Nigel Edwards: NHS reform is nothing new, but it's about time leadership delivered

30 June, 2011 | By Nigel Edwards

When I was asked by HSJ to reflect on what I have learnt about in my 12 years at the NHS Confederation, I thought I would specifically reflect on the constant process of reform including at least two which were billed as a once in a generation chance to change the NHS.

First, the policy making process is messy and this is true across time and different countries. While many of those involved are very talented and committed there are some persistent and repeating problems. The frequency of reform suggests impatience, unrealistic expectations about change and the urgent need of politicians to make a difference. It may be because far too much weight has been put on the ability of the centre to design incentives and policies that will elicit a precise response. The potential for adverse unintended consequences and the fact that policy may work differently in different areas are still too often ignored.

There has been an obsession with major structural and upheaval in spite of the well known fact that restructuring loses at least two years of progress. Except for trusts the half life of NHS bodies is now less than 5 years, this is particularly the case for intermediate tier organisations which are proclaimed as the answer before rapidly being condemned as too distant, too small or too big.

In policy there is much talk about structures, incentives and policies but much less about patient care or clinical practice. A lot is said about involving patients, putting the patient at the centre etc. but there are few policies to make this real. Policy makers lament problems with nutrition, pain control and providing compassionate care, but they do not address the root causes.

This reflects a fact common to health policy across many countries – that most of it is about trying to change clinician behaviour but without taking direct action about it or having any difficult conversations about what this means.

For example, the fact that GPs are going to being taking responsibility for rationing during the most difficult financial period the NHS has ever experienced is hidden way in the impact statement.

We have seen many cases where policy makers try to solve the problems created by the previous reform that were hobbled by poor design, inaccurate diagnosis or evidence-lite policy ideas. So there have been four attempts to design regulation and patient involvement machinery, eleven years of discussion of revalidation and a variety of approaches to try to make partnership work. Getting the policy right by being clear about what you are trying to achieve and using the evidence. If there isn’t any or it’s weak then allowing room for experiment and variation is a good idea. Unfortunately the words experiment and variation are rather unpopular with policy makers.

The ingrained habits of thinking (especially about hierarchy) added to the careful husbanding and acquisition of power by some parts of the system, the need to reduce risk and control innovations and the phenomenon of path dependency – in which current and future decisions are shaped and constrained by previous decisions - means that many apparently radical policies produce apparently very little change. This tempts policy makers back into the ‘the once in a generation’ reform or to try to create disruptive new forces such as ISTCs, PBR, GP commissioning and economic regulation.

Almost every change mechanism available to policy makers in the UK has been used in the last 20 years: including targets, improvement and capability building, attempts to shift power, top down management and markets. The lack of a coherent narrative about how the different reforms and the multiple, sometimes conflicting approach to managing change were supposed to fit together has been a real problem. Sometimes the story about what problem reforms are trying to solve is also unclear, a particular issue recently. This leaves a worrying impression of explanations being made up in a hurry after the event. But the truth is that this has often not been done well.

A key lesson is having some clear principles for reform, supporting evidence, a strong narrative about why it is needed and how it will work and that allowing evolution and experiment generally works better than ‘intelligent design’ and the one-off creation of policy.

So the conclusion I came to some time ago is that the best thing for health care organisations to do is to focus on doing the right thing. This is like the television programme Scrap Heap Challenge where contestants have to construct complex projects out of a variety of different parts that don’t fit together, were intended for another purpose and may be broken. Policies and incentives need bending, bolting together or otherwise adapting to make the local system work. But this is not an easy task. The definition of the right thing is often contested and the incentives and accountabilities are designed so that organisations, or departments have to look after their own interests. An optimal goal for a local system cannot be achieved by each of the participants trying to optimise their own position.

The chances of creating good local solutions is sometimes undermined by features of health care management that I have noticed in a number of countries – a very short time horizon and too little use of evidence. Ideas based on hunches and common sense are a poor guide to the management of complex processes. So we get attempts to shift care closer to home which cost more and require more visits than a one stop hospital appointment, demand management interventions that increase cost and demand, and a range of other faith based initiatives. This may be because while the importance of leadership has been recognised, the role of management has been neglected and is not sufficiently grounded in a theoretical and evidence base. The Modernisation Agency represented a brief flowering of a movement that, while it had faults, could have reversed this. But here we learnt that if those in power don’t understand something or it is slightly subversive it will be dismantled. This was a shameful episode.

