Cowper’s Cut: On dismantling fences

I’ve been meaning to write this column for a few weeks. It was inspired by two things. One of them, you won’t be surprised to hear, was dismantling a fence.

The other was an occasion when one of my ideas cohered properly when I wrote it down. I wrote in a recent column about how the NHS is currently being implored, incentivised and induced to act in an ecumenical, “integrated, “system” way when most of the legal incentives in place are highly parochial, aiming to create a competitive market.

‘That would be an ecumenical matter’

You can argue about whether, as I discussed, it is a problem that “sustainability and transformation partnerships and accountable care organisations are non-statutory and cannot hold budgets”.

It is certainly true that NHS Commissioning Board’s absolute monarch Simon Stevens has got further, faster than anyone could have imagined by ignoring the legislation (as I was the first to point out, four years ago).

And while no likely-to-govern political party has any discernible ideas at all about health policy, this might possibly not matter. But then, it might. It is a brave or stupid person who makes predictions about where politics is going in 2018. Things can and may get worse politically, and they are not good now.

And I still believe, as I wrote back in 2014, that the likely challenge to Stevensism Mark Two (ignoring the living daylights out of the legislation) could come from the independent sector and/or CMA getting concerned about NHS “lockout”. In this context, my colleague James Illman’s recent exclusive about potential use of private sector capacity bears rereading.

Why the fence was built

But one lesson from this, and from my fence dismantling experience, is that you need to understand why the fence was built. You need to be sure that you have the right to take down a fence; otherwise you’re doing vandalism, not property maintenance.

In NHS terms, why were the parochial incentives introduced/strengthened?

To put Stevenism Mark Two into context, we need to remember why Stevensism Mark One (the new public management NHS quasi market and reinforcement of payor provider split with elective tariff and patient choice) happened in the early 2000s.

The main reason it happened was that there became money for the NHS to spend and we wanted more of a thing: specifically, elective activity, to address very long waiting times then present.

When you want more of a thing (elective activity), then a fixed price (the national tariff) prevents the wrong incentive being created for providers to cut quality and safety to compete. So, they seek to compete on volumes to grow income. This increase in activity, sustained for many years, cuts waiting lists.

Providers needed to be confident it would be worth doing this, so foundation status was invented both to give them some fiscal autonomy and the right to generate and retain surpluses (in those dear, dead days beyond recall, when tariff was not set below the cost of providing care by Stevensism Mark Two, to renationalise FTs’ surpluses!).

FT status also got some direct ministerial control of local NHS organisations out of the way (though the peerless Nick Timmins’ Alan Johnson chapter of Glaziers And Windowbreakers bears re-reading on what happens when the rubber hits the political road – TL:DR Johnson told then Monitor boss Bill Moyes “piss off, I’m dealing with this”).

And we need to be clear that Stevensism Mark One worked spectacularly well. The review by Dixon, Mays and Jones for the King’s Fund gives the data, but those of us who remember 18 month waits for elective care as routine facts of life will not lightly forget the achievement of 18 weeks. And we mourn its loss, as when we saw one year waits rise by 13 per cent in June, having doubled in the preceding six months. 

Of course, Stevensism Mark One was very expensive. Buying more of a thing, and creating the right capacity and capability, always tends to be. And it will be expensive when it has to be done again, once public discontent with waiting times becomes even stronger than it already is.

How the fence was built

I write all this because another thing you need to understand is the mechanics of the construction of a thing you want to dismantle.

You can, of course, just use brute force. But that can be quite painful if you get it wrong. It also makes the job of recycling the various components far harder than it needs to be.

So, you also need to look properly at the fence, and spend a little time working out what the most effective and safest way to dismantle it will be.

In the old tailor’s adage, “measure it seven times, cut it once”.

Having the right tools to dismantle it

Once you’re eschewing the brute force approach to dismantling a fence, having the right tools is really important.

It goes without saying that you need a hammer: that vital piece of power maximising physics in design form. Also, what else are you going to use to make everything look like a nail?

But the fence I had to dismantle was part wood and part wire mesh. While the wood had rotted, the wire mesh was keeping the fence in one, albeit heavily broken, piece. (Insert your own metaphor here about the state of the NHS.)

The wire mesh was stapled into the wood in tens and tens of places, and unpicking all those staples was a non-starter. So, I had to go out and buy some heavy duty wirecutters, and they helped me do the job in far less time than seemed possible.

Towards integrated wirecutters

So, what would the NHS wirecutters be? I’ll probably come back to this in future columns, but it’s unlikely to be the needed legislation because of the current wafer thin government majority in Parliament. And because nobody’s apparently got any ideas what legislation would look like. 

Nor do I think an organisational structure will be the NHS wirecutters. Redisorganisation is a terrible thing to wish on the NHS at the best of times, which this is clearly not. 

Radical cooperation might be A Thing, though. People might rediscover the still extant provisions in the 2003 and 2006 Acts giving NHS organisations a “duty to co-operate”. Agreeing to be led by local government might, in a few areas, also be A Thing.

But there will not be a one size fits all wirecutter: the era of policy onesies surely ended with dear old Lord Lansley’s 2012 legislation.

Taking down fences isn’t the most fun you can have with your clothes on, but when it has to be done, these are pretty much the ways to do it.