Cowper’s Cut: Absolutely nobody has a plan (Don’t panic, Captain Mainwaring!)

We underestimate the hell out of the values of confident and competent improvisation. We really do.

And that’s puzzling.

Because right now, confident and competent improvisation is what we’ve got. And in the current economic and political climate, this might well be as good as it gets.

The Lansley reforms that didn’t happen

If you want to see just how bad certainty and concrete plans can be for health policy, you need think back no further than the Lansley reforms. Carefully planned. A “perfecting the NHS machine” scenario. And a massive waste of time and effort, which as I have pointed out, didn’t actually really happen (other than to administrative NHS structures).

Just remember Lord Lansley’s very language: those who supported his NHS reform plans were “absolutely right”. Opponents were “completely wrong”. The real world isn’t like that, fortunately.

Clinical commissioning wasn’t and isn’t driving anything much. Yeats was respectively wrong, right and fairly much right: “things fall apart: the centre cannot hold. Mere anarchy is loosed upon the world”.

There is a fair case to be made that Lord Lansley never ended up getting his reforms (and the peerless Nick Timmins made it brilliantly in his seminal book Never Again?). Nick’s take is that what ended up happening was a “cut and shut” of the Lansley vision and the Lib Dem manifesto.

It’s pretty much true. And as such, all involved need to own their part in the hybridisation process. Lord Lansley, for the appalling communications and lack of a prepared and wide community of reform supporters; Oliver Letwin, for letting them go ahead once reviewed; David Cameron, for fundamentally not paying attention to their contents. Likewise the Lib Dems.

In fact, the only redeeming feature of the Lansley Reforms was the greater fame and glory of Simon Burns, whose quote “you cannot encapsulate the thrust of this in one or two sentences” Timmins rightly implies is both an authoritative summary and the flagrant reason they should not have gone ahead.

What a health secretary Simon Burns would have made. He would have been “mostly harmless”. And funny.

The four most useless words

Creating commentary sometimes feels a bit pointless. And the four most useless words a commentator can write are “I told you so”.

But I did predict that the Lansley reforms would be a nightmare. I did so at some length. I made myself quite unwell for a bit by doing so.

So, you know, yes: I told you so. And guess what? It doesn’t keep me warm at night.

As they say in France, “that’s life”.

Why plans are hard to do well

The world of politics and complex adaptive systems such as healthcare systems are ones where commentary and prediction are often a mug’s game. And I am evidently just such a mug, as I have frequently admitted in this column and elsewhere.

Why is it hard to plan well in these environments? One problem is that in both fields, Cowper’s Ninth Law Of Health Policy holds true: for every action, there tends to be an equal and opposite over-reaction.

Some of this comes down to what Lynn and Jay defined in Yes, Minister as “the politician’s syllogism”:

• Something must be done

• This is something

• Therefore this must be done.

A bias towards action may sometimes be useful, but if it is to be useful then it needs to be action informed by evidence and tempered by experience. The career length of NHS chief executives suggests that we have a big old problem with this.

Another problem is that doing meaningful and durable improvement (as opposed to just change) is hard and can take a long time. Political timescales tend to be short. The tendency to redisorganise structures (in the late, great Alan Maynard’s famous phrase) is a quasi autistic fetish which probably doesn’t tend to help matters.

Meaningful management

If I were trying to manage a thing (a scary thought, I admit), then I would want to know:

1. What I was trying to do, so that I could explain it clearly and concisely

2. That I had the resources and time to do it properly

3. That I could work with the organisational format and, critically, culture

4. That its processes and outcomes could be transparently and meaningfully costed and measured

5. That there was a genuine commitment to the project by whoever was paying for it

At the best of times, politics makes a lot of the above quite hard.

Right now is not the best of times in politics.

We have the most useless versions of the Conservative and Labour parties that I can remember, and a centrist party that cannot capitalise on this. We have a prime minister who is trying to deliver a task of fearsome complexity and contentiousness – Brexit – against which she campaigned and in which she pretty clearly doesn’t actually believe.

So if we think about planning in healthcare, then just now of my list above, 1 is debatable (but you could probably say “crash the car as gently as possible”); 2 is evidently a nonsense; for 3, the organisational form is in flux and the culture has evident and deep problems; we’re better at 4 than we were, but not nearly good enough. And 5 is probably true, as Nick Timmins pointed out in his brilliant lecture to the 2018 Nuffield Trust Summit, but I don’t think that many NHS staff believe it, due to a combination of the Lansley reforms, years of pay restraint, endless allegations that the NHS is being privatised and (BMJ link) the ugly mishandling of the junior doctors’ contract.

So, expecting a grand plan is probably not all that wise.

Confident improvisation is likely to be as good as it gets.

We are fortunate to have a confident improviser in charge: the Sun King of Skipton House; The Artist Formerly Known As The Messiah.

The original Sun King Louis XIV had various key phrases: “l’Etat, c’est moi”; “laws are the sovereigns of sovereigns”; “it is legal because I wish it”. If I were to suggest a slogan for the 21st century Versailles of the NHS Commissioning Board, it would be “whatever can’t be ignored can simply be worked around”.

There is absolutely nobody driving, influencing or shaping the politics around the NHS who is better at politics, strategy and tactics than Simon Stevens.

That isn’t the unelected Simon Stevens’ fault: that is the fault of the people involved in politics. It is time for people to notice and pay attention to this difference. It is an important difference

Nobody has got a big plan for the NHS right now, and that’s OK. It’s scary, but it’s OK.

Because this decade, the track record of big plans for the NHS frankly sucks.

The NHS is going to have to work it out for itself. We know that it doesn’t have the money: it has a vague prime ministerial promise of the money.

And it is about the money, but it’s not all about the money.

The important bit is to have hope. There is always hope.