In the battle against Whitehall maybe the NHS needs its own Arab Spring – led by managers, suggests Kieran Walshie.
For as long as I can remember, the Department of Health has talked about devolving power and responsibility to the front line in the NHS, called for greater localism, and claimed that it would stay out of running the NHS in future.
But it has never lived up to its own rhetoric. Instead, civil servants and ministers in Whitehall continue to direct and micro-manage the NHS, intervene routinely in issues of detail, and allow very little local freedom to act for managers or clinicians.
Our health service is already the most centralised in Europe, and managers and clinicians in Germany, Sweden and the Netherlands view with bewilderment or horror the way health policy, management and clinical practice in England are dictated from Whitehall.
Last year, health secretary Andrew Lansley titled his white paper Liberating the NHS and spoke of putting clinicians in the driving seat – but the reality of the current reforms is that they create a massive new centralising national quango in the NHS Commissioning Board. Paradoxically, David Nicholson claims that while he wants to decentralise the NHS, in the transition it is essential to maintain and even increase central grip on performance, and to centralise control in PCT and SHA clusters.
The current NHS reforms have been flawed from the outset, but after the recent “pause” the legislation now making its way through parliament is, if anything, more confused and muddled than ever. Even so, NHS managers have marched onward, implementing the changes as directed in advance of the legislation and in the process demolishing organisations and systems they themselves did so much to construct, and sacking many of their colleagues without question or complaint.
So should we simply resign ourselves to many more years of top down direction and stultifying micro-management from the DH, and accept the inevitable adverse impact this has on innovation, creativity and leadership in the NHS at a local level? If not, whose responsibility is it to make change happen?
Well, perhaps NHS managers get the DH they deserve. As Cassius tells Brutus in Julius Caesar: “The fault… is not in our stars, but in ourselves, that we are underlings.” NHS managers are complicit participants in a healthcare system which values unthinking obedience over creativity, innovation and independence of thought and action.
It does not have to be like this. There are at least three ways in which the current reforms – and the chaos they have created – present an opportunity for real change. First, NHS foundation trusts could start to use the freedoms they mostly already have to demonstrate their independence and autonomy from government. When a foundation trust first takes a DH decision it doesn’t like to judicial review, we will know the foundation trust movement has come of age.
Second, the new health and wellbeing boards could become bastions of democratic legitimacy at a local level – prepared to face up to the NHS Commissioning Board, Monitor and the DH in demanding that issues like service reconfigurations are worked out locally, and in framing a much more localist health agenda.
Third, if managers and clinicians, especially GPs, can park their respective, long-held suspicions about each other and work together in clinical commissioning groups, those organisations could be powerful local forces for change and – working collectively – could become genuinely community-led local counterweight to the powers of the new NHS Commissioning Board.
Will it happen? It could, but part of the problem with the current relationship between the DH and the NHS is that no one has been able to persuade most NHS managers and clinicians that things could be different. Their lived experience teaches them that amid all the ceaseless organisational restructuring, these centralising, directive behaviours don’t change.
Localism in the NHS is never going to come about through the Department of Health voluntarily ceding control and giving up power – it does not know how to do that. Localism will only come through the local NHS, FTs, clinical commissioning groups and health and wellbeing boards demanding it.
One final point. No serving NHS manager could have written this opinion piece and expected to keep his or her career intact. The NHS has outsourced responsibility for thinking and writing about controversial issues to what Lansley and Nicholson have both called somewhat dismissively the “commentariat” – academics, think tanks, associations like the BMA and the NHS Confederation, the media and so on. Perhaps the NHS needs to have its own Arab Spring – for managers and clinicians to be prepared to stand up in public for their values and beliefs, to protect their organisations and their staff, and to put patients’ interests before the demands of Whitehall.
- Acute care
- Andrew Lansley
- Board Talk/governance/assurance
- British Medical Association (BMA)
- David Nicholson
- Department of Health and Social Care (DHSC)
- Foundation trusts
- Government/DH policy
- GP commissioning/practice based commissioning (PBC)
- NHS Confederation
- NHS England (Commissioning Board)
- Regulation of managers