In the second of a three-part series, Victoria Vaughan turned to primary care trust chief executives for their views on Tony Blair's legacy to the NHS. They were found angry and disheartened by continued change.
'We have lost good people, killed the organisation's memory and are constantly on the back foot in getting to grips with the day job of improving health.'
Asking the leaders of primary care trusts for their views on the NHS after 10 years of Labour, one opinion crops up repeatedly: thanks to ministers, organisations have wasted far too much time coping with the fallout from structural change.
Many PCT chief executives are angry that the latest restructure - cutting the number of PCTs to 152 and strategic health authorities to 10 - brings the service almost full circle to where it was five years ago, when 100 health authorities were replaced, and eight regions dismantled.
With that in mind, it is perhaps not surprising that many are vesting some hope in the idea of an independent board for the NHS. But in other areas views are more mixed - while some see local councils as key to restoring the NHS's democratic deficit, others fear prime minister Tony Blair has 'created a monster' in overview and scrutiny committees.
The cycle of reorganisation in primary care over the past decade has infuriated chief executives.
Most accepted the evolution of primary care groups into 303 PCTs by April 2002, and believe that the changing landscape of the NHS requires a certain amount of organisational change.
But the latest restructure, creating a system which closely mirrors the one abolished less than five years ago, has left many PCT leaders feeling angry at the amount of time wasted adapting to new structures.
Several believe the focus on organisations has set the NHS back years. HSJ's poll last week showed 100 per cent of PCT chief executives surveyed said managers felt 'battered and bruised by constant reorganisation' (news, pages 5-8, 1 March). A further 88 per cent said high turnover of chief executives made it hard to speak out about poor decisions.
A chief executive in the South says: 'Everybody complains about reorganisation but the last three or four years has been especially wasteful of talent, commitment and focus. Shifting the Balance of Power killed 100 health authorities, created 303 PCTs and 28 SHAs, and in a very short time we are undoing that.
'In four years we had people at a senior level being sacked, made redundant and then reapplying for their jobs. We have now got a completely new structure taking us back to where we were; that chaos has set us back years in terms of the progress we could have made.'
Another, based in the South, while acknowledging that measures had to be taken to strengthen commissioning, questions why all organisations were forced to start again. 'If the aim was to create effective commissioning bodies I don't understand why they didn't focus on failing organisations as opposed to a completely ubiquitous reorganisation of everything.
'Why on earth would you reorganise everything? What was the benefit of a huge loss of talent to the NHS, a huge loss of corporate memory and a feeling among a lot of NHS staff of being significantly messed about for no good reason?'
All of those who spoke to HSJ believed the policy had been driven through the Department of Health far too quickly without being properly tested or costed.
One chief executive from the North gives the example of the fitness for purpose programme which started two weeks after the new PCTs were set up. 'As the DoH had already paid the consultants McKinsey to carry out the work, they had to go through with it. I only had 10 people in place at the time, the thought of being assessed was ridiculous.
'The whole purpose of the reforms was not clear, payment by results was not clear. There is no overall purpose to the reforms,' she believes.
Another, also based in the North, suggests Bill McCarthy was brought in as DoH director of policy and strategy in 2005 specifically because of a need 'to put the pieces of the jigsaw together'.
And one London chief executive backs up the point: 'The funding commitment to the health service was around a big-scale political commitment to get us up to EU standards.
'The NHS plan that was published in 2000 wasn't costed and the NHS typically introduced a whole series of changes without thinking through what the full consequences would be.'
He makes a cautious analogy: 'I am loath to say this but it's a bit like the Iraq war - it's very easy to do the big military thing but the follow-through and the consequences are not given sufficient attention, and you can see that again and again.'
'The last set of reorganisations have been damaging to morale and expertise and the NHS will take a little while to recover. There are some major things which remain unanswered like the future of provider services within PCTs,' another leader adds. He believes much of the current confusion in the system is the deliberate result of what policy-makers have called 'creative destruction'.
