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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.

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Whistling in the dark in Liverpool. What messages are people bringing back from the confed conference?

Filed Under (Culture of the NHS, Reform of the NHS, Secretary of State) by Paul on 25-06-2010

A year ago a lot of the earlier posts in this blog concerned the powerful and closed nature of NHS culture and I realise that I have been remiss in not returning to this in the current context of the new Government’s reform programme.

Over the last few weeks I have been trying to understand the detail of the reform policy and in the detail of this we can forget the power of culture to impact upon change and non change in the NHS.

There are two times when culture shows itself at its clearest. The first is at about 10 o’clock at the bar at a Conference. The second is when a culture is under attack and it comes together to defend itself. Both of these take place at a Confed Conference.

(And here a point of critique of any earlier post. I was quite rightly picked up by someone pointing out that the Confed (capital C) is saying very clearly to its members that the Government is going to bring about very radical change. My point is that the members (the confed small c) find it painful to hear that)

On May 20th it started becoming clear how radical the new Secretary of State planned to be. For the next few weeks running hospitals, PCTs or SHAs the members of the confed were facing this challenge on their own at work and the scale of the change feels very scary. Big Government and small NHS manager.

But get everyone together for a few days and it feels much more like small Government and big NHS managers. During the Conference it feels much more like “OK Mr Secretary of State bring it on because without us you can’t do anything”.

Also after a few drinks culture swops the war stories of the past with each other. Do you remember back in 1994 when they tried to implement fund holding; or in 2002 when they tried to implement choice; or 2003 with payment by results; or 2005 with practice based commissioning etc etc. How many Secretaries of State have you seen off since you started working in the NHS 32 years ago?  Culture eats those Government policies for breakfast and you know we can do it again.

So what I have heard people learnt at Confed Conference is how weak the new Secretary of State really is.

“ Do you know that he is isolated in Cabinet and no-one agrees with him?”

“Do you know that the Treasury won’t allow him to carry out GP-led commissioning?”

“Do you know that the Lib Dems are in revolt about cutting PCTs out of commissioning?”

“The Secretary of State was nearly booed off the stage”

“SoS is not being allowed to publish his White Paper because everyone is stopping him from being so radical”

Etc etc etc.

(And in only a few hours I have heard these remarks from 3 or 4 people)

For a few days the entire NHS becomes hyper expert on the granular detail of what is going on in Government and funnily enough all of this knowledge points only in one direction. It all adds up to the fact that the change agent (politics) is weaker and “we” (NHS culture) are stronger.   

So after the Conference every one feels a little easier. Change will be halted in its tracks and we can get on with business as usual.

My interest in this is not to defend the current Secretary of State and his reforms.  But it is to try and understand change and its enemies, better.

I am certain that when I was working with Alan Milburn and John Reid all of the above (and a lot more) was said about how the reforms would not happen. In fact of course many of those conflicts within Government are true. BUT it is only wishful thinking to believe that all of them fall in the direction of the status quo.

Of course the Treasury has concerns about radical changes in anything. (They did with FTs)  But they also have concerns about the nature of the status quo not having the drivers in to provide better value for money in the NHS.

Of course there are tensions in the Cabinet. If I am going to lose 25% of my budget because the NHS budget stays the same then those tensions are inevitable. (There were in 2002 when the Prime Minister announced the levels of increase in NHS spend).

Of course the SoS who wants to change everyone in the room’s jobs  is heard with some frostiness. (Alan Milburn 2002)

But none of that means that the reforms won’t happen. It may be that there is delay. It is certain that there will be differences between intent and outcome. BUT direction and radicalism will take place.

After a few weeks back in the day job – working with GPs to develop their commissioning intent and dealing with the management costs cuts – the tunes being whistled in Liverpool in mid-June will sound faint.

When you get a couple of thousand people together all whistling in the dark it sounds quite loud and reassuring. But it’s just whistling and it is still in the dark.


One Response to “Whistling in the dark in Liverpool. What messages are people bringing back from the confed conference?”

  1. Hi Paul

    I think there is a considerable difference in the 2010 vintage to the attitude of NHS Confeds past.

    For one thing, New Labour kept getting re-elected with thumping majorities. Managers may or may not have liked the direction of policy travel and the means and ends of redisorganisation, but they couldn’t say the government lacked democratic legitimacy.

    Many of them also got a lot more power and independence with FT status. They all got much better-paid, too.

    Policy-wise, from 2000-6, there was also a bit of a political TINA – there is no alternative. The Conservative Party kept choosing unelectable-looking, right-wing party leaders and Dr Liam Fox kept being shadow health secretary, with his marvellously popular Patients’ Passport policy.

    I didn’t read any intention to block or challenge policy from all the people I could talk to in Liverpool about things.

    I did read disappointment and frustration that the plan for GP-led commissioning and governance arrangements for an independent NHS board (in place since 2007’s ‘Autonomy And Accountability’ document) appeared not to have any detail.

    They are ultimately civil servants, and their job is ultimately to make healthcare systems work.

    I would suggest that the problem is despite the suggested direction of travel overall being clear (towards the three Cs of choice, competition and commissioning), there is important uncertainty about such key issues as:
    when will the new system start?
    what is the accreditation and failure regime for GP commissioning consortia?
    how long will a ‘licence to commission’ last?
    who will appoint and sack the chief executive / chair of the independent commissioning board?
    where is the evidence that GPs want to explicitly ration care?
    given GPs’ resistance of revalidation, how confident could we be in an adequate assessment system of clinical commissioning being agreed?
    do primary and secondary care clinicians trust each others’ data enough to mean commissioning can drive the changes required? (think discharge summaries)

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