Ministers must slow down to avoid another Mid Staffs

12 January, 2012 | By Alastair McLellan

What did the newly minted coalition government describe in May 2010 as “a champion for patients”? The answer, of course, was primary care trusts.

Back in the coalition’s honeymoon period PCTs were slated for a central role in the proposed NHS reforms, responsible for commissioning “best undertaken at a wider level” and taking “responsibility for improving public health for people in their area”.

Then came the deliberations that led to the white paper proposals and the Liberal Democrat demand that local authorities should take the lead on public health. PCTs’ sacrifice must have seemed the easiest of wins for a coalition looking for ways to be accommodating to both partners.

Fast forward to the end of last year and a slimmed down Department of Health is working desperately to find a home for all the functions undertaken by disintegrating PCTs against a deadline which seems more unrealistic with each month. As one HSJ reader commented online, the exercise is being conducted in a climate where “no one knows who to ask, and those undertaking the function do not know who to tell”. Even the script given to managers briefing staff admits that – 15 months before the new system is meant to be up and running – there is “no clarity” about which functions are transferring to which organisations.

Commissioning reform is doing great damage to careers and morale. But there is an even greater concern.

PCTs may be heading for abolition, but the DH function mapping exercise shows the tasks they undertake are not disappearing too – but simply being transferred to new homes – some barely more than shells, some unknown. These tasks are being transferred because they are important, because they support and drive care quality. Confused and rushed reform makes it very hard for staff to perform those roles well.

The Mid Staffordshire Foundation Trust inquiry has already shown us how reorganisation, of a much smaller kind, can blind the system to poor quality care. It does not take great imagination to conclude what may slip under the radar during these, much more extensive, reforms.

The legislative reforms may have been “paused”, but on the ground reorganisation has ploughed on regardless, driven in part by the need to deliver management cost savings. The government should slow the pace, provide the missing clarity about future functions and – only then – move on.

Readers' comments (15)

Anonymous | 12-Jan-2012 12:15 pm
Alistair, would it be possible for you to write something about where the Bill is in the approval process, and what may/ may not happen for it to get Royal Assent and become an Act? All I can find out is that it's at report stage in the House of Lords, but no timings. Many thanks.
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Alastair Mclellan | 12-Jan-2012 2:51 pm
Hi
It is very, very unlikely that the Bill as a whole will fail. The report stage, during which amendments to the bill we be tabled, will run until late Feb/early March (7 separate days). There follows a third reading. At that point the bill either goes for Royal Assent (in April/May) or ping pongs between Lords and Commons until agreement is reached on amendments. Very hard to see a scenario where the government would drop the entire bill (but stranger things have happended).
Alastair McLellan
Editor, HSJ
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Anonymous | 12-Jan-2012 2:55 pm
Thank you, and apologies for mispelling your name!
That also explains why the HR info we're getting is so vague, the legal advice must've been equivocal.
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Anonymous | 12-Jan-2012 10:48 pm
Key functions - mental health, learning disability commissioning, safeguarding adults, children and the role of designated professionals all undecided. It is when, not if, in terms of a mid staffs or castle beck.
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Daniel Steenstra | 13-Jan-2012 0:44 am
The last thing that should happen in order to avoid another Mid Staffordshire is ministers slowing down. There is a severe disconnect between policy; organisational structures; and capabilities. The consequence of this is that at when policy is changed, the Department of Health, NHS management and the ‘shop floor’ lag behind and waste precious time, resources and human lives to reconfigure and mesh with the new policy. I would argue that this disconnect is the root cause of Mid Staffordshire where managers were focussed on financial performance, driven by government policy of Foundation Trusts and not capable to keep their ‘eyes on the ball’ ensuring that clinicians delivered basic healthcare. I also suspect that Mid Staffordshire is not an isolated incident but symptomatic of this systemic disconnect. On 27 Oct 2011 the HSJ published NHS Information Centre data on 14 other Trusts with above average mortality rates.