The reason for all of these phenomena is rarely bad or incompetent people. Most of the people in policy or the service I have worked with have been smart and values driven. I think the difficulty is that many of the business models – our ways of organising services and some of the mental models that underpin how healthcare is commissioned and delivered are at least past their sell by date if not completely broken.

Hospitals are collections of activities that don’t fit very well together, they are often insufficiently specialist to deal with the most demanding problems but have too many specialist silos to deal well with patients with complex multiple conditions. They contain many mechanisms that stifle innovation and while they are too big to be agile they are often too small to create business model innovation. Successful organisations that have the financial and managerial resources to revolutionise their business model have the least incentive to do so. Models are often overly focused on institutional care and the need to sweat expensive assets.

Primary care has many strengths but is sub scale and without more federal working is unlikely to be able to respond to the changing demands of patients. It is insufficiently integrated with specialist care and often failing in more specialist areas such as children’s care. The division between primary and secondary care has its roots before 1900 and that between health and social care from at least the 1930s if not 1834 or 1601. Neither have any obvious logic. Mental health services face their own challenges of a lack of integration with primary care and a nagging concern that when users hold the budget they don’t chose what we provide.

I am concerned that if the current reforms represent the equivalent of telecoms deregulation then much of the NHS – public and private providers alike - are the GPO circa 1980. About to face a significant challenge which will require a fundamental rethinking of the business model, unbundling and rebundling of activities and a savage reduction in prices. I doubt the politicians are ready for how this may play out.

We do not yet know what new models will work or how best to organise services to respond to these challenges or the changes in the dependency ratio and workforce that the ageing of society will bring. Further mergers will take place but one key bit of learning is that this will at best delay the day of reckoning. Making a broken model bigger, does not make it less broken. Although everyone knows this they also know that their merger will be the one that bucks the trend.

The development of new models and solutions takes time and the interest in integration and co-ordination of care rather than organisations is surely where some of the answers are. Porter, Christensen and others who have been looking at these questions may have other parts of the puzzle. This is one of the most challenging question facing health services and the current reforms in this and many other countries doesn’t even go near it. Finding solutions and telling a much better story than governments have managed to tell is down to local leaders and particularly clinicians and I hope to spend more of my time in the field working with organisations that are at the leading edge of this thinking.

I have enjoyed my time at the Confederation and I have tried not to be cynical but there is one area where I have sometimes found it hard to stay objective. The huge scale of the changes and challenges facing the NHS require high quality leadership and management. The day to day workings of complex systems requires bureaucracy in the positive sense of the word. And yet, healthcare is the one area of the economy in which management is seen as a cost rather than a value adding activity.

I have become weary of countering the cheap lines and huge inaccuracies. It has been even more frustrating to hear secretaries of state talking, sometime contemptuously, about people who are their responsibility and upon whom, with others, they depend for the effectiveness of the system. They then wonder why it is hard to encourage clinicians to sign up. Defending management is not always easy and it sometimes doesn’t help itself, but as the King’s Fund’s recent report shows it has never been more important.

Perhaps we can weather the storm, maybe the pressure for change on our current business models will take more time to be felt, but we need all the time we can get - and it’s probably later than we think.

Readers' comments (25)

Anonymous | 30-Jun-2011 2:55 pm
Excellent. Lets hope that Nigel continues to provide us with insight like this.
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Anonymous | 30-Jun-2011 2:58 pm
Such a clear and thoughtful article. Let's hope that EVERYBODY in DH takes time out to read and understand. I dread to think what the policy makers will come up with in 5 years time as the antidote to what, by then, will be deemed to be the failed implementation of the Lansley policy upheaval. Thank you Nigel.
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Trevor Campbell Davis | 30-Jun-2011 3:45 pm
An insightful and accurate analysis by Nigel, who remains one of the best informed and clearest thinkers in the NHS. It should provide a template for (re)consideration in many quarters.
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Anonymous | 30-Jun-2011 4:17 pm
Genius. Enoble him and make him SofS.
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Anonymous | 30-Jun-2011 4:53 pm
Superbly crafted, well thought through piece as usual from Nigel. So it isn't rocket science, but why oh why will they not listen? We are all weary of the deluge of dogma driven ideology, from all political parties, the constant churn of reorganisation, and the instability and lack of Trust this generates at the front line. We are all overwhelmed with the sheer weight of the bureacracy and regulation designed mainly to cover the backs of those in power. And I hear that the new Commissioning Board is going to employ 3,500 people. Utter, utter madness. And what do 3,500 people in a central bureaucracy do with their time? They think up lots of things to change. Can't wait.
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Anonymous | 30-Jun-2011 5:13 pm
Well done again, Nigel. Makes it worth trying to do the right thing. We're told to do the right thing by Nicholson. Lansley and Co., but they could help by dismantling some of the incentives and mindsets that stand in the way. Witness an influx of non-exec directors into our Trusts all of whom seem to value the private sector business / profit model and apparent organisational success more than any public sector ethos, and have very little understanding of how their pursuit of those goals undermines the possibilities of better care for more people. (The result (around here at least) is a determination to share information as little as possible as that may threaten their competitive position.)

