Professor David Colin-Thome
NHS Reform Blockers
In my recent blog, I described why the NHS needs reforming, catalogued all reforms since 1990, highlighted attempted essential disrupters, and noted the lack of sustained change. My hope is that the current NHS Reform policy will succeed, as the public now has more authority. However, my nearly 60 years of NHS involvement have identified two perennial blockers: the prevailing leadership culture and disabling commissioning. The way the NHS is funded likely compounds these issues- but more of that another time.
I have long described the disbenefits- clinicians included- of a sadly too common controlling leadership style. A ‘top-down’ approach, reinforced by a compliance-based governance, dominates. Of course, manager-leaders cannot allow a complete ‘laissez faire’ approach, but the best I’ve met keep control by letting go.
How can we mainstream that cultural paradigm shift? A good start would be choosing leaders for their personal attributes, coupled with technical knowledge. The new Plan places far more emphasis on localism than before. Can we pair this with the principle of subsidiarity- central authority only performing tasks that cannot be done locally? That’s a development we should all continue to push.
Commissioning: Too Narrow and Too Complex
I believe commissioning has been too narrowly defined and delivered. Secretary of State Wes Streeting, in a welcome supplement to the 10-Year Plan, encouragingly focuses on de-cluttering NHS administration. The duplicative NHS England is to go, and now we face a veritable bonfire- not of the ‘vanities’, but of maybe vanity projects.
Whenever the NHS surfaces a new problem, a new quango seems to appear.
“Creating new quangos can make for a good announcement but rarely solves the problem. Over the past decade and a half, an overly complex system of healthcare regulation and oversight has been left to spiral out of control.”
The current system is too complex, and the NHS needs “more doers and fewer checkers.” In total, 201 organisations will be scrapped. There are currently more than 150 bodies assessing quality in health and care settings and providing guidelines. That number ‘has been allowed to increase’ over the past ten years. The Government says these are not joined up and are having the opposite effect of what was intended- issuing guidance in an uncoordinated way.
I fully support this radical NHS reappraisal. It reminds me of speaking at a conference when a GP ranted about the Care Quality Commission (CQC). I responded by asking, “Why we do need the CQC?” My viewpoint was if providers had good clinical governance and leadership, and commissioners truly commissioned, the CQC should be redundant.
What has commissioning achieved since 1991, when the clear separation of provision and purchasing was introduced, and 1997, when purchasing morphed into commissioning?
The problem, as I perceive it, is the change sanitised the word ‘purchaser’ but over-focused on the transactional element of the role. I am not advocating abolishing commissioning, but I do want to shift focus to its partnership function- as an enabler of system creation and governance.
The culture should be relational, not contractual, with two-way accountability across all providers- even if contracts are held elsewhere. This is exactly what I mean by a new style of leadership. Contract methodologies could include alliancing, as used in the Antipodes.
Why This Change Is Urgent
We still have a healthcare system plagued by performance scandals. Maternity services are in crisis. I’ve been disappointed by the missed opportunities in several reforms and often invoke Machiavelli’s famous dictum on change.
Predominantly, I see weary, dispirited staff and a worrying sense of alienation- a fertile environment for destructive strike action. Unless we instil a sense of hope and purpose, even in cash-strapped times, I fear for our beloved NHS.
We all love its purported values, but many feel things are done to them. A sense of control is a prerequisite for well-being, and working for the NHS should embody that. Our Secretary of State is right: we need more doers, not checkers.
In closing, we urgently need to change how the NHS is led and managed:
- Commissioners should be participators, not a discrete authority.
- Providers must be accountable for service output and outcomes.
- Gaming of standards must be radically reduced, with all metrics in the public domain.
- Accountability should be transparent- not imposed.
- Local budgets, including personal ones, must increase.
Only then will reform be meaningful, and the bold overarching three shifts in policy of the current Plan become the transformative force we need.
This is the second blog in our series. If you missed the first post, you can catch up here. Don’t forget to read the final blog for a full overview.