Rather than ministers slowing down a policy that is based on common sense and economic reality; I would argue that ministers, the Department of Health, NHS managers, clinicians and other staff deal with this disconnect by speeding up; working together and achievetotal system integration.
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Daniel Steenstra | 13-Jan-2012 8:01 am
The last thing that should happen in order to avoid another Mid Staffordshire is ministers slowing down. There is a severe disconnect between policy; organisational structures; and capabilities. The consequence of this is that at when policy is changed, the Department of Health, NHS management and the ‘shop floor’ lag behind and waste precious time, resources and human lives to reconfigure and mesh with the new policy. I would argue that this disconnect is the root cause of Mid Staffordshire where managers were focussed on financial performance, driven by government policy of Foundation Trusts and not capable to keep their ‘eyes on the ball’ ensuring that clinicians delivered basic healthcare. I also suspect that Mid Staffordshire is not an isolated incident but symptomatic of this systemic disconnect. On 27 Oct 2011 the HSJ published NHS Information Centre data on 14 other Trusts with above average mortality rates.

Rather than ministers slowing down a policy that is based on common sense and economic reality; I would argue that ministers, the Department of Health, NHS managers, clinicians and other staff deal with this disconnect by speeding up; working together and achievetotal system integration.
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Cassander | 13-Jan-2012 10:01 am
@Daniel Steenstra

I agree with you on the dangers of a disconnect between policy and practice. However, I cannot see how speeding up the current direction of travel will lead to greater working together or total system integration.

The consequence of an emphasis on markets and competition will make organisations distrustful and focused on their own survival. Uncertainty will erode the goodwill which both commissioning and provision rely upon to function. Establishing new structures without primary legislation will be at the risk of costly legal challenges
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joe farrington-douglas | 13-Jan-2012 11:09 am
@Daniel Steenstra

There is a disconnect in your argument for accelerating a set of reforms that replicate the mistakes that you identify as leading to Mid Staffs (bearing in mind the Inquiry hasn't reported yet but it is a reasonable diagnosis).

The only argument for pushing ahead seems now to be that the reorganisation has gone too far to reverse. That is a neat but dishonest political trick, and leaders have a responsibility to set out the sensible path ahead.

There is a credible plan B to stabilise the reorganisation, develop clinical involvement in commissioning and use the existing legal architecture to achieve the professed aims of the reforms.
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Anonymous | 13-Jan-2012 12:34 pm
@Daniel Steenstra

"Rather than ministers slowing down a policy that is based on common sense and economic reality;"

Is it really common sense to hand over £60bn of public money to a professional group with a) no significant experience of the function they're being expected to undertake, and b) for the most part very little appetite for it based on many surveys, the latest of which by the RCGP as highlighted yesterday by Roy Lilley had 98% of GPs voting for the bill to be dropped.

and what on earth does it have to do with economic reality? sorry you've lost me completely. The economic reality is the NHS has a savings target of £20bn over 5 years (if you accept the MckKinseys calculation) - a financial challenge on a scale never achieved in any industry anywhere in the world, ever - are you honestly saying that the best way to go about achieving it is to completely restructure the existing organisational architecture and hand the financial reins over to people with no relevant experience, and for the most part little interest...?
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Daniel Steenstra | 13-Jan-2012 1:27 pm
At the risk of being perceived as too mechanistic in my view there is a whole healthcare system that consists of a number of different ‘cogs’ such as policy; structures; management and front line capability. The chaos is caused by these cogs not being engaged and working together. The result is that policy- makers say that managers and clinicians should change. Managers say that politicians need to slow down and clinicians say that policy makers got it wrong. In the meantime each of these cogs has set off a series of irreversible changes; which is precisely describing the situation that we are finding ourselves in now. Advising ministers too slow down for everything else to catch up is far too simplistic.