Wherever we are in all this, we can only use our time and place as best we can. I would suggest that managers in PCTs and Trusts work around their Boards and try to do the right thing for patients and population as if we were all on the same side.
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Anonymous | 30-Jun-2011 5:13 pm
A moment of lucidity amongst a miasma of rhetoric. Thank you Nigel for a well drafted commentary.
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Roy Lilley | 30-Jun-2011 7:35 pm
National Treasure!
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clive smee | 30-Jun-2011 11:26 pm
Well said Nigel. Looking back at the 18 years when I had some responsibilty for advising on health policy in DHSS/DH, including the 15 years before Nigel joined the Confederation, I would particularly undeline his comments on:
- unrealisitc expectations among politicians and senior advisers about the rate and scale of change in health outcomes and health inequalities and particularly in health service efficiency;
- the obsession with major structural changes in organisation and governance and the gross underestimation of their costs and exaggeration of their benefits, in part because there has been a refusal to subject them to the same systematic ex ante appraisal and ex post evaluation that has become normal for, say, new medical technologies;
- the ignoring of evidence, and the discouragement of experimentation, variation and evaluation when they might question Ministerial priors;
- the slowness to take direct action about out- dated clinician behaviour or to give clinicians adequate support to change that behaviour;
- the neglect of NHS grass roots management and under investment in improving its quality.
One would like to say that there is growing recognition of these weaknesses and atttempts to learn from them. Maybe there is in the Confederation and the academic community. Whether there is in the Departement, where civil servants "speaking truth to power" appears to have gone out of favour (under both governments) and institutional memory gets shorter with each re-organisation, is much more debateable.
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Clive Peedell | 1-Jul-2011 1:41 am
Nigel Edwards identifies many of the key issues that have plagued the NHS over the last 20 years.
In particular, I think the issue of clincial leadership is critcal in this debate because it forms the central plank to understand where things have gone wrong.
It is now almost universally accepted that clincial leadership (and followership) is crucial for the success of healthcare system reform [1]. Nigel talked about all the redisorganisations over the last 20 years. In fact the NHS Confederation did a good report about this issue [2]. We should therefore look back 20 years and ask what happened. In 1991, the purchaser-provider split was introduced in keeping with Thatcher’s neoliberal economic counter-revolution. At the time, the BMA had a huge fight with Ken Clarke. He did not involve the BMA in the policy making process. This signalled the end of the “double bed” of policy making, brilliantly described by Rudolph Klein in the BMJ [3]. The corporatist approach to policy making was thus killed off and has never returned.
Why didn’t Ken involve the doctors? Because he was introducing a market system that he knew would not be acceptable to the profession. Nigel Lawson said this in his diaries (A View From Number 11). Doctors back then, just as today, rejected the idea of a market in delivering healthcare. This is not surprising because doctors control access to the healthcare market. In fact, Professor Paul Starr said that medical professionalism presents an obstacle to market reform because “medical sovereignty” exerts control over the market through a combination of cultural authority on patients and political influence over policy making [4]. Markets don’t like being controlled! They have their own invisible hand of the price mechanism to sort themselves out.
In addition, doctors like to work collaboratively to build high quality local services. What could be more anti-market than supporting your local incumbent provider? This is why the BMA MORI poll showed overwhelming rejection of the idea of competition, which just happens to be Lansley’s first guiding principle! This is why the originally proposed legislation aimed to enforce competition through the patient choice agenda and the economic regulator, Monitor, and enforce all GPs to become members of GP Consortia.

