Nigel Edwards On policy cohesion

Published: 29/07/2004, Volume II4, No. 5916 Page 17

One of the things that strikes you when working with directors and senior managers in trusts and primary care trusts is the huge number of projects they are working on. The hazard is that the silos in which policy is created nationally are replicated locally.Worse still, the objective of the policy can be forgotten in a single-minded pursuit of delivery.

This makes it very difficult to make links between policies. For example, how could payment by results be used to create incentives to take practices beyond the new general medical services contract quality and outcomes framework; does choice fit with the development of case management? These important questions can feel like a distraction to managers, who have short deadlines and enormous volumes of work.

There is an even greater problem when it comes to frontline staff.

By definition, projects are time limited: if you ignore them they might go away. Secondly, the NHS seems to have a habit of taking ideas that would make sense to frontline staff and turning them into abstract, highly conceptual and managerial language which greatly reduces its chance of connecting to clinicians.

So it is little wonder that we need strategies for clinical engagement when they are faced with large numbers of disconnected projects that seem to be removed from practice.

Does this suggest that something has gone wrong? Are we doomed to take a subject like chronic-disease management - something that many staff spend their working lives addressing - and turn it into a project that fails to connect to other policies and that manages to create cynicism and disconnection?

Part of the problem may be about who sets the agenda.

Engagement implies that it is already set and the task is to get people to sign up to it. Success becomes defined as meeting someone else's objectives rather than negotiating a shared view of what it might look like. Research suggests that organisations tend to succeed by working with their clinicians to negotiate objectives that align the interests of patients, the organisation, clinicians and payers.

A second cause seems to stem from the lack of a connecting story that is capable of helping people see how the different projects join together and can provide a way of making sense of them. The overall message in the NHS plan and its later reincarnations ought to be able to do this but also tend to suffer from the same problem of too many silos, objectives and projects. Broad statements about creating patient-centred care are often just platitudes.

One of the most significant challenges for local leaders is to create a new and compelling connecting story about how the different pieces of reform can be used together to make care more systematic, improve outcomes and experience and connect clinicians and other frontline staff to their original reason for signing up with the NHS.

Nigel Edwards is director of policy at the NHS Confederation.