@ Anonymous | 13-Jan-2012 12:34 pm I am not going to debate the reality of the global economic situation. The consequence however is that the NHS is faced with a rapidly increasing need for healthcare, no extra funding and a demand to provide better quality of care. This can only be achieved through fast integration and innovation; not just of primary and acute care; or health with social care but policy with structures, management, front line staff, patients and the wider community. Resisting change and apportioning blame are not helpful and could lead to further damage of an already fragile system and then lead to many more Mid Staffordshires.
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Daniel Steenstra | 13-Jan-2012 1:54 pm
@Joe Farrington-Douglas – Many thanks for your comments. I would be grateful if you can help me understand the disconnect in my argument for accelerating reforms as the healthcare system shows symptoms of severe stress that has a negative impact on the patients it is supposed to care for.

I am intrigued by your suggestion that this situation of staggering complexity can be stabilised and be put in a state of ‘suspended animation’. How do you suggest in practice that this is achieved? I fear that we just don’t have the skills, expertise and will to do this as it requires an integrated approach to ‘pull the lever”. Tragically if we had the capability to stabilise the situation now it would not have arisen in the first place.
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Anonymous | 13-Jan-2012 4:46 pm
If ever there was a wake up call about the headlong rush into the private sector then the implant debacle should provide it. Profit before quality care in the provision of boob jobs - hope this doesn't apply to other healthcare in the private sector.
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Anonymous | 13-Jan-2012 4:51 pm
@ Daniel Steenstra

"The consequence however is that the NHS is faced with a rapidly increasing need for healthcare, no extra funding and a demand to provide better quality of care. This can only be achieved through fast integration and innovation; not just of primary and acute care; or health with social care but policy with structures, management, front line staff, patients and the wider community."

please describe how the Health Bill will help to achieve these things (as opposed to making them immeasurably more difficult)
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Anonymous | 13-Jan-2012 5:00 pm
I think there are lots of solutions but they are mostly politically unpalatable. Closing/ selling/ demolishing old buildings/ estate that's no longer fit for purpose, opening services 7 days a week for longer than just 9-5, charging for more things (like GP appointments, unless 65), formal integration of the DoH and social care (budgets, staff, pathways), changing the way PbR works....
Nigel Edwards wrote an excellent piece about how the best way to implement policy was to take a "Scrapheap Challenge" approach and this is how many successful people (consciously/ not) make things work as best they can. Policy makers are always tempted to tinker and/ or are convinced something mandated nationally will work locally everywhere.
Part of me is tempted to say for goodness sake, get on with it and get this whole wretched stupid reorganisation over and done with so I can get on with the day job and find out what I'm supposed to be doing for which boss in which organisation..... but that's only personal frustration at being held in this horrible limbo since last summer. I want an end to it so I can get on with whatever it is my contribution will be to the greater good, whether £20bn efficiencies/ being part of the management savings. So yes, selfishly, I want it accelerated. But will any of that help? No.
More clinical involvement "feels" like the right tack to take but this botched job has lost too much in political capital to make the genuinely difficult changes necessary. The fuss and focus has been on the wrong thing, structural change. Waste of time and money.
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Anonymous | 17-Jan-2012 1:56 pm
I find myself in the rare position of agreeing with Daniel Steestra . Reassuringkly, it's only on a small point. I believe the process for reform is now unstoppable, but a swift and purposeful slowdown to clarify functions is exactkly the right thing.

What is key is that DoH should actually focus on getting one thing right at a time. At the moment, it's a dyke-plugging exercise, with more holes than available fingers or toes. The Reforms have completely lost any intellectual or organisational coherence, and the only way that we can start regaining it is by starting off with effective mapping of tasks, where they are now and where they should be in the future. Everything else follows from this, and it should be done properly, competently and swiftly.

It does utterly beggar belief that we're having to say this now, so far into the Bill process. This mapping was promised earl;y last year and - as with so many of the La La and DoH timesscales - it's been missed completely. The Project Management on these reforms has, at the centre, been dispiritingly poor. We need the central core questions answered now and quickly; if they aren't. nothing that is being done lacks any full context or sense.
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