conference focus: The first day of the NHS Confederation conference started grimly with the news that managers felt their ability to modernise was hampered by the iron grip of centralisation, but it ended in a glimmer of hope

Published: 30/05/2002, Volume II2, No. 5807 Page 14 15

With accusations of 'control freakery' hanging in the air, NHS chief executive Nigel Crisp attempted to soothe delegates with the message that strong central control was a symptom of a 'transition' period that would not last forever.

With the words of earlier speakers ringing in his ears, Mr Crisp admitted to a gap between 'the rhetoric of devolution and decentralisation' and what was happening at grassroots level.

He told the conference: '[The NHS] feels top down. There is more money, but a lot of it is earmarked. New organisations are finding they have obligations and deficits to deal with. It feels as if there is little freedom and almost no discretion locally in how to spend that money.'

He acknowledged that many had found this year's strategic and financial framework round tough. The role of the centre, 'but only for the time being', was to oversee the 'six big service priorities', which started as national drives, supported by countrywide taskforces and/or modernisation programmes. It was important that they became 'embedded locally' as soon as possible. Central control would remain strong in 'increasing the capacity and capability of the whole system'.

As far as capacity goes, this meant securing more staff and facilities from home and abroad.

The other two areas were implementing the national IT strategy and 'introducing the mechanics of the system, the changes in money flow, the new inspectorates and the longer-term planning'.

He added: 'This is a very big national agenda and you can see why it feels very top down. But we really do need to think about this as a transition. By the time these systems have been put in place, we will be able to reduce the role of the centre and, as this happens, we must also make sure that relationships and behaviour change. We do not want primary care trusts to become health authorities and we need to make sure that strategic health authorities do not just become regional offices.'

Challenged on the 'name and shame' culture in the NHS, Mr Crisp said ministers and the Department of Health 'need to exercise natural restraint' when involving themselves in high-profiles disputes at hospitals. 'Local problems should be dealt with locally, ' claimed Mr Crisp.

Reviewing the performance of the NHS over the past year, Mr Crisp said that although significant momentum had been created in driving towards the NHS plan targets, improvement efforts had achieved limited results.

He said that 90 per cent of what had been achieved in the past year had come through 'working harder', and only 10 per cent through 'working smarter'.

The day before, NHS Confederation chief executive Gill Morgan opened the conference with a warning that NHS managers were weary and worried by three key issues: 'finance, targets and organisational fatigue'.

Ms Morgan said that in travelling around the UK, she had found managers hamstrung by organisational change and targets that do not encourage organisations to change. Even worse, the government 'rewarded' success with ever harder targets.

Though the extra£40bn to be spent in the NHS over the next five years was very welcome, Ms Morgan said the SAFF round had been 'very bruising'. She said:

'Long-standing pressures in organisations could still not be solved because of year upon year of annual efficiency savings, which have stretched organisations and diluted levels of service.

'Policy has confused cheapness with efficiency and many services are now simply threadbare.'

Ms Morgan said managers had told her 'releasing 10 per cent of 'real' efficiency over five years would be easier than 2 per cent per year'. And they had also made clear they were concerned about constant reorganisation.

She said: 'There is a real tiredness that the solution to every complex problem is seen as another reorganisation in search of the perfect structure. No structure is ever given time to bed down and deliver.

'The message I hear is unequivocal: there is no perfect structure, give us some stability, set us clear simple targets and give us the space to deliver what we know needs to be done.' l l Reporting by Alastair McLellan, Laura Donnelly and Paul Stephenson