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.

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First stop digging..

Filed Under (Coalition Government, GP Commissioning, Health Policy, Reform of the NHS) by Paul on 31-03-2011

Today the ever helpful NHS Confederation provides the Government with some advice about its reforms. Rather than the onslaught of horror and disagreement that most other commentators offer, this is a judgement of the story to date. It recognises that there is a lot of disagreement with the Government’s position and suggests some refereeing between the Government and other stakeholders.

Without using the language, it suggests various ways in which an orderly retreat can be created.

It concentrates on four policy areas of controversy where it suggests some new departures

  • Competition
  • GP Commissioning Consortia
  • Accountability and
  • The risks of transition


Unlike some of the NHS, the Confederation has had no problem with competition between providers. Its previous CEO, Gill Dixon, was wise enough to recognise that the Confed needed different parts of its organisation to represent different providers for NHS services. Therefore, alongside the FT network, she made sure there was an organisation of non NHS providers within the Confed (NHS Partners). The Confed are therefore pragmatic about competition.

They are right in saying that the case for competition – as with so many other cases – has been made badly by this Government. It sounds as though it is an abstract medicine that is good for you in its own right. Whereas what competition is good for are the outcomes it creates; patient choice, innovation and efficiency. The Confed therefore suggests pragmatism about where competition should apply (where it will deliver the best outcomes) and how a much better case needs to be made for it.

GP Commissioning Consortia

The Confed is questioning the depth of support for pathfinders from the GPs in the areas where these exist. They quite rightly point out that GP leaders without followers will not be able to develop any real organisation. They argue that the Government needs to do much more to encourage rank and file GPs to become a part of the process.

This needs to be done by being clearer about what GP Commissioning is, and is not. Too many GPs feel that they will have to stop doing what they enjoy as providers.

And the Confed quite rightly say that unless there is much greater clarity about the conflict of interest between GPs as providers and GPs as commissioners, then this appeal to rank and file GPs will fail. GPs and the public need a clarity about how GPs should and should not gain from better commissioning decisions.


There is a sensible discussion in the document about ways in which you might enhance local accountability. Given the importance of the “N” in the NHS and the political fact that this service is paid for 100% from national taxation, there is little mileage in pretending that the NHS could ever be a local government function. But they do argue for clearer and better local government scrutiny of commissioning decisions.

They also recognise the importance of what are called the Nolan principles – selflessness; integrity; objectivity; accountability; openness; honesty and leadership. These principles apply to all public bodies and their governance and their application to GP Commissioning consortia would be welcomed by most GPs and the public.

Transition Risks

The Confed, which is after all an organisation of “NHS bosses”, gently points out that the Government onslaught on NHS bosses last July has now rather rebounded on them. Across the country in many places there are now too few of the vilified bosses left to make the system work, so PCTs now have to be clustered to get them to work.

It was always a naïve policy for the Government to attack the very people upon whom you are relying to carry out your policy.

But the Confed also points out that since the current Secretary of State spent his first month in office reopening parts of hospitals that clinicians had said should close there is a clinical and financial problem caused by having stalled reconfigurations. If this continues the NHS will go bust.

Communicate, communicate, communicate

Two Fridays ago the Financial Times, yesterday the Times and today the Confed all point out the political and organisational disaster that has sprung from the Government’s failure to communicate a ‘compelling vision’ for change. No one knows what was broken so no one knows whether these reforms will fix it.

It all felt very New Labour when on September 14 I pointed out that the Government was failing to develop a narrative to explain what it was trying to do and why. But now this has become the main problem.

Next steps

There are three things happening in Whitehall as you read this.

First, Nick Clegg has let it be known that he will lead the Liberal negotiating team to get the changes in the NHS reform programme that the Lib Dem spring conference demanded. The Government, the Lib Dems and Nick Clegg all need a big victory to keep his party at all on side.

Second, most of the Government and its supporters now recognise that they cannot simply plough onwards with the Bill as it is and enforce the reforms as legislation. There needs to be a change of policy to reflect where the politics of reform actually is. As yesterday’s post suggested finding what this might be in April 2011 will be very hard, since the institutions upon which  they need to fall back have disappeared – before they are abolished.

Third, if Nick Clegg needs a radical shift in the policy and if the Government agrees that there needs to be one, then they need a story which explains what is going on to the public. The Government were hopeless at explaining what it was trying to achieve with the NHS when the reforms were going forward, it is going to be much harder to explain what you are doing when you move backwards.

But as we have seen in the last 10 months it doesn’t matter what you are trying to do, if you can’t persuade people what it is that you are doing and why you are doing it. If people don’t “get it” you don’t get anywhere.

In the spirit of public service tomorrow I will outline what a persuasive Government narrative of retreat might look like.



One Response to “First stop digging..”

  1. Very good points here.

    There is no doubt that the management of the introduction of this bill has been a disaster. Undoubtedly much of this has been due to the missing, but essential, narrative mentioned. However, one cannot get away from the lack of judgement shown by the main instigators in thinking the bill as it was tabled had a chance.

    Having said that I believe this bill will be significantly amended by House of Lords – see Lord Owen’s paper released today if Mr Lansley has not succumbed by then.

    Methinks there will be a reshuffling of the chairs in cabinet before this scenario is allowed to crash into the rocks in the ‘other place’

    But in the meanwhile the NHS sinks deeper by the day…



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