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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The need for a compelling narrative in times of great change

Filed Under (BMA, GP Commissioning, GPs, Health Policy, Reform of the NHS, White Paper) by Paul on 14-09-2010

Over the last week I have run four different sessions about the development of GP Commissioning Consortia.; one to a PCT Board, one to the senior managers of a PCT; one to a local authority and the fourth to a regional group of PCT staff whose job it is to develop and make markets.

This was an interesting set of experiences since, whilst they were different audiences, there were some similarities in the experience.

First, people are not really being helped to know what is going on and why the reforms are happening. I start these sessions with a set of slides about the new architecture of the NHS that will emerge from the reform programme.  This presentation is drawn from the 6 posts that I posted about the White Paper on this blog. They give my understanding of how all of the proposed changes fit together. I am not saying my interpretation is the only or even the best story to encompass what is happening, but at least it’s a story which tries to fit all the very different things together.

The Government seems to think that the White Paper speaks for itself and doesn’t require attempts to turn it into a narrative. They see it as a clear argument for change which needs to over-arch narrative.

The Government are wrong – and I say this based on having learned from my own mistakes in the past. It is the same mistake that I helped to make when working for Alan Milburn and John Reid between 2001 and 2005.We felt then that the whole reform programme – in its totality – was explained through the publication of the NHS plan. So in 2002 we published Delivering the NHS Plan, followed in 2004 by Implementing the NHS Plan – both of which assumed that readers would be able to place very specific reforms into the story outlined in the NHS Plan. All of those reforms, we felt, were clearly a part of the overall programme explained in the NHS Plan.

But we were wrong. Whilst White Papers do contain an argument, they are very long and full of detail. They don’t provide a compelling narrative about how all these things fit together and why I as a nurse, doctor, or manager should change my practice to fit in with new ways of working.  It’s true there were some really good speeches by Alan and John outlining this but we didn’t stick to the same story over and over again. And to help people understand why things need to change you really need to be able to fit yourself into that familiar narrative.

It is, for example, an amazing claim for the White Paper to say that we will create in the NHS the biggest social enterprise sector in the world. If you want a big, ambitious goal for a reform programme – this is certainly it! But it is difficult to see how and why GP commissioning consortia will buy health care from such new ventures and help to create them.

It also makes a lot of sense for local authorities to have a duty to commission public health services, but it may well mean that GPs don’t ever see it as their responsibility to commission services such as smoking cessation.

It’s not that these things are necessarily in contradiction, but unless people are helped to see how they all move in one direction it just doesn’t make sense.

The NHS needs a straightforward story about all this fits together. I know David Nicholson is going round the regions and making it known that he expects everyone to do a good job in the transition but he is not in a position, as a civil servant, to provide a clear moral case for these changes. This is especially hard since everyone can see how much of the change is coming in his direction.

The Government really needs to get out and sell – not the detail of this or that mode of commissioning – but why this new way of working will be so much better than what is there at the moment.

It’s a moral narrative that’s needed, not a technocratic road map.

The second problem is that to make GP Commissioning really fly, a significant number of GPs need to create a social movement that will get out and argue about how good it will be when they are in charge. We need several thousand GPs with a very high level of motivation in favour of this new way of working.

In reality most GPs that get up and talk about the possibility of their taking over commissioning are at best lukewarm. When they report on how their colleagues feel about this they describe it as being somewhere between anxiety and terror. I am pretty sure that’s true for a lot of GPs but when a GP leader says it, it’s a real dampener. 

I am never quite sure whether this is a complex negotiating ploy by the BMA – (If we are not keen then the Government will have to give us more money to do it; but if we appear keen they will think they can get it for free) – but its very difficult to feel motivated by these changes if the people who are going to gain the most from them don’t appear to want them.

By the end of this calendar year there needs to be about a thousand passionate advocates amongst the GPs of England and they need to be spread across the country. Without that the policy is in trouble.

The point is not that there need to be 25000 GPs who all want to become commissioners but that there must be a leadership that is highly enthusiastic and will lead their colleagues into the unknown with passion.

