The HMSC at 40
At different times our attitudes to history vary.
At one stage, the language was of New Labour, a new millennium and a process of modernisation, with a sense that we should be looking forwards rather than backwards. More recently, there have been attempts to place current debates in a broader context. Thus, current debates are badged in terms of the biggest reorganisation or the most sustained and significant financial challenge in the history of the NHS. Parallels are also being drawn with other coalition governments in the past and with other internal economic downturns.
Amid all this, the Health Services Management Centre at the University of Birmingham celebrates its 40th anniversary this month. As is often the case with birthdays, this is both an opportunity to look back at the past, but also to take stock of where the NHS is now and what the future may hold - particularly in a difficult policy and financial context.
We have been celebrating throughout the year in various ways. However, two of the highlights include our 2012 annual health policy lecture, given by one of our honorary members of staff, Sir David Nicholson, and the launch of the HSMC 40 website with photos and memories from people who have worked with us and for us over the years.
At the former event, we published our usual newsletter - but with each of the directors of HSMC since 1972 reflecting on the key challenges that faced the service during their day and the ways in which HSMC responded. Editing the newsletter, what has struck me most is how much the issues raised resonate with the debates that surrounded the Health and Social Care Bill.
In the early 1970s as HSMC came into existence, the emphasis was very much on the development of more integrated structures in preparation for the 1974 reforms. Indeed, HSMC’s first director, Derek Williams, describes HSMC as a “reorganisation child” formed to help support widespread structural change and develop more integrated management training and development for the relatively disparate parts of the previous system.
In the 1980s and early 1990s, the focus shifted to the role and limitations of markets (both in health care and in higher education), with HSMC supporting trust chief executives to prepare for and understand the implications of the internal market and also becoming more accustomed itself to operating in a more business-like, commercially-minded higher education system.
Interestingly, different directors had different interpretations of these changes, with some seeing the 1990 reforms and the current Health and Social Care Act as similar attempts to promote a discredited notion of market-based reform and others believing that such changes can bring opportunities as well as threats.
In the 1990s, HSMC was working with pairings of chief executives and medical directors to find ways of promoting medical leadership. Although the importance of medical leadership was increasingly recognised, achieving it in practice remained problematic - and HSMC is just about to publish national research into exactly these issues nearly 20 years later.
Also at this time, HSMC was exploring ways of reducing hospital waiting times, carrying out research into private practice which helped shape the renegotiation of the consultants’ contract and developing approaches to patient choice which later became part of the choose and book policy.
Interestingly, the former work around private practice and waiting times relied heavily on the contribution of John Yates and colleagues, who were early pioneers of the use of routine data to understand performance - in a way that is now commonplace with organisations such as the Information Centre and Dr Foster. All too often it felt as if data was being collected but not being put to sufficient use to answer some of the key questions facing the service.
Under New Labour, HSMC worked on a series of projects to deliver more integrated health and social care, both for adults and for children. Although this is now back in vogue following the work of the NHS Future Forum, our experience at the time was that more joined-up services make sense intuitively - but that delivering this in practice (especially in a system not designed with integration in mind) can be difficult.
Alongside work on topics such as delayed transfers of care, intermediate care and children’s trusts, our main early experience was of working with the first care trusts to explore the impact of structural changes on front-line staff, to work with values and professional culture at ground level and to try to understand the extent to which integrated organisations could deliver outcomes that other agencies couldn’t.
In the 2000s, much of our work was around care closer to home and ‘making the shift’, with a series of projects around developing the primary care market, improving support for people with long-term conditions and reforming community services.
Overall, what stands out from previous directors are concerns about the limits of market-based approaches; the importance but also the difficulty of achieving medical leadership; the importance of good information to guide policy and practice; the elusive nature of integrated care; and the need to - but also the complexity of - trying to shift care closer to the community.
Of course, these are exactly the issues that the current NHS and the current reforms are grappling with. Ultimately, it probably depends on your point of view as to whether this lack of underlying change over time is slightly depressing or is a reassuring reminder that we may not yet have solved these problems because they are genuinely hard.
Learning from past experience is crucial - particularly with current staff changes and reductions leading to substantial loss of organisational memory. Citing Hegel, George Bernard Shaw is often quoted as saying that the only thing we learn from history is that no one ever learns anything from history. Einstein is also commonly cited as defining insanity as doing the same things over and over again and somehow expecting different results.
Faced with rapid and difficult changes, we could do worse than reflect on where we’ve come from and use the past as a way of understanding how we got to where we are now and where we might be headed next.
Professor Jon Glasby is director of the Health Services Management Centre, University of Birmingham