It is rather apt that the former Culture Secretary, Jeremy Hunt, who has now taken over the Health portfolio, spoke about culture in his first public foray at the Conservative party conference last week.
He was talking about care of the elderly when he said: “I want to be the Health Secretary who helped transform the culture of the system”, but culture change in the health service could, and should, be applied more widely.
Of course it applies to a culture of kindness and caring for patients, and a system that is open to innovation and enterprise. But it goes wider than that, and should apply to the way that the whole NHS runs. As Jeremy Hunt himself pointed out, it is famously the fifth largest organisation in the world – bigger than the Indian railways and just a little smaller than the Red Army.
Our new Secretary of State says that he has a desire to transform the system and ensure that it is not overly centralised. “We will never meet the challenges we face with over a million people trying to meet a thousand targets to satisfy one Secretary of State sitting behind his desk in Whitehall,” he told the party conference. He also, pointedly, said “no to top down bureaucratic procurement”.
He is quite right. A ‘command and control’ culture based on uniformly measuring progress against hundreds of targets is not the way to get the best out of the NHS – something with which even Tony Blair now agrees. It’s been interesting to watch the former Prime Minister’s personal conversion to the same cause as that now advocated by Jeremy Hunt: empowering those on the ground to deliver, making them accountable to local people and service users but also responsible for national standards underpinned by a robust regulatory regime. If this sounds familiar, it should do. It’s the Foundation Trust model.
The Health and Social Care Act has decentralising the NHS at its heart – for example by abolishing Strategic Health Authorities and enshrining the concept of provider (and Clinical Commissioning Group) autonomy throughout. But structural change needs to be accompanied by cultural change to make the decentralist vision a reality.
Paul Corrigan makes the powerful point that despite its stated intention, there is a danger that the Act is leading to more centralisation, not less. He points , for example, to the significant percentage of the commissioning budget that will now be spent nationally by the NHS Commissioning Board as opposed to locally by Clinical Commissioning Groups.
So, as the new national bodies established by the Act begin to assume their responsibilities, they need to ask themselves, which of the two visions of running the NHS do we want to adopt? The one that’s about a million people trying to satisfy a thousand targets or the one’s that about genuinely empowering local organisations to deliver local needs? The way these organisations behave and the culture they adopt will largely dictate the outcome. The argument applies across the piece from commissioning to leadership training and education.
As a final thought, there may also be occasions when the new Secretary of State needs to be reminded of his decentralising instincts. One intriguing section of his speech said: “We have many committed managers in hospitals and care homes. But I need to say this to all managers: you will be held responsible for the care in your establishments. You wouldn’t expect to keep your job if you lost control of your finances. Well don’t expect to keep it if you lose control of your care…I have asked my Department and the Care Quality Commission how we can make sure managers are held accountable for the care they provide, both in the NHS and social care sectors”.
This sparked speculation about a whole new regulatory regime governing managers with some suggesting that managers would be subject to the same type of registration and assessment that characterise the relationship between the Royal Colleges and clinicians.
There is a real danger that this will end up confusing and diluting as opposed to clarifying and strengthening management accountability. It is NHS Trust Boards who must and should hold accountability for the management and leadership of care in their organisations. Setting up a parallel regulatory structure undermines the key relationship between a Board and its managers. If there is a fundamental failure of the board then there are other remedies as recent events at both Mid Staffs and Sherwood Forest have shown.
It’s a good example of how we should subject each new initiative to that basic test – is this about a million people trying to satisfy a thousand targets to satisfy one Secretary of State sitting behind his desk in Whitehall or is it about genuinely empowering local organisations to deliver local needs?