

Filed Under (National Commissioning Board, NHS England, Strategic Health Authorities) by Paul on 11-03-2014

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Having posted about last year’s developments in the politics of NHS reform, I would now like to look at what is happening to reform within the NHS itself.

I stopped blogging just before the Health and Social Care Act began to be implemented in April 2013. If it seems as if the Act has been around for a lot longer than 11 months that’s partly because most of the new architecture was up and running before last April.

How does it seem a year on?

The most significant impression I have is that very few people within the NHS actually understand how their organi

sation fits into the system. One of the main reasons for this, which I reflected on last week, is that the politicians who were responsible for the reforms have not taken the time and effort to explain how they should work. So no one has explained to the people who have to make the system work how each bit of it interacts with another.

This political failure was compounded by the fact that one of the main parts of the new architecture, the NHS Commissioning Board, was allowed to change its name to NHS England from April 2013. This change of name was deliberate in that it gave everyone in the NHS the impression that one organisation was in charge of everything.

If an organisation is called “NHS England” then it seems reasonable that the average person in the NHS – working in England – would believe that this is in fact the organisation in control of the NHS in England.

Once the name sticks the legal fact that it isn’t in charge of the NHS seems a bit contrary.  The law becomes secondary to the organisational title.

This leads to many happy hours of explaining to people that whilst the label “NHS England” may appear to put that organisation in charge of the NHS in England that is not in fact the case.

Consider the important example of an NHS local hospital trying to develop a new model of care. This is a really important issue for the future of the NHS and tens of local hospitals are trying to do just this.

Since NHS England is a commissioning organisation of specialist and GP services it has a role in these areas – deciding what care it wants to commission.

But it has no role in deciding what new model of care an NHS provider should develop.

Locally that task falls to the Board of the hospital itself. It is the Board that has to work through the possible future offer of health services and to work out with local commissioners what they might want to commission.

Nationally, if the local hospital is a Foundation Trust, then the board needs to work with Monitor to think through how they will assist with that development.

If they are not an FT that task is carried out by the NHS Trust Development Agency.

Both of these organisations have the legal responsibility to help Boards develop their models of care.

NHS England – at a national and local level – has no power over provider’s boards.

But that does not of course stop them from claiming it.

They do so because NHS England, at a local and national level, has a lot of staff who previously worked for Strategic Health Authorities (SHAs) and, when they worked for the SHAs, they were used to telling providers what to do. For non FTs SHAs had the responsibility to performance manage such organisations.

The fact that they now work for an organisation that has no such role does not stop them from exercising it.

However, as I said last week, you can hardly blame staff in NHS England when the Secretary of State himself regularly ignores the law, that he voted for, enshrined in the Health and Social Care Act.

Many commentators seem to wish for the SHAs to be recreated sometime soon. In fact I am told that many of the staff of NHS England see this as inevitable. They are imminently expecting another reorganisation to give them back their powers to run the system.

So having created a title that gives them the appearance of running everything, all they need now is a law to back that up.

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