Published: 14/03/2002, Volume II2, No. 5796 Page 24 25 26 27
Dr Gill Morgan Chief executive, NHS Confederation
The current level of micro-management of the NHS by government is worse than ever before. The Department of Health gets involved in far too much detail, which individual organisations have the capacity to sort out themselves. Guidance on the composition of cleaning teams would be one example.
I understand the principle of 'earned autonomy', whereby you have to prove yourself in order to gain management freedoms, but in many ways the very time when organisations need the most freedom to innovate is when they've been performing poorly. The one thing you can guarantee you'll push out when you micro-manage is innovation.
I am not in any way suggesting we should abrogate ourselves from performance management. This is about being much cleverer about what's being monitored - we need to measure the things that really matter and are useful to organisations, not a whole bunch of proxy outcomes and the processes in between.
Introducing too many targets is not just cumbersome, It is also counter-productive - you can also disincentivise people because they know that the better they do, the tougher the targets will become.
Instead of aiming for comprehensiveness in everything, the government needs to develop a culture of continuous quality improvement, where - within a national framework - individual organisations work to improve on what they know is important.Managers need to have the confidence to identify when they're in trouble, and the resources there to turn to.
The government is aware of all this, and Shifting the Balance seems to be the 'head' signing up to a less controlling approach.What's also needed, though, is a leap of faith to really allow it to work - whether the 'heart' is there, too, remains to be seen.
Brian Stoten (right) Chair, University Hospitals Coventry and Warwickshire trust
For this trust, which had its two-star status removed as a result of a Commission for Health Improvement report last autumn, I can honestly say my only concern in terms of central government 'interference' has been a financial one. That is the extent to which money given to health authorities has had luggage labels and instructions attached.
This has not given us the degree of local flexibility we would have liked, and it feels as if It is out of kilter with the need for local discretion, which would allow organisations to take decisions and shift priorities more appropriately to their particular needs.
Apart from that, I simply feel that It is a great pity our hospital had its stars taken away - I would have preferred to have lived with the ambiguity of being a good two-star trust and CHI having another view. Others obviously felt it was better not to confuse people with two different assessments of our performance. Still, you would be hard-pressed to find anyone in the NHS to say we were one of the worst trusts around.
Having said that, the consequences of all this haven't felt like central interference - since the announcement of our move to no-star status, the department, [NHS chief executive] Nigel Crisp and especially the Modernisation Agency have been spectacularly helpful.
Trevor Campbell Davis Chief executive, Whittington Hospital trust
We fool ourselves if we think public services will not have a degree of central regulation. But I think there can be a danger of confusing the setting of consistent quality standards with the need centrally to determine how the process of meeting those standards is managed.
I suppose what Labour has done is to pull us back towards being one big, central organisation, rather than things going in the opposite direction as happened under the Tories. The temptation has been to set national standards and then seek to pull levers at a central government level to make them stick.Having tried that, it should have been very quickly realised that you can pull levers as much as you like at the centre, and it will not work.
I am certainly in favour of setting standards at the centre, and I think there are a number of models through which you could make them a reality.
On one level, for example, you might want to simply set national quality benchmarks and then contract for private organisations to deliver on them. The problem with that, of course, is that it wouldn't allow for strategic management of the kind needed, for example, in north London.Here, trusts working in isolation would be a disaster because they would do nothing to tackle the fact that the physical configuration of hospitals was set up in the 1800s and is a million miles from what's needed now.
For that reason, I am keen to see how the strategic health authorities shape up - though they'll need levers to influence change, too, of course. Generally, I am in favour of NHS bodies being more decentralised and relatively unregulated, other than in terms of their outputs. In other words, we should leave local bodies to develop the processes by which they deliver the goods.
Like any other government, this one has gone through a rapid process of learning in terms of finding the best ways of managing the NHS. Some of the lessons were pretty clear in 1997 - with others, It is taken a while to reach that depth of understanding.
One area It is vital for the politicians to focus on now is capacity - not just numbers of doctors and nurses, but also of highly skilled managers.Having come in from the private sector myself, I am aware that the NHS is not comparably well served in terms of management expertise. Senior management is very good now, I think - but the middlemanagement structure still needs to be built up. There is a temptation to think you can solve this by parachuting people in from outside, but I do not think life's quite so simple.
Stuart Marples (right) Chief executive, Institute ofHealthcare Management
The key points of the King's Fund's report about over-politicisation and excessive centralisation - and with them the danger of too many targets - are ones we have made consistently, and ones our members will recognise as issues.
As Alan Milburn himself said recently, we have some brilliant managers in the NHS, and recognising the need to free them to manage brilliantly is the best way to ensure delivery of the NHS plan.
Ofthe big solutions proposed by the King's Fund, I believe two have inherent problems.
The first is that allowing local innovation inevitably leads to local prioritisation - and the seemingly unacceptable consequence of postcode prescribing.
Unless we address this issue head on, there will be a continuing tension between central direction and local freedom.
The second is that, before the NHS could become arm's-length from government, there seems to me to be a need for a debate about the nature of democracy. At the moment, taxpayers influence health policy and delivery through the ballot box and therefore via politicians.How would the taxpayer - or patient - exercise a democratic mandate over arm's-length NHS bodies?
Carolyn Regan Chief executive, North East London strategic health authority
I think everyone, regardless of any political allegiances, can see some signs that the government is backing off in terms of the level of detail in the guidance It is issuing. The planning guidance for next year, for example, is short and to the point.
The approach now seems to be that if you're making a reasonable fist of the star performance indicators, you get the freedom to manage the show. If not, you get 'troubleshooters' landing on your doorstep to help you sort things out. The picture for managers is much more encouraging than it has been. Labour had a big job to do in dismantling the internal market, and then in gaining the confidence that the service can and will deliver the stuff in the NHS plan.
We have to remember that, whichever party's in power, the health service will always be an easy target. All of us - press, politicians, whoever - have our own personal experiences to draw on, and when things go wrong we all want to know about it.
I suppose in this sense, centralised bodies like the National Patient Safety Agency should be a source of support, and help us to manage better.
With the number of acronymed organisations around at the moment, It is quite a job to find your way around. The government needs to make sure they do not just act as one-hit wonders who just come in, fiddle around a bit and then disappear once the media glare has subsided.
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