'We are trying to do everything at the same time. Blair and others have become impatient with the NHS for not reforming fast enough, so they have quite deliberately cascaded reforms - many of which are incompatible - in the hope that by putting a huge amount of pressure on the NHS the ones that survive will be the ones that work.'
But one chief swims against the tide: 'Financially it's the best year I remember. All the crap is working through the system, Agenda for Change is working. We have never been better off and I have been a very senior manager for 20 years. I can't remember a year where it was as good as it's going to be next year.'
And however disheartened he is about the damage caused by structural change, the PCT leader from the South is keen to flag up the 'fantastic progress in terms of waiting times and the range of services available in primary care'. He adds: 'I am really very supportive of better clinical engagement that initiatives like practice-based commissioning are delivering.'
A state of independence
With the NHS absorbing nearly 9 per cent of GDP, many PCT leaders believe it will always be at the mercy of politics. But they hold some hope that an independent board could reduce the government's tendency of 'knee-jerk reactions' to media scare stories.
'An independent board would be less prone to having to manage things because they have appeared in the Daily Mail,' says one, echoing many sentiments expressed in HSJ's poll of chief executives.
'If a new bug was reported in the press we would have to act. The government would want answers from SHAs regardless of what else was going on. There is an awful lot of interference. A board may help divorce the NHS from politics,' she adds.
And a PCT leader from the South highlights the fact that around the world healthcare is always subject to political pressure, irrespective of how it is managed. Nonetheless, he would welcome steps to separate the day-to-day running of the NHS from Whitehall.'
And a London chief executive adds: 'Nine per cent of public money is spent on the NHS. It will never be non-political and nor should it.'
He believes the big problem is that ministers do not understand the processes that occur between deciding policy in Whitehall and seeing the difference on the ground.
'Ministers think the health service is like the civil service - you just ask for a report and it should get done.
'Then they ask why it isn't done; why practice-based commissioning isn't introduced everywhere from Carlisle to Truro.'
'Structural solutions alone are never going to be the answer but if having an independent board makes organisational problems more transparent it would be a good thing.
'Then somebody like [NHS chief executive] David Nicholson will be able to say 'OK minister if you want us to abolish waiting times altogether these are the resources, organisational structures and processes we need.'
'At the moment the quality of that debate is not very sophisticated. I think an independent board would give people who are left to run their organisation more clout.'
Priorities for the future
On the whole, PCT chief executives were in agreement that the future priorities of the NHS needed to focus on better cross-working with local government and targeted prevention of ill health.
'We need to work harder at getting closer integration between health and social care and there needs to be greater emphasis on targeted primary prevention. PCTs should have information about people with a family history of disease and actively target those people. We need to be far more proactive,' says one.
Another felt that there needed to be a better balance between power, accountability and resources. 'People who have the power are not accountable and those who are don't have the resources or power to deliver what they are accountable for. If you're going to work on one thing, look at putting that triangle back together again,' they suggest.
There were mixed views on oversight and scrutiny committees, with half those who took part in the debate wanting them abolished and half appreciating their democratic function.
One puts it bluntly: 'Blair has created a monster. The local authority is fine when times are smooth, but when a PCT is in turnaround it becomes a battle.
Another adds: 'Overscrew and mutiny committees are entirely negative. Scrutiny causes nothing but aggravation.'
But in the other camp, a leader from the North suggests OSCs have an important function to perform: 'There is a democratic deficit in the NHS and they have been elected to ask us questions we must answer.'
Are there any radical ideas out there about how else to improve accountability? One chief executive unveils an ambitious proposal: 'Something has to be done about this 19th century mindset of GPs as small shopkeepers, independent contractors who are not really part of the NHS. The DoH has tried using a whole system of incentives, which is frankly wrong.
'My radical solution would be to bring them under control and make them salaried NHS employees, accountable in a line-manager way to the PCT.'
As the nightmares of structural change begin to recede, perhaps it is good that chief executives can still dream.