The NHS long term plan says networks are going to offer solutions to many of the NHS’ problems but the NHS is a hierarchy and bureaucracy and these three are not organic bedfellows, notes Andy Cowper

It’s interesting when you can’t find any actual source for a quote that you’ve heard used a lot of times in relation to management issues. For me, the latest example of this is “the network beats the hierarchy”.

I mention this in the context of the increased expectation in both The NHS Long Term Plan and the recent GP contract update that networks are going to offer solutions to many of the NHS’ problems.

(Data fans will be pleased with one aspect of the new GP contract as noted by my colleague Dave West: “working with NHS Digital, GP activity and waiting times data will be published monthly from 2021, alongside hospital data… publication of the data will expose variation in access between networks and practices and we will include a new measure of patient-reported experience of access.”)

Well, maybe in certain circumstances, networks will be the solutions in primary care. The evidence base is perhaps best described as emerging, with this more mature (15 years) example from Canada. Dr Rebecca Rosen has done interesting work in this area.

Yet we do seem to be forgetting the long shadow of our dear old friend culture here. The NHS still needs a Chief Anthropologist much more than it needs any chief inspector, or regulator.

Equally, we ought to be clear that the NHS, as a near-wholly single-payer tax-funded national universal healthcare system, intrinsically is a hierarchy. That hierarchy is designed into the plumbing of the politics, the philosophy and the economics of the NHS.

In praise of bureaucracy

The NHS is also, inevitably, a bureaucracy. That is obliged by the multiple requirements of fairness, governance and tax funding.

I use the word bureaucracy in a totally non-pejorative sense here: you can call it administration if you prefer. Call it what you like: bureaucracy, administration, Eric: it is the act of ensuring that we have a robust system that treats people fairly, and distributes resources according to priority and clinical need.

It is not immediately apparent to me that hierarchy, bureaucracy and networks are organic bedfellows.

The Jimmie Lunceford Effect

We also risk forgetting the importance of Cowper’s Fifty-Third Law Of Public Policy. That is The Jimmie Lunceford Effect: it ain’t what you do; it’s the way that you do it – that’s what gets results.

As one seasoned observer of NHS management reform noted, “I am really worried about enhanced services having to be at the network level. In a network, it is more likely that the one practice that does the service will stop, rather than the others taking on a new service. My CCG confirmed they thought this may happen”.

And as Londonwide LMCs CE Dr Michelle Drage replied, “our experience from past practice - ostensibly in the 1990s - tells us that collaboration over a population around 30,000 with community, social, mental health and voluntary services works on the ground. But only if they operate without bureaucratic intrusion and demarcation.”

Mmmmmmm. I suspect that the recent experience of NHS provider organisations is not one of operating without bureaucratic intrusion and demarcation. And as I pointed out above, some of the fundamentals of administration require some such intrusion and demarcation.

The question is, I suspect, to no small extent about consent. The advantage of a hierarchy (the word apparently derives from the ancient Greek hierarchia – literally the rule of a high priest, and was first used to describe the heavenly orders of angels) is that we probably don’t waste too much time arguing about what the organisation is there to do.

Form ever follows function

In these sort of debates, the old modernist architecture maxim “form ever follows function” always comes to mind.

And again, here is a famous quote of interesting origins.

I thought it came from Le Corbusier, but the original proponent was the American architect Louis Sullivan, who wrote “Form follows function—that has been misunderstood. Form and function should be one, joined in a spiritual union”.

Sullivan’s protégé Frank Lloyd Wright later adapted it to “form and function are one”.

Perhaps the question behind the question is “which approach do we need here?” Where it is a network, let it be that; where a hierarchy, likewise. And it is likely that it will often be a blend. Which will require skilled mixologists.

There is another interesting conundrum here. If we are putting our faith in networks and systems to solve problems, we need to ensure that national leadership and regulation cohere with this approach.

As such, it is surprising that, as my colleague Shaun Lintern found, the Care Quality Commission’s efforts to secure funding support from the Department For Health But Social Care for its new system reviews team. And the CQC did not even get the courtesy of a reply to its letter to ‘Appless Matt ’Ancock, Secretary Of State For The Time Being.

The CQC’s letter on this issue to health select committee chair Dr Sarah Wollaston MP describes the decision as “disappointing”, a deliberately understated adjective. 

(It would be remiss to allow the HSJ’s 127th birthday yesterday to pass un-noticed. The Poor Law Officer’s Journal has come a long way since its launch in 1892, and it’s great to be a small but perfectly formed part of one of the best publications in the country.)