Andy Cowper draws a parallel between the decade long global financial crisis and the NHS’s own struggles
It’s 10 years since the global financial crisis hit. In these 10 years, I’ve learned a lot more about economics and finance, and I’m basically much more scared than I used to be.
The more you read about its causes and effects, the more it’s extremely clear that large parts of the global financial industry have only the sketchiest idea of what they’re doing, and are profoundly insulated from the consequences of their actions.
The root cause of the 2007 crisis was bad lending practices in the US mortgage market – sub-prime loans, which were basically offered to people whom the banks knew could not afford to repay their debts.
These sub-prime loans were then packaged up and sold on as low risk investments (mortgage backed securities) backed by credit default swaps (an insurance). While the US property market saw a boom, the problem was not evident. Once the economic reality dawned of poor borrowers’ inability to repay their loans once the teaser introductory rates ended, these resold loans with high rates of default were spread throughout the world’s banking systems.
Governments around the world played their inevitable roles as lenders of last resort once the global credit markets seized up. The Conservative opposition swiftly and skilfully spread the myth that the UK’s economic crisis was caused by the then Labour government’s overspending (a myth subsequently rebutted by senior civil servants, and independent economic bodies.
Labour failed to fight this with the necessary vigour, and the Conservatives won the war of narrative. In the 2010 general election, the Conservatives promised to eliminate the deficit in one Parliament, while Chancellor Alastair Darling promised slower retrenchment with a return to financial balance by 2020.
The Conservative government is currently on course to miss the Alastair Darling trajectory by some way.
We know the effects on the UK’s public sector, and on the poorest in society. The NHS has enjoyed relative protection, but it hasn’t felt like that as the population has continued to grow (numerically and obesity wise); longevity has continued to increase (as do years in ill health), new technologies can do more at higher cost. Oh, and there’s way too little capital available to transform services.
Another of Cowper’s Universal Laws Of Healthcare is the Inverse Scare Law: the effectiveness of “NHS crisis” stories is in inverse proportion to their frequency and volume
There feels like a nagging parallel between Labour’s unnecessary and invertebrate loss of the economic narrative over the financial crisis and the NHS’s own struggles to clearly articulate why it should get preferential treatment when public spending is not being helped by the strong economic growth that one would normally expect to follow a recession.
We do have some signposts. The NHS Commissioning Board’s Five Year Forward Hallucination articulates an attractive vision of the triple aim, and a radical upgrade in prevention accompanied by some important work in the new care models. The Naylor Review on estates neatly highlighted the capital drought.
And Professor Tim Briggs’ Getting It Right First Time work on clinical variation brings a key issue into present focus, with his clear articulation that the NHS should not ask for more funding until it gets its house in order on this variation.
Oh, and STPs (sell the premises) are a stealth attempt to reinvent strategic health authorities without any, you know, actual legislation. Making laws is so 2012, darling!
Yet it doesn’t feel as if the issue of what the NHS needs (as opposed to what it wants, which is “give us more money and leave us alone”) is getting political traction. Of course, UK politics is currently overwhelmed by watching the slow motion car crash of Brexit, overseen by David Davies, Liam Fox and Boris Johnson: three politicians you wouldn’t trust with your car keys in a month of Sundays.
Another of Cowper’s Universal Laws Of Healthcare is the Inverse Scare Law: the effectiveness of “NHS crisis” stories is in inverse proportion to their frequency and volume. Frankly, too much of the NHS system’s leadership cadre has spent too long sketching and resketching how difficult the situation is (and don’t get me wrong, it’s very difficult indeed), but been woefully underpowered on articulating possible solutions.
One reason for this is that a big part of any solution that will increase full time NHS workforce is more immigration. That would take political courage of a kind absent from the current scene.
We’re going to need a lot of discretionary effort from a workforce that I think may have stopped being willing to give it as freely as previously
Another reason is that if you want to drive out clinical variation, you’re going to need more and better managers and management. Dear old Lord Lansley allegedly saved lots of money by sacking lots of “bureaucrats”. What a success the 2012 Act has proven!
So it feels as if we’re invested long in woe, and we’re short selling hope. That’s not a great trading position.
One of the best books on the financial crisis is John Kay’s Other People’s Money. Kay writes persuasively that more and better regulation cannot rebuild trust and proper intrinsic motivation in the financial sector: “regulation which has been applied with more and more intensity and less and less effect through the era of financialisation is part of the problem – a major part … What is needed is an entirely different regulatory philosophy”. This is almost certainly transferable learning to the NHS.
Kay cites the work of sociologists Ferdinand Tonnies and Max Weber in differentiating Gemeinschaft (the personal and informal) from Geselschaft (the formal and the regulated). There is something important for the NHS here too. We don’t have a project plan for change. We have signposts, and implicit permission to change (provided you don’t screw up publicly, of course), but there’s scant capital and transformational, double-running-type sums of money are not coming.
(We are also seriously short on change management capacity and capability, but that’s several other columns in itself.)
The point is that there are no cavalry coming over the hill to save the NHS. We are the cavalry (or rather, you are: commentators don’t deliver much healthcare that I’ve ever noticed). It’s going to be DIY, it’s going to be messy – but above all, it’s going to be impossible if we don’t bring all the staff teams with us, in administrative, clinical and every kind of role.
To stand a chance of making this work, we’re going to need a lot of discretionary effort from a workforce that I think may have stopped being willing to give it as freely as previously. The real leadership challenge in the NHS today is Gemeinschaft – the personal and informal. All businesses are people businesses, but maybe none more so than healthcare.