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 »

What do you need to do to carry out health service reform?

Filed Under (Health Policy, Narrative of reform, Public service reform, Reform of the NHS) by Paul on 22-09-2011

This week I spoke to a meeting of international CEOs from various countries and different parts of their respective health services. They wanted to know how the reforms were going and what the prospects are for the NHS.

There were three different aspects to my talk.

First was a set of ideas with which you must engage if as a Government you are going to be successful in reforming a nation’s health system.

Second I tried to outline how far the reforms have gone in England.

Third I outlined the problem – which I think is global – about ‘the money’.

Today I’m blogging about the first of these, how do governments in democratic countries carry out reform? This is drawn from my experience of both the problems of the last 18 months and my experience of working in Government between 2001 and 2007.

Let’s begin with a warning to governments, “don’t try this at home – unless you’re prepared to see it through every day for a decade”. It’s very hard to reform health services and it needs constant weekly attention if you are going to have any success.

The reason it is so very hard is the obvious point that health systems matter a lot to the public. So don’t fiddle with them unless you really mean it

In all developed countries the institution that you are trying to change is enormous. It is therefore not at all surprising that there are some very big vested interests in the current model of value production in health services. I am old enough to remember that in the 1960s the political left referred to a sizeable chunk of the US economy as the “military industrial complex” and if you took them on it would be very hard to change them.

In the US today the “medico-industrial complex” is much bigger than its 1960s military equivalent. The same applies to the NHS in England. Always remember that every time you touch an organisation of this size  you are taking on a massive organisation – which will resist.

I outlined five themes central to successful health service reform,

1     Have a reason for change that matters to the core of the public

When reforming a national health system policy is nice, but politics is crucial. The essence of politics is the mobilisation of power and public argument to ensure that you win an argument.  If you think you can effect real change simply because you want to, you will quickly find out that without that mobilisation of argument and power, ideology is insufficient.  For health reform to happen it really has to matter to the public, and the extent to which they are shouting at you will demonstrate the extent of their concern. The public make you do this. They are active. The best argument for change is that you, as a Government, won’t be able to face the public if you back down. The public need to feel there is a big problem and to expect you to fix it. From 1997 onward the big problem for the public was the maximum length of time that people had to wait for treatment. The public demanded these improved.

2     Have a narrative that regularly demonstrates how your new policy changes solve the problem that the public agree needs changing

It’s obvious really but it’s still a good idea to make sure that you can easily demonstrate how your health service reforms really solve the problem the public are asking you to solve. When you construct policy initiatives it is important to relate them to the overall narrative for change – every week. How do these policies fit in with the overall narrative and how does the overall narrative fit with the little policy things? This is hard work and needs constant attention. In my experience – in tackling waiting lists – there were some parts that were easy to explain. The creation of independent sector treatment centres were clearly aimed at cutting waiting lists and also through competition increased the productivity of existing NHS institutions. But other parts of the reforms – improving commissioning for example – seemed to be just a policy idea that we failed to fully bring into the main narrative.

3     An electoral mandate is insufficient ; recreate your mandate every month to maintain momentum

Democratic government believes that when you have won an election you have a clear mandate for the changes that were in your manifesto. Dick Morris, who worked with President Clinton half way through his first term, argued that the electoral mandate degrades from the day following the election. For a government to get permission to make real change it needs to recreate that mandate every month. You need to make sure this takes place through a variety of real and different forms of communication which can get across both your aims and achievements. You need to say that you will deliver real improved outputs for the public and then you need to deliver them. This contains risk. With maximum waiting times the government pledged that no one would wait longer than a given period – that was reduced every couple of years. The public could watch this slowly come down every month and, whilst setting the targets was a risk, they were a vital part of proving that the NHS could improve its relationship with the public.

4     Expect conflict and make most of it take place when you want it.

Those with vested interests in the current health care system will fight very hard to maintain the status quo. There is a lot of very real interest (status and wealth) involved here. Therefore it is important not to be surprised when people fight very hard to defend their interest. So expect it to get rough. What has struck me as odd about the present Government and its attempted NHS reforms is that they have been surprised by the reaction to them from vested interests. But it is certain that this conflict will happen and, given that it is, don’t wait for them to conflict with you. Most vested interests have very predictable positions. Use this predictability to ensure you know when they are going to attack and on what..

5     Bring in narratives and examples from outside of the health system that make everyday sense to the public but are resisted by those vested interests.

There are a lot of aspects of life outside of national health systems that make common sense in people’s lives, but will be treated as odd and dangerous in the NHS. When, from 2003 onwards, New Labour constructed a system which paid NHS organisations for doing work, many in the NHS felt this was a mad reform. Expecting NHS organisations only to get paid more if they did more work was seen as odd for the NHS. However it is the way in which most other institutions work and pretty normal for the rest of society. Similarly expecting people to have a choice in the NHS when they have a lot of choices outside was something that was normal for the rest of society. Both were odd in the NHS. If you base your reforms on elements of your society that are ‘normal’ it makes resistance to them look odd.

On a previous occasion when I outlined these ideas, a GP who has been working closely with the present Government and their reforms went through these five themes one by one and said that the present Government had failed to do any of them with any power.

Which might explain where the reforms have got to…

Leave a Reply