With the debate about freedom from political interference raging, strategic health authority chief executive Mark Britnell outlines his model for compromise and wonders what an NHS charter might contain
There has been a lot of chatter recently about Gordon Brown's intentions for the NHS and bold claims that he might be preparing some big announcements for health if and when he becomes prime minister.
I think the speculation is just that. We should simply wait and see. However, we do know that Conservative leader David Cameron is starting to think about the NHS and its relationship with patients, the public and politicians.
In many ways, any major politician or party that makes a bold announcement on future healthcare policy will, inevitably, force its opposition to respond at some point.
It might legitimately be the case that the NHS should have a view of its own, and I can see great merit in the leading national health and social care bodies attempting to form a professional consensus prior to any political policies being 'launched' on an unsuspecting public or the NHS at large.
I have been intrigued by the recent spate of articles concerning NHS independence, political control, bureaucracy and incompetent management.
I want to consider and juxtapose three matters: recent literature and discussion around NHS independence; the BBC2 series Can Gerry Robinson Fix the NHS?; and the HSJarticle by Ian Smith, former chief executive of the General Healthcare Group, based on his report Building a World-Class NHSpublished by the independent think tank Reform. All three have merits and similarities, as well as shortfalls.
Let us take the arguments from Mr Smith and, to a certain extent, business guru Sir Gerry Robinson first. While Mr Smith applauds the bravery of some politicians and their advisers, he points the finger of poor health reform, suffocation and bureaucracy at senior civil servants and senior NHS managers. He cites London mayor Ken Livingstone's comments that people in these positions seek to 'manage decline gracefully'.
Sir Gerry, in his thumbnail sketch of a decent district general hospital, laments the fact that its chief executive is desk bound, tussling with and figuring out great strategies from the Department of Health and the health secretary that keep him away from the staff who can find the solutions and make change happen. It is an attractive argument which has some merit - but only in part.
There is a profound weariness of top-down reform but I am sure many of us cringed when we saw the manner in which doctors were supposedly set against the Rotherham chief executive. I am equally sure that many of us roll our eyes when clinicians in a superficial fashion lament the role of politicians in the health service.
I think we should acknowledge that some clinicians do not want reform or managing, in the same way that some managers would be frightfully exposed if they did not have someone else to blame.
The real trick is to take these arguments apart and remove them from the vocabulary of the NHS. That is quite a task, especially when all of us would recognise that top-down reform does not really unlock innovation and creativity. In fact, over time, it breeds helplessness and disempowerment which was graphically - perhaps shamefully - illustrated in the TV series.
The only way that we can engage in the right debate is to take politicians out of the day-to-day process of managing services while strengthening management, staff responsibility and local accountability.
That is not the same as de-politicising the debate on health and well-being - it is just a much more beneficial and pragmatic way of managing the NHS. I have rarely met a local councillor or MP who does not want the NHS to succeed - it is just that they face short-term news and election pressures that they have to respond to. It is their job to do that just as much as it is ours to take management decisions to make the NHS more responsive and quality-oriented.
So, in this sense Sir Gerry and Ian Smith are both right and wrong - it is not that central expectations are wrong, it is just that the targets are set, then micromanaged from a central point that is subject to immense political pressure. Played out in the press with short-term perspectives from those who have to respond, these pressures create anxiety and alarm across the public.
Right of return
It is the duty of any government, especially one that believes in the NHS as the most progressive social insurance and health system in the world, to make it explicit what type of return on investment it wishes.
We have become trapped in using arcane language to explain health system improvement and have become transfixed with a medium-term narrative for reform which, at best, describes some means to an end and not the end itself.
So, if I were limited to five outcomes that a government should seek from a new, five- to 10-year charter of independence for the NHS, they would be the following:
First, that average life expectancy would rise by one or two years across the population as a whole. Given per capita funding of around£1,300 a year, this must represent an excellent return on investment. It is a fantastic insurance policy for each individual and is certainly worth the cost of a flatscreen TV each year.
I often wonder why the debate about health and well-being is not put in terms of life expectancy - it is an obvious outcome from our health service and the partners with whom we work. When I ask people to guess how long and quickly average life expectancy is increasing by, you would be amazed how they under-estimate our rate of improvement.
Second, a reduction in health inequalities by at least 20 per cent for the most disadvantaged and deprived. Once again, while there are strong moral arguments for making this a key consideration, there are also economic considerations that will not be lost on any incoming prime minister.
Arguably, the relationship between health, social care, ageing and poverty will become more prominent over the next 10 years. We need to find new solutions with local authority and voluntary partners.
Third, that all health and social care services receive - through a national independent quality assurance system - acceptable, good or excellent ratings for health and social care. This independent assurance system would make sure that clinical outcomes and priorities were vigorously assessed, as well as the more basic process and hygiene factors.
I would be more directive on care pathways set up to reduce our major killers and would expect independent assurance that clinicians and organisations were following them and not just ignoring or opting out of them in the current discretionary manner.
Fourth, that public and patient satisfaction levels exceed 75 and 80 per cent respectively for general approval of the NHS and clinical services. Also, that satisfaction ratings form part of the pay settlement with NHS staff to ensure the hefty interests of staff and providers do not outweigh the voice of the consumer and patient through a monopoly social insurance system.
This is a vastly under-developed and under-exploited form of accountability. Staff and pay systems should be linked to an unrelenting focus on patient satisfaction as this would drive out many of the professional or tribal issues that still beset the NHS.
Finally, that the health system, and each organisation in it, produces a surplus of 1-3 per cent a year and that this surplus is reinvested in public health and patient care through clinical services, education or research.
Respect for money and the discipline of managing cash need to be driven through the system to ensure that staff respect the wishes of taxpayers as one of the major shareholders in a social insurance system.
I am sure it is much more complicated than that, but we need to distinguish between legitimate political control and inappropriate political interference. Setting health and social care outcomes is a duty and a legitimate form of involvement for politicians. Of course, it is only a short step from input to interference and this is what has happened over the past 60 years. Fortunately, we now have good examples of how a new approach can make matters better.
It is a little too early to say whether the pioneers of the hotly contested foundation trust policy were right, but we can point to a body of evidence that suggests performance and responsiveness has improved across foundation trusts.
Being a foundation trust is no magic solution but, from my experience at University Hospital Birmingham foundation trust, staff feel more accountable for solutions and you certainly cannot blame your performance on anybody else. It is just very sensible management.
The difference is that you have legal power and autonomy and, while critics might argue that these freedoms have not been rapidly capitalised on, they are very real and give you a different outlook. I would like this extended to commissioners.
Independence, not reform
It is here that I take issue with Sir Gerry and Ian Smith. Mr Smith argues that the DoH and politicians can simply decentralise, de-politicise and de-bureaucratise - but this has all been tried before. That is why reform has become a byword for bungled, time-consuming and energy-sapping reorganisation.
If you want it to work properly, create a charter for NHS independence, then new legal freedoms for providers and commissioners that remove direct, day-to-day political control.
As for the arguments put forward in the BBC2 series, it is not just a matter of making the chief executive walk the floor and urge improved performance from staff.
If organisations take more legal responsibility, then a new form of accountability should apply to staff. But it is about holding them to account in a different manner.
Mark Britnell is chief executive of NHS South Central.