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 »

Running a “system” called the NHS – or running the NHS as an “organisation”

Filed Under (Health Service Unions, Primary Care Trusts, Secretary of State) by Paul on 13-01-2010

Leaving aside the knockabout comedy value of a Secretary of State being brought up before a panel whose job it is to look after the rules that his own Government has agreed to……there is an important set of principles about the nature of the NHS that are being tested at the present time.

At the moment the NHS half believes it is a single organisation in which everyone can be told what to do, and half believes that it is a system where people don’t obey a set of management instructions from the top, but work to a set of transparent rules which make it work.

Most people have grown up with an NHS that exists as a single organisation. They believe that it has a single management structure within which people do what they are told. It’s like a single organisation in that people look upwards to the top of a single management structure.  It’s true that it is a big organisation with lots of levels between the top and the bottom, but that just means the people at the top need to shout very loudly down the hierarchy to be heard by the people at the bottom.

The Secretary of State is at the top of this organisation and they work with someone who is actually called the NHS Chief Executive. If you work with someone with this title, then in truth you can be forgiven for thinking that this is a single organisation.

It’s also the case that if everyone treats you as if you are the head of a single organisation – as most people do with this Secretary of State – then it is perhaps not surprising that you think you are at the head of a single organisation

So at the moment, if something goes badly wrong in a hospital the press and Parliament expect the Secretary of State to make a statement and answer questions in the House of Commons. Both public and Parliament also expect that  having made the statement, the Secretary of State will make sure that the hospital improves its outcomes.

Interestingly it was Parliament itself that passed a law which stated that the Secretary of State was no longer accountable for NHS Foundation Trusts. This was a very contentious piece of legislation which, at the time. captured everyone’s attention.  And let’s not forget that the legislation was passed.

What this means is that when a few weeks ago problems with safety were uncovered at Basildon and Thurrock Foundation Trust hospital, and the Secretary of State was expected to make a statement he should have said that he is not allowed to do so. In law he has no say in the running of the hospital in question. But Parliament doesn’t let a little thing like the law stop it from demanding that the Secretary of State answer to it for something over which he has no power!

Monitor does have a lot of say over Foundation Trusts. They can remove the chair of the Trust; and from next April the Care Quality Commission will be able to take away the registration of the trust for a range of services. But actually the Secretary of State – who is treated as if he were at the top of the whole NHS organisation – can do nothing, and should have said as much to Parliament.       

It’s not his fault- although he did personally vote for the legislation- it’s the fault of a Parliament that passed the law taking away his power

What this means is that he is not – and nor is David Nicholson as Chief Executive- able to simply tell every part of the system what to do. There are now different, interlocking, powers which do not run to the orders of a single person at the top.

Another group who don’t agree with the change from a single organisation into a system are the trades unions. They were against Foundation Trusts for precisely the reason that the legislation set all FTs free from the single power at the top of the NHS. The Unions want an NHS where the Secretary of State can tell everybody what to do. Their problem is that they believe that because this is what they want, that this is what actually happens.

This is why last September it all appeared deceptively easy to the unions. All they had to do was persuade the Secretary of State that he had a personal preference for the NHS as provider. Given what they hoped were the power relationships in operation they believed that when he declared his personal preference for the NHS as his preferred provider, it would automatically happen in every part of the NHS because he is at the top of the organisation. The top says” jump” and every says “yes sir!”.

To the unions it was simple. Persuade the person at the top and they will then tell everyone what to do – that’s how policy changes.

But as we can see from events of the last few weeks, the NHS now operates as a system with a set of rules that everyone – including the Secretary of State – is required to abide by.  It would appear that if his personal preference breaks those rules, then it’s the rules that matter and not his wish.

This is what it means to have a system that is transparently rules based.  Those PCTs that did what they were told by the Secretary of State are now surprised to find that in the modern NHS this is not a defence. They have to explain and defend their actions in line with a set of rules about competition not a set of instructions from the top

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