The NHS Confederation has changed shape many times in its history. As it dances a line between its members and government, can it finally evolve to meet the challenges of the next few years?

In the spirit of good governance, let me start by declaring an interest. I am a big fan of the NHS Confederation and spent two interesting years there from 1999 to 2001 as policy director for human resources.

This article is about the future of the confederation, but it is important to note some startling parallels with the past. Up to 1990, the body representing all healthcare organisations was the National Association of Health Authorities.

In 1990 the Conservatives created self-governing statutory bodies called NHS trusts, with greater freedom to innovate and be entrepreneurial. The first-wave of “galactico” trusts were impatient with NAHA and created the exciting new Trust Federation. NAHA responded by adding a “T” to its name, to become the National Association of Health Authorities and Trusts, and battle was joined - the Trust Federation versus NAHAT.

The two bodies vied for membership and media presence. On both sides there were strong personalities who became well known: Roy Lilley, Rodney Walker and Marco Cereste at the Trust Federation and Philip Hunt, Mike Schofield and Bryan Stoten at NAHAT.

After a few years of increasingly unhealthy rivalry, most members had had enough. Two subscriptions were too many, two voices were too confusing and rather than being powerful lobbying forces, the government was able to play the two off against each other.

Eventually in 1996 the family reunited and the NHS Confederation was born. The following year, Labour came to power, chief executive Philip Hunt departed to become a Labour peer (and eventually a government minister) and Stephen Thornton became head of the new organisation.

Wicked dichotomy

After two years of an avuncular Frank Dobson but little new policy direction, Tony Blair told Breakfast With Frost he would raise NHS spending to match the best in Europe. Alan Milburn was brought in as health secretary to write the NHS Plan and create a “modernisation” movement. The confederation was already very much on the inside in those heady days and produced many ideas that surfaced in the NHS Plan.

But the members were not always happy with everything the government did and they expected to hear the confederation say so.

This is a wicked dichotomy that the confederation will always face: members want to hear the government criticised for its failings, while government wants a diet of undiluted praise. Meanwhile, the media likes nothing more than conflict and will not give air time to an organisation that only ever offers sycophantic endorsements.

After much consideration, the confederation decided to position itself as a critical friend, calculating that it could bank considerable credit by offering ideas, advice and support most of the time and then spend its surplus by occasionally speaking out. It grew bolder and bolder but eventually became too big for its boots.

After one particularly critical media performance, Alan Milburn felt it had gone far too far. He made it clear that it was unacceptable for a body funded entirely from government money to use those resources to bite the hand that fed it. He threatened to close the confederation unless it changed its ways. The threat felt very real. After a period of silent reflection, it retreated to adopt a much more muted tone.

Then the long Gill Morgan era began, characterised by her immense skill in walking the tightrope between membership dissatisfaction on one side and government opprobrium on the other. She seemed to do so effortlessly because, as others have said, Gill had the ultimate combination of service credibility, clinical expertise and above all, political schmoozing skills. But the tensions were all still there: members wanting to hear more outspoken views, sectors wanting their own separate voice, the arrival of private sector providers wanting to join the party, the permanently negative image of NHS managers and the perpetual irritability (and worse) of government if it detected anything other than fulsome praise.

With this history relatively fresh in its mind, the confederation will soon select a new leader. Its council and leader must decide how to satisfy the needs of the itchy-footed foundation trusts, work with a government under increasing pressure and build an appropriate relationship with other parties at a time when political change seems increasingly possible.

The three challenges

The new chief executive will inherit an impressive collection of strengths. A total of 99.5 per cent of NHS organisations in membership, a voice to which the media turns first, a strong team of experienced directors and network leads, and much appreciated member events and networks. Add to this a solid business base, highly valued policy advice and publications, the wonderful and practical service of NHS Employers and the most successful annual health conference in the UK.

The confederation expects to have its new leader in post by December. Armed with these strengths, the appointee will face complex and sensitive issues. Here are three top challenges and, for what it’s worth, my view on how they should be tackled.

Challenge number one is how to keep everyone inside the tent, particularly the foundation trusts which sometimes seem tempted to seek a separate voice. A major force driving their dissatisfaction is the raft of policies pitting commissioners against providers. Policy makers have long seen hospitals as overly powerful and resistant to even enlightened change, such as moving services closer to home, shifting resources into health improvement and reducing inequalities.

They see hospitals as bastions of protectiveness, hence the “New NHS” system of competition, private sector provision, choice, tariff and stronger primary care trusts executing world-class commissioning.

These are the policy grit in the hospital oysters, designed to produce pearls of improvement. But the tools given to PCTs only work by causing pain and threatening destabilisation to hospitals. It is little surprise many local relationships are at best uncomfortable and in many cases downright hostile. Does anybody care about this? If they do, it’s not obvious. Here is a challenge that the confederation is perfectly placed to tackle. It could articulate a clear charter for a healthy balance between collaboration and competition. It could work to define a new framework of mature relationships between purchasers and providers. It could offer an arbitration and conciliation service to ease the biggest problems.

The second challenge is to maintain safe political neutrality as the country moves towards an election with the biggest prospect of a change of government since 1997. This will be mightily difficult, as the media will be waiting to pounce on the merest hint of partiality.

Look what happened a few weeks ago when the confederation made a mild comment about polyclinics, which was presented by the media as an attack on the Conservatives. As has so often happened in the past, the NHS itself may be the political battleground. The confederation faces the daunting task of offering an authentic independent commentary on the battle without showing favour to any of the contestants.

In its favour, it has always persevered in maintaining strong relationships with all political parties at all stages of the electoral cycle - excellent foundations for the challenge ahead. I know it is contemplating issuing its own manifesto for a strong and healthy NHS. This may be an excellent way of getting its message across, but my advice would be that once an election is declared, the confederation should voluntarily put itself into purdah.


The final challenge is to improve the image of NHS managers and management. Despite its other achievements, the confederation has not yet succeeded in this.

It can take credit for at least persuading politicians of all parties not to adopt a knee-jerk reaction of blaming managers, though this still does happen from time to time: witness Maidstone and Tunbridge Wells.

But the public still firmly believes the NHS is not well managed, however much most of us would argue that this perception is wrong. Perhaps the key is that the people who complain most about bad management are not patients but staff. Research shows staff admit to constantly badmouthing their organisations and exaggerating the negativity of their views.

It seems complaining is part of the culture. There is much the confederation can do here by setting out the facts and arguments about how managers really add value. But the greater share of the burden probably falls to the NHS itself. Employers must work to develop a new culture of pride in, and loyalty to, their employing body. Some organisations manage this much better than others.

And lastly there is another challenge, the biggest of all, to the Confederation Council, to recruit someone with the wisdom, political skills, deep knowledge of the NHS and the courage and strength necessary to take full advantage of Gill Morgan’s legacy.