The new NHS's greatest risk
What is the greatest risk to the new NHS? The answer is not financial meltdown or reform fatigue, although they remain serious threats. It is alignment.
This has always been a challenge in a healthcare system as large, complex and comprehensive as the NHS. But the essential characteristics of the transformation the service is undergoing magnifies the difficulty of aligning priorities, policies and ways of working. The NHS’s new approach is designed to mean local decisions will have greater weight than central diktats; the actions of regulators and the precedents they create should trump “top-down targets”; effective risk management should replace “doing what you’re told” as the best way to prosper; the increased contribution of the private sector will create a mixed economy of organisations with different cultures - a trend echoed by a change in the makeup of the service’s leaders, with clinicians bringing a different mindset to decision making; and managing inputs should be replaced by the more demanding task of improving outcomes.
Finally, there is the speed with which some elements of the reforms are being pushed through.
Every one of these changes makes it potentially harder for the NHS to act in an aligned way.
The frantic work that is continuing through the dog days of August has once again thrown a spotlight on the greatest vulnerability of the NHS’s new ecosystem.
We can see the difficulty of achieving alignment in Sir David Nicholson’s sensible decision to begin to shift management responsibility to the NHS Commissioning Board. For the rest of the financial year many new system leaders will find themselves serving two masters, as accountability for 2012-13 performance remains with some of the most influential old guard figures.
More significantly, the torrent of consultations and guidance pouring from the centre highlights the predicaments ahead. The National Quality Board’s draft report on the proposed “quality surveillance groups” points out that: “No longer will there be a ‘system manager’… to hold the ring in the event of failure”.
Most important of all are the details of how Monitor will attempt to align its treatment of different types of providers and procurement methods.
Alignment is a key “concern” for NHS Confederation chief executive Mike Farrar. He draws attention to the need for “national organisations… to ensure they are driving towards the same goals, not myriad conflicting policies”.
Alignment is also singled out by Nigel Edwards in his perceptive piece on payment reform - a very important, but too often ignored ingredient in the developing modus operandi.
He points out there is already “poor alignment” between NHS payment methods, before concluding they may grow even more complex.
Just because alignment will require more thought and effort in the new environment does not mean we are set on a wrong track. The idea of service redesign being driven by the right mix of local stakeholders as opposed to one size fits all national strategies, or a sensible regulatory function replacing a command and control system too susceptible to political short-termism, has much to commend it.
But working effectively in the future will require leaders to do more to align their behaviours as well as their priorities. It will do little good for national and local groups to work together if they remain wedded to their own interests - something it is very easy to do if you represent a body struggling to establish its influence or to justify its survival.
Despite the fearsomely technocratic nature of the reforms, it is likely to be the success or failure of those with a wide range of motivations in aligning their actions which will determine whether or not the summer of 2016 will be equally awash with plans for change.
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Readers' comments (10)
Phil Kenmore | 23-Aug-2012 3:41 pm
A great piece Alastair. The penultimate paragraph is key - all the other elements will help but a genuine shift in behaviours and culture is the only thing that will create sustained change.
Is it time for a more socialised leadership model? One where organisational and personal self interest from leaders is less tolerated (or encouraged) by the service? Is this possible with continuing fragmentation of delivery mechanisms and a push for localisation of commissioning through CCGs?
The answer may be in a central push to recreate a new, refreshed, less cynical and less organisationally individualistic or target focused culture of leadership in the service. Not only will the new modus operandi of the NHS need this but post Mid-Staffs the public may well expect it.
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Anonymous | 23-Aug-2012 5:36 pm
Aligning a now even more fragmented ecosystem of separate organisations with often no clear sense of primacy will be incredibly difficult. The system is now riven with the cost of an initiative in one part and the consequences in another. Mostly I think we will keep our heads down and try to do our best until the dust settles and we can figure things out.