In addition, market theory in the form of public choice theory rejects the idea of medical professionalism and the public service ethos. James Buchanon, “the father” of this theory admitted in a BBC documentary (“The Trap”, by Adam Curtis) that he didn’t believe in the concept of the public service ethos. Julian Le Grand famously used the “Knights and Knaves” metaphor to explain this. The solution to “rent seeking behaviour” is the discipline of the market. This would turn “pawns in queens”. The introduction of the market also explains the rise of New Public Management (managerialism), which favours narrow economic priorities and micro-management practices (e.g audit, inspection, performance indicators, league tables, monitoring and centrally imposed targets) over professional judgment [6]. (I was politicised by MMC, by the way, because I rejected its anti-professional tick box aims. It was about delivering a new breed of doctor to suit the needs of employers in the new healthcare market).
And there’s more! (as Frank Carson used to say). Markets undermine the social contract between doctors and patients and damage the doctor patient relationship, because decision making becomes increasingly finance based rather than needs based. It is no coincidence that the American medical profession lost public support faster than any other profession during the rapid commercialisation of the US healthcare system in the 1970/80s [7].

So policy makers have a very difficult problem here. They universally accept the need and importance of clinical leadership to deliver their market reforms, but those reforms will actually damage the professionalism of doctors.
I agree with David Marquand when he stated that “public service professionals are not just non-market, they are anti-market” [8]. I think the current opposition to the reforms from across the public sector is a testament to this argument.

So we can quote a few controversial papers and argue about the pros and cons of choice and competition all we want, but the elephant in the room is the erosion of professionals standards by the market. Since clinical leadership is so important, this has profound effects on the practicalities of delivering market based reforms to the English NHS. When is someone in Richmond House actually going to listen to Kenneth Arrow [9]?

References:
[1] Ham C. Engaging Doctors in Leadership. A review of the literature. Available @ http://www.hsmc.bham.ac.uk/work/pdfs/Engaging_Doctors_Review.pdf
[2] http://www.nhsconfed.org/Publications/Documents/Triumph_of_hope180610.pdf
[3] Klein, R. The State and the Profession. The Politics of the double bed. BMJ. October 1990. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1664062/
[4] Starr P. The social transformation of American medicine. Basic Books, New York.1982
[5] Le Grand J. Motivation, Agency, and Public Policy. of Knights, Knaves, Pawns and Queens. OUP 2006
[6] Bottery M. Education, policy and ethics. Continuum. New York, 2000
[7] Blendon R. “The public’s view of the future of medical care” JAMA 1988 259: 3587-3593
[8] Marquand D. Decline of the Public. Polity Press 2004
[9] http://www.theatlantic.com/politics/archive/2009/07/an-interview-with-kenneth-arrow-part-two/22279/
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Neil Jessop | 1-Jul-2011 8:59 am
Brilliant article as all commentators have said one can only hope that CCGs take up their new roles and provide some much needed stability and sustainabilty for the patients and the service as a whole.
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Jay Verdi | 1-Jul-2011 9:24 am
Very good article indeed.
I also value the contribution from Clivel Peedell; but ending with a new question. That question is "Is having a single dominant and highly paid profession the only way of protecting a public service from market erosion?"
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Patrick Newman | 1-Jul-2011 9:49 am
There is nothing remarkable about Nigel Edwards article except he says it all and in one place. Some of the above contributions decidedly add value to his thoughts. The one theme that strikes a loud chord with me is - "There has been an obsession with major structural and upheaval in spite of the well known fact that restructuring loses at least two years of progress." Add to this the underestimated priority of presentation in the minds of this and previous governments and you have a credible explanation of the motivation of political policy makers. Currently it is competition and choice which the Coalition's form of 'motherhood and apple pie' but which the medical profession are successfully exposing for the dangerous fool's gold that it is. In the responses attempts have been made to identify the principles that may lead to a better NHS and perhaps HSJ could create a proper debate among the professions?
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David Hooper | 1-Jul-2011 1:49 pm
I agree!!! There is no more to say.
Let us hope that politicians' and ministers' ears will listen to Nigel more now that he is with the respected King's Fund rather than with that load of pen-pushers and bureaucrats that are represented by the Confederation, and so despised by the Daily Mail.
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sjburnell@focused-on.com | 1-Jul-2011 2:49 pm
Ah, but Politicians will always be Politicians!

So, what will work?

Perhaps we need a politically independent NHS (SoS merely to set rolling 5-year Funding Policy) to avoid the above problems & excess, stupidly short-term decisions.