The third problem stems from PCTs’ staff interaction with this scepticism from many GPs. If your organisation is being abolished and your job is going, and you have to sit in a meeting and listen to the people who are going to do it saying that, on balance, they don’t really want to do it, it can create a very embarrassing interaction. A PCT manager would need to be a saint not to think, “If you don’t want my job, can I have it back?”

The fourth problem is similar to the one I described at the NHS Confederation in June. In June the consensus at the Confed was that there would be no White Paper before the summer recess. There were many reasons why people felt this was the case, but they all came down to the belief that the current Secretary of State wasn’t strong enough to see it through the Cabinet.

As I suspected at the time this was just a piece of collective wishful thinking – that it would all go away.

There is a similar feeling now. People who really don’t know much about the internal workings of the Government are finding all sorts of splits and hiccups which they believe mean that the reforms will not happen.  Again I think this is wishful thinking.

All in all  – at the end of these sessions – the majority of people are up for putting their shoulders to the wheel to make these radical changes. But there needs to be a much bigger motivational drive for change if this is really going to be developed in the next 18 months.


7 Responses to “The need for a compelling narrative in times of great change”

  1. All very interesting but I think you miss the main point; people feel there is no real “why” beacuse there isn’t. Andrew Lansley has not provided any evidence to show why his ideas are any better than any other course of action. The simple mantra is “managers bad, clinicians good” great soundbite but vacuous spin in reality. It is without doubt politically and idealologically motivated in order to distance the current Government from blame from NHS failure in the future.

  2. Excellent summing up of the current situation reflecting the business side of the NHS!!but what about how all this is effecting the product(Patient Care)? it feels as if we the patients are on a rollercoaster to give you an example.My ENT appointment through C&B was confirmed on Dec 19th 2009 my follow up appointments been cancelled for the 3rd time you have to wonder if we have an NHS at all? As at today’s date I have yet to get a new appointment date.Really bad if you are a patient so someone needs to do something urgently Who is accountable and what is Mr Nicholson doing about reporting on the the NHS Constitution

  3. You are of course quite right to say this is politically motivated and that
    is unsurprising because the changes come from a politician. Given we have a
    100% state funded health service and given one of the main issues for
    politics concerns the nature and form of what the state does, then it is
    very likely that very big scale change will have a political motivation.
    What I am asking for is, given that is where the change comes from, the rest
    of us have the right to expect that political ideology does what it can do,
    which is explain in a narrative why this is happening. What are the big
    moral and political issus behind this and why will it make the world a
    better place? Mobilising people behind big visions for change is the point
    of politics.

  4. Agree with Ian. What is the big narrative that the white paper is meant to implement? It’s not even ‘managers bad, clinicians good’ because there will be a whole heap of managers coming in: to commission primary care, “encourage” the new market, run the new regulatory and outcomes framework… even to provide the information that patients will use for choice.

    To me, the white paper reads as if Lansley has come across different problems over his time shadowing the health service and come up with responses to them. But those responses don’t add up to one clear vision of what is ‘wrong’ or what would be ‘better’; and they often pull in different directions.

    So: PCTs are not very effective. We can agree with that. GPs might make them more effective. Ok, but you don’t need to scrap and reinvent them. Particularly if you are not going to address some of the reasons they are not effective (lack of clout vs big, powerful hosptials, lack of transparent information, etc).

    The provider reforms have stalled. Again, we can agree with that. So all trusts will be FTs. Ok. But we haven’t got there in several years, and there’s no reason to belive that saying it will make it so – unless Monitor is going to be forced to approve some very weak looking organisations.

    Meantime, foundations haven’t had the impact they might have. So Lansley wants Monitor to ginger them up with a market in which patients will have more choice. Yet at the same time he’s noticed that healthcare and health and social care is not very joined up, so he’d like these newly competitive providers to link into co-operative care pathways, thanks; and for GPs to commission pathways not episodes of care, so goodness knows what patients are going to choose…

    Oh yes, and while Monitor will be focusing on price, there will be a huge outcomes framework to get everybody to focus on outcomes that will be monitored from the top in what looks very like the present, centralist way.

    Hence such nonsense in the original press release as “there will be more competition and more accountability.” At Richmond House, journalists laughed. It’s hardly surprising that out in the field people are struggling to see the big picture. Although they certainly are not laughing.

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