Cowper's Cut: The NHS has Bonnie Tyler Syndrome

In this era of the two main Westminster political parties are giving us a virtuoso display of both the awfulness of tribalism and the tribalism of awfulness, it can be challenging to want to read, think or write about politics. Still, nobody ever said writing a weekly column for HSJ would be an easy gig.

With a new health and social care secretary, you’re basically asking yourself about their operating system: ”what sort of person is (s)he?” It’s very early days for Matt “The App” Hancock, but we now have two speeches to go on: his debut speech (which was a tour d’horizon effort) and his most recent one to NHS Expo 2018 this week in Manchester.

Words, words, words

Speeches only get us so far. We are not ever the things we say (particularly about ourselves – that is almost always PR); we are the things we do consistently.

Mr Hancock has been in the job for too little time for him to have consistently done enough on which to judge him.

His speeches reveal the areas from whom he’s been getting advice to which he listens. The emphasis on social prescribing suggests that a smart GP or two are somewhere in the advisory mix.

One thing that appears to be an evident through-line in the evolution of recent health secretaries is tech-enthusiasm. Jeremy Hunt, who in my view evolved a long way as health secretary, went through a long tech-enthusiasm phase, strongly influenced by his friendship with tech disruptor (and all-round disruptor) Tim Kelsey.

Enthusiasm for tech is surely not a bad thing per se. Much of the NHS is still woeful with tech. But the concern has to be that tech enthusiasm ignores the many very real problems that also beset the NHS.

Big Issue 1: Culture

One, which I have often described in these columns, is culture. I have long maintained that the semi-feral tribalism in clinical groups, let alone that between clinicians and managers and administrators.

As I have written, the NHS needs a chief anthropologist to start to map and then address this ludicrous tribalism far more than it needs any chief inspector.

If you want to look at the integration the NHS really needs, it is not an integration of organisational forms: it is an integration of genuine teamworking, and real mutual acknowledgement of role legitimacy.

There is a deeply unhelpful pathology among some clinicians which truly regards management as “the dark side”. That is crass and infantile.

Just as bad, in the opposite direction, is the failure of many managers to durably and genuinely cooperate with their clinicians – the people whose decisions spend all the money and determine the performance and patient experience.

One of the key political phrases of recent years of austerity was ex-chancellor-turned-editor George Osborne’s “we are all in this together”. The tribes within and across the NHS workforce need to own this phrase in a different sense. All of the workforce has got to be in the NHS together (and indeed to cooperate with non-NHS actors like the voluntary and third sectors, and probably at points the private sector).

Big Issue 2: Workforce

I did this one as part of my “big problems” series of columns.

Nothing has changed. Workforce planning still isn’t really A Thing. Brexit has already made matters worse, and will continue to do so, while highly likely to negatively impact economic growth and so future potential NHS funding.

Matt The App was clear in his debut speech that workforce was the first of his three main priorities, so let’s see how far that gets an area that has basically stumbled from crisis to crisis.

Big Issue 3: The Operating System

Having mentioned tech enthusiasm, the metaphor of an operating system seems almost inevitable. The crucial problem is that the NHS doesn’t really have one.

In recent columns, I have been highlighting the tension between an NHS with largely parochial legislative drivers and the ecumenical efforts of the Sun King of Skipton House, NHS Commissioning Board boss Simon Stevens to get the NHS to act like a system.

In particular, last week I drew out the crucial contrasts between Stevensism Mark One and Mark Two.

A critical problem for NHS management is that there is no standard operating system. Commissioners and providers do not even all book waiting lists (which are inevitable in single-payer systems where demand outstrips capacity) in a standard and transparent way.

There is obviously and insanely non-standard patient administration systems. GP softwares are non-standard, though there is an obviously dominant system. Commissioning support units have brought some elements of standardisation to aspects of the process, but the range of NHS organisations still work far more differently than they do similarly.

In a Stevenism Mark Two era, the non-standard operation system is hard to defend. You could legitimately make a case for standardising system functionality, and allowing plurality of provision to drive innovation and reward the instinctively user-friendly, but we do not even have standardisation of system specification.

The root of fear

I think this might be at the root of the dysfunctional culture of much of the NHS. People often behave badly when they are terrified.

Hopefully, someone has talked Matt The App through the accountable officer contract. It places a terrifyingly huge and wildly unrealistic burden of expectation on the chief executive of NHS organisations to be responsible for every single thing their staff do in the high risk industry of medicine and healthcare, in a situation where the chief executive has almost no real control over revenue; cannot select the healthiest patients; and are paid below the costs of production of the care, as the Nuffield Trust’s data diva Sally Gainsbury has consistently observed.

The NHS management trainee scheme is good in many respects, but it could do far more – as could the system overall – to introduce standard training in statistical analysis, blocking and tracking patients, segmenting population, building demand models to inform capacity planning.

Allied to this is the frankly terrifying “Not Invented Here” Syndrome. Too many NHS organisations are terrifyingly incurious about how other comparable organisations do what they do. Having spoken to more than a few leaders of high performing organisations, they almost universally say that they are surprised by the incuriosity of many of their peers.

Diagnosis: Bonnie Tyler Syndrome

This cocktail of fear with poor training in vital aspects of data management and standard operating procedure of the system, leads the NHS management community towards what I think might be the biggest risk to progress.

I am referring, of course, to Bonnie Tyler Syndrome.

Bonnie Tyler Syndrome is the chronic tendency towards “Holding Out For A Hero”. In healthcare, where heroic leadership is not a myth, it is inevitably a crap idea and a recipe for burnout. One of the key problems with big beasts is that not much tends to grow in their shade.

Bonnie Tyler Syndrome is in many ways very Brexit: it distrusts experts. It has much in common with the worst traditions of the English national men’s football team since the 1970s – it goes for the long ball over the top, hoping to get a lucky break up front and nick a goal. That approach means the failure to become skilful passers of the ball or tacklers (let alone penalty-takers).

When NHS managers are not properly trained and supported individually and systematically to arm, them with the data, analytical and anthropological tools to do the job, it is little surprise that the myth of “heroic leadership” and “passion” can take root – but the roots are always shallow and weak.