Then, a small DH sets areas of National Strategy like better Prevention & Early Detection of LTCs or greater Mental Wellbeing.

Then, HWBs set local Strategic Priorities like better & more sustainable Dementia Services based on local population needs.

Then, CCGs + Service Providers focus on design & delivery of better local Services & optimisation of high quality, accessible Care.

We all need to see the NHS become demonstrably more values-driven, supported by intense Cooperation + rigorous Inter-Dependencies, focused on Quality of Service + Access + Sustainability.

A strong healthy culture based on just a few, simple & persistently re-enforced values - that's all we need to get the best out of whatever resources we are given.
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Peter Huskinson | 1-Jul-2011 4:15 pm
The best article I can remember HSJ ever carrying.
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John Toby | 1-Jul-2011 4:56 pm
I should like to add my sincere thanks to Nigel for what I hope, and expect, will only be an interim swansong. Extremely impressive and refreshing, nonetheless. I should, however, like to take issue with the statement that there is no logic to the division between primary and secondary care and, perhaps, that the 'sub scale' nature of primary care will necessarily prevent it from responding to the changing demands of patients. The logic of the division lies in the distinction between generalist and specialist clinical care and the importance of the former has good academic support and international recognition. There may be other ways of delivering these different approaches but it would be unfortunate if these were lost in the adulation. It may also be helpful to remember that the development of general practice and primary care which occurred from the 1960s onwards owed much to 'sub scale' practices. It is, of course, clear that the provision of high quality and responsive care across the population from small units presents many challenges but I hope that Nigel will help to support and develop this in his next incarnation.
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Karen Webb | 1-Jul-2011 5:30 pm
A thoughtful essay Nigel. "Doing the right thing" but in whose competing interest? political, professional, historical, hysterical?

You are right I think to point out that no Minister wants to be saddled with a predecessor's policy. Changes, the perceived need for which a Government is elected (though not this one interestingly) must be delivered before the next election charge/reshuffle. The past is littered with initiatives (and bodies) of those at the vanguard of a pet policy initiative just when the music stopped. Timing, not long term outcome, evidence shows is everything. This is why the heat is now on to "get something done" before the public start to see the seams splitting.

And in whose interest?

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Anonymous | 1-Jul-2011 5:50 pm
Clive Peedell - 1.41 am - I agree with your viewpoint, but I would be very interested to hear how clinical leaders are going to engage with the rationing that is required to manage within limited resources.
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Clive Peedell | 1-Jul-2011 6:00 pm
Jonathan,
"Is having a single dominant and highly paid profession the only way of protecting a public service from market erosion?"

This is a key question that gets to the heart of the NHS and its problems

The answer is partly yes, but with a very strong dose of proper professional accountability. This means external peer review (from doctors, managers and patient representatives), and meaningful measures of clinical performance made publicly available. It also means zero tolerance of abuse of private practice in NHS time.
This was all lacking in the past. Consultants were too powerful and there was clearly private practice abuse of the NHS system. The profession needs to openly acknowledge this was a problem with some members of the profession. It poisoned the relationship between doctors and the political class and trust was completely lost. This has caused untold damage to the NHS, because the “trust model” of healthcare delivery was abandoned, when it should have been strengthened through proper forms of accountability.

We need to recognise faults on both sides and get some trust back. Unfortunately, a market system is the antithesis of what is needed to do this.

I would confidently state that the majority of the medical profession are not “rent seeking knaves”, but some have abused the system. I admit to having a vested interest in wanting a well paid lifelong job with a good pension. However, in return I want to work in Middlesbrough for the rest of my professional life to build a service that I am proud of, and that the local people in our region can have absolute confidence in. This requires hard work, continuity, collaborative working and professional integrity. The last thing it needs is the creative destruction of a market. So my vested interest in providing a lifelong service to the local region is in the public interest too. That contrasts wildly with the vested interests of those doctors that like to see waiting lists grow in order to maximise their private practice. That sort of behaviour is a disgrace and the sort of vested interest that needs to be tackled with the strongest possible measures. I would once again state that the majority of the profession are in my camp and the majority do way over the odds for what they get paid. That is precisely what the consultant contract showed.

Let’s build that trust again. Then we can have a system which gives doctors a fair deal, but gets a lot back in return. You only have to look at the market rate in the private sector to see how much of a bargain we really are.
Don’t let a few greedy sods tarnish the rest of the profession.
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