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Kosta Manis | 24-Aug-2012 11:12 am
Interesting to see how successful the Monitor will be in "aligning" City speculators, circling over the NHS.
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Tom Frusher | 24-Aug-2012 11:26 am
Alastair: your insightful piece echoes a number of the key observations in my recent HSJ Harkness blog:
http://www.hsj.co.uk/opinion/blogs/the-harkness-fellows/candy-coated-cartels-fear-and-loathing-is-there-a-better-way-forward/5048100.blog?blocktitle=Latest-blog-posts&contentID=719
"..it is not enough to simply establish a set of rules and issue guidance but rather the hard work must focus on building relationships that encourage engagement, generate understanding and foster confidence – sadly, all too often lacking in the regulatory environment applied to the NHS."
"A key observation is that working toward what should be common goals is reliant on having informed and knowledgeable participants in the process. At the most basic level, this requires a regulator that comprises credible experience and expertise."
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Anonymous | 27-Aug-2012 9:12 pm
it will be a miracle if individual CCGs can get the 10 or more GPs on their board to align on decisions. i fear total stagnation as egos and long-standing personal differences get in the way of collective responsibility. either that or individual chairs will set all direction and make all decisions.
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Anonymous | 29-Aug-2012 9:45 am
'Commissioning' has no clothes. As a slavishly lauded concept it should stand and look magnificent but really what has ever changed? Patients identify themselves, go in to doctor's rooms in private, have their problems managed and leave to self manage or be referred to have more investigations or specialist treatment. Nurses, AHPs and managers support the process. Any slow changes in local health and social care services occur due to the relieving of pressure points in the system. The superstructure's role is simply to align finances to stabilising local systems.
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Anonymous | 29-Aug-2012 2:54 pm
One word: bullying. Get rid of the years and years of systematic terrorisation [and NO, this is NOT too strong a word to use] before all the fine notions and concepts outlined above have any hope of taking root. Pigs might fly.............
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Anonymous | 29-Aug-2012 3:20 pm
"'Commissioning' has no clothes. As a slavishly lauded concept it should stand and look magnificent but really what has ever changed? "
I agree with my Anon colleague. Since the early 90s, this ridiculous overblown system has sucked cash from patient services through pretend markets and kept a generation of people with dubious or irrelevant skills in fat salaries. These individuals have mostly escaped accountability through frequent reorganisations, which no longer pretend to have any HEALTH related purpose.
Just consider the opportunity costs of this foolishness!
It'll be a brave economist who starts to count the costs of this in public money, let alone public health.
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glynis@archealth.com | 31-Aug-2012 3:19 am
Now all we need to know i why? Is due to inadequate staffing levels? No pre or post operative physiotherapy? That is leg movement and deep breathing exercises.
Lack of training on patient handling techniques? No routine patient "turning" or relieve of pressure by standing. Lack of trained staff supervision? Poor nutrition leading to development of pressure ulcers?
It is all food for thought!
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Anonymous | 18-Sep-2012 6:09 am
Alignment is only a threat to the leaderships precious hierarchy diagrams, it's no threat in the real world.
Those blasted charts are the bane of the NHS, with endless tranches of new executives fiddling with which line goes from where to where and renaming the boxes with their favourite words.
The Numpties think that the diagram is a way of describing how the organisation works! In fact they are ancient Egyptian pyramid schemes and the higher up you get the more you get paid. Hierarchy diagrams are in fact, little more than an accountant's theoretical wet dream of where the money goes, or a personnel-er's strategy for distributing the blame.
Meanwhile, down here at the bottom where the work happens, we've been lined up and working together for years. We don't function like the pathetic diagram and prefer not to tell the hierarchy that the buttons they push and levers they pull are not, in fact, connected to anything.
We cheat and lie and tell them what they want to hear, so that we can get the outcomes that the patients want, despite the system. We're like an underground network of resistance fighters keeping people alive, while the communists and the capitalists are busy inventing new weapons to overthrow each other!
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