Conflicting messages from the top hint at growing resistance
Have the tone of messages from the NHS chief executive and health secretary ever been as different as those emerging from Sir David Nicholson and Andrew Lansley? At last week’s health questions in the House of Commons, ministers got stuck into “pen pushers”. Contrast this language with Sir David’s latest letter to the service.
He writes that NHS managers “have a very strong track record of delivering” and should be “rightly proud of their achievements”. All of which “underlines to me the excellence of the public service managers we are lucky to have”. Note the “to me”.
Is this simply General Nicholson pepping up the troops as Field Marshall Lansley orders them over the top? No doubt. But HSJ also suspects Sir David’s extensive NHS network tells him that resentment over the government’s plans is reaching boiling point - and that some influential figures are rapidly reaching the conclusion they can only take so much.
This smouldering revolution may, of course, fizzle out. However, it could also ignite into an internal resistance movement to the reforms and may do real damage during these delicate early stages.
Sir David also stresses in his letter how much has not changed. Mr Lansley trumpeted the end of the 18 week waiting target, Sir David chooses to specifically remind NHS chief executives that it “remains a constitutional right” and commissioners have “a responsibility to ensure that commitment is met”.
In bold type he warns that work on “designing the new system” must not “distract us from the major operational challenges we continue to face”.
Sir David has also turned the volume up on the need to take that design work steadily - again a sharp contrast with ministers who are happy to leave the impression that GPs will be taking over the NHS tomorrow, rather than in two and half years.
The union-inspired judicial review into the reforms has clearly instilled some caution into the government plans, but just as influential will have been the nervousness being expressed by GPs.
This caution is underlined by the British Medical Association’s observations on GP consortia commissioning.
The document is full of statements that would sit very easily in Sir David’s letter, for example, a warning that primary care trusts should not “select a consortium leadership team”.
But there is one statement which should send a chill down both Mr Lansley and chancellor George Osborne’s backs - and makes Sir David’s plea to focus on the cost saving challenges of the here and now all the more sage.
Faced with the need to slow growth in spending, the health secretary has rightly suggested that more effective commissioning is the best way to drive efficiencies. He has also suggested that GPs are best placed to spot potential savings.
The BMA begs to disagree. “There should be no expectation that an effective commissioning process will generate freed-up resources on a regular basis,” it says.
Let us hope this is simply a negotiating position, otherwise the NHS is heading for a very painful reckoning.
Provider changes
HSJ is pleased the Department of Health has taken up its suggestion to establish “a national reference group” of provider trust chief executives to feed into the transition process. Manchester’s Mike Deegan, although not our original suggestion, is an excellent choice as chair.
As Sir David points out, the NHS is facing fierce challenges from the rise in emergency activity and other cost pressures - which the forthcoming comprehensive spending review will accentuate. Moving to an all foundation trust future in this environment is best handled by the people meeting those challenges day to day.
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Readers' comments (6)
Anonymous | 16-Sep-2010 9:19 am
An interesting Commentary, but all the rhetoric needs to be turned into solid information and action.
For instance, as part of the NHS front line do I let my waiting list continue to breach (following Mr Lansley) or do I insist that my commissioners bring it down (following Mr Nicholson)? Answers please on the back of a fag packet.
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Joe Bloggs | 16-Sep-2010 12:05 pm
Great story AM. It sums up very well almost the entire predicament facing the NHS right now. No agreement. No consensus. And three main players: Lansley, Nicholson, and BMA all saying different things.
As the post at 9:19 says we need fact not rhetoric. But alas as a person on the frontline s/he would not appreciate what a truly awful mess politics and management really is at the dizzy heights of the 4th floor of Richmond House where the production of facts is something many are employed to prevent.
Some key facts are:
Nicolson has been disagreeing with Lansley since Nicholson first said he in public at the NHS Confed he didn't believe the reforms could be achieved
Nicholson believes managers have a strong track record of delivery - which is at odds with WCC reports, NAO reports, PAC reports and the like
Nicholson says the NHS must deliver on 18 weeks, probably because he knows 1) it's a contractual requirement which could result in legal action and embarrassment 2) extending waiting times would cripple the future of the NHS in a time when money is going to run short 3) providers will overspend causing embarrassment.
Don't get me wrong, we know bullying and gagging has been used to pressure some people to deliver targets, and that is unlawful, but increasing waiting times will wipe out his CV.
Nicholson now says major operational challenges are more important than reforms which goes back to the original issue of not supporting Lansley's plan. Of course Nicholson is right that there are big problems out there.
However, if I were in charge of something for 5 years that still had 'major operational challenges' and no plan to resolve them and my boss said I had to implement his/her plan but I said NO WAY (whilst publically disagreeing with him/her) because I wanted to muddle along with the non-plan I had...well I expect to be sacked rather quickly. Nicholson must get an award for survival or some skeletons no one wants to know about.
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Anonymous | 16-Sep-2010 3:00 pm
Thank you Joe for picking up on my 9.19 anon input, and your further lucidation.
Please do not think that no front-liners know about the dizzy heights -- some of us follow the issues and the politics very closely indeed.
My illustration was merely included to demonstrate how very muddy the water is at present, in provider services as well as PCTs, SHAs and DH. Although HSJ naturally focusses on the mud at the top, it does not mean that the mud does not sink to the bottom too.
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Anonymous | 17-Sep-2010 10:47 am
Lansley needs to do something about Nicholson fast before he totally wrecks the White Paper. Nicholson is sabotaging the White Paper day by day and will sink it unless Lansley sidelines/removes him. The best way to handle this is for Lansley to bring in a project director who believes in the vision of the white paper, who is directly accountable to Lansley, has the authority of Lansley, who will issue all communiqués from now on, and leave Nicholson to reminisce about his vision for PCTs and SHAs.
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Anonymous | 17-Sep-2010 4:02 pm
Anon 10:47: I am fascinated by your suggestion that the *best* way Mr Lansley can handle this is to bring in a Lansley-man to put Lansley's vision into practice and shape the National Lansley Service of the future.
I wonder on what mandate this individual would be operating - without moral, democratic or executive authority; without financial or legal responsibility and without the support of the DH or NHS. I presume that this would attract a salary greater than that of the PM at least!
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Anonymous | 19-Sep-2010 9:58 am
You make a good point 4:02 but in defense of 10:47 NHS Trusts have been instructed to bring in turnaround directors since 2005. These people effectively takeover the organisation and lead its change programme albeit from the safety of being completely unaccountable. DH sent these individuals to Trusts so it would be with a sense of irony for the DH to receive some of its own medicine. Therefore 10:47s suggestion may not be so unreasonable after all.
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