Cowper’s Cut: Mandatory guidance

I’m going to try to take a break from my recent run of writing about NHS finance and political lying this week.

I may not succeed, but that’s all right: National Institute for Health and Care Excellence guidance is explicitly clear that we have no evidence that a misconceived HSJ column ever killed anyone. Yet.

So what do we know just now?

Known knowns

We know that more money is coming, and we know that it’s not going to be enough.

We know that bitching about it not being enough isn’t going to make it enough, and we know that other areas of the public sector have fared far worse and will keep on faring far worse.

We know that Brexit remains almost certain to cause harm to the UK economy, and the value of sterling suggests that financial markets are pretty clear that it could be significant harm. We know that David Cameron’s plan to resolve the Parliamentary Conservative Party’s disunity about EU membership has failed spectacularly.

We know that the proponents of Brexit do not have anything approaching a plan to make it work in practice, with wishful thinking about “max-fac” and fantasy technology solving the Northern Ireland border issue.

We know that full time buffoon and foreign secretary Boris Johnson wants to sire another child with the UK business community – yes, the one that employs people and creates wealth.

And we know that health and social care secretary Jeremy Hunt found the warnings of Airbus that Brexit risked its future UK investments “completely inappropriate”.

This is the state of the government and the Conservative party.

There is also the Labour Party.

Ahem.

So I think we can safely rule out the possibility that politics is about to help un-Brexit matters.

(Indeed, the Sun King of Skipton House, NHS Commissioning Board boss Simon Stevens outlined on the BBC’s Andrew Marr Show that the NHS is having to prepare for a no-deal Brexit.

The UK’s other royal family

Oh, and the most bizarre revelation of 2018 also appeared in the same interview: that Simon Stevens watches Love Island.

WTAF?

It’s a bit like finding out that the boss of the UK’s other royal family, HM The Queen is into The Fast And The Furious films.)

Known unknowns

What the current state of our politics means for the NHS is that it is of huge importance that the system is run as un-Brexitly (ie coherently and sensibly) as possible, at national, regional and local levels.

I wish I could feel hugely optimistic here. Unfortunately, a conversation with a friend dragged me down into the harsh mire of reality that is the working life of NHS chief executives.

In short, we have not got system management and regulation right: not by a long way. This is distinct from but linked to the many problems with NHS culture which gave birth to my much used line that the NHS needs a chief anthropologist far more than it needs any chief inspector.

It would be buffoonery to pretend there is no need for regulation, obviously. Quality, safety, patient experience, outcomes and use of resources all matter fundamentally.

Equally, it would be blindness to think that what is in place at the moment is proportiionate or well set to do the tasks we need them to in today’s and tomorrow’s NHS.

Too much of regulation is a rear view mirror. Too many of the national demands for assurance are the same, causing considerable wasteful multiple handling.

My friend’s example was superb: a recent document labelled “mandatory guidance”. In their perfectly chosen words, “so which is it? It can be mandatory, or it can be guidance. It can’t be both.”

Well, quite. That is either an ironic homage to the other Mr Blair’s classic 1984, or it is an example of bringing all the stupid. I suspect it’s the latter.

Why we regulate as we do

I have written previously that much of how we now regulate the system is best understood as an overreaction to Mid Staffs and an attempt to prevent a recurrence. The Department For Shutting The Stable Door After The Horse Has Bolted is not where it’s at, I suspect. One of Cowper’s Universal Laws Of Healthcare is that for every action, there is an equal and opposite overreaction.

It’s unfortunate if symmetrical irony that my friend’s trust was given a Care Quality Commission report filled out with information from another organisation’s report. Some of these problems are mistakes – but imagine if the mistake had been made the other way? Perhaps it sometimes is …

The new reality

HSJ reported that Matthew Swindells of the NHS Commissioning Board re-underlined the new reality: “the days of competition are over” for the NHS, but said people should still be offered more choice and control over their care: “We should be thinking about more ways of empowering people to able to control the care they need. This means there will always be some transactions where someone decides to have their hip replacement near where their children live rather than where they live, and we need to manage that flow.”

Mmmmmmm. Empowering patients and offering greater choice are good things. They are just not free good things.

None of this is to deny that there are some excellent staff in each of the national system regulating organisations. Indeed, some of those staff are (in private) candid that there are some significant areas of their organisations that do not add value, require avoidable duplicate information and are not of practical assistance to NHS organisations in trouble.

It remains unclear to what extent Sustainability and Transformation Partnerships are a bid to recreate the ring holding role of strategic health authorities (which were much derided in life and much missed in death). The retrospective fondness for SHAs obviously has deep roots in the system chaos that followed dear old Lord Lansley’s reforms.

2006 And All That

Nostalgia isn’t what it used to be … but thinking about the many imperfections in how we now run the system, I was irresistible drawn back to something the late Professor Aidan Halligan wrote in 2006 for a magazine I used to edit. (The context was that Lord Crisp had just resigned as NHS CE, due to 2005 election related overspending of £1.2 billion during the years of 6 per cent real-terms year-on-year budget growth.)

Aidan’s comments were picked up by the FT’s peerless Nick Timmins, and used against then-PM Tony Blair by then-leader of the opposition David Cameron at PMQs.

So writing this cost Aidan his job as deputy chief medical officer.

Aidan was a grown up: he didn’t mind.

Aidan wrote, “The instinctive, logical, politically right-headed (and completely wrong) response is to focus exclusively on financial recovery. The spirited solution would be to reflect on the expensive lessons learned, and apply the learning.

“This episode in the history of the NHS is a turning point: a propitious moment when a particular action could lead to colossal damage.

“We have learnt that throwing money at the problem only allows us to do more of what we have always done. Any suggestion of real reform has been a deceit: working patterns, practices and customs are at the heart of many capacity issues, and have never been challenged.

“Though their introduction was courageous and appropriate, targets have become an end rather than a means and, together with blinkered performance management, have distorted healthcare priorities and promoted initiatives built on little clinical understanding and massive overmanagement …

“A much greater deficit than any of a financial nature will be the motivational deficit when staff are commanded to perform work of poor quality in a context of uncertain expectations. We need to move from a culture of performance management to one of performance leadership …

“The healthcare system is populated by bright, dedicated, well intentioned people. Now is the time to surface that talent in meaningful leadership positions across the NHS and, together with smart processes and enabling technology, allow the best mediocre healthcare service in the world to become truly the very best”.

That was 2006. Aidan was not wrong, was he? And things have got better in some areas, but there is a big vein of truth running through those comments about today’s NHS.

Sometimes, absent friends are never more present.