For several of the last few weeks this blog has been somewhat sceptical about the capability of NHS planning to deliver anything but a document called ‘a plan’. To make something actually happen because of a plan published in London requires the establishment of a set of relationships between the plan and say, a practice nurse in primary care – or even more difficult – a working-class man lying awake worrying about a persistent pain in his chest. If these relationships don’t exist, little will happen.
The people who are accountable to Parliament for the running of services often tend to believe that because they are upwardly accountable they actually run the service. Organisations such as NHSE/I consequently believe that they have a downward power to make new things happen.
Let me put that another way.
During the long-term planning process within the NHS many senior leaders will refer to, for example, what we are going to do to improve services for children with mental health problems. And the awkward reality is that they are not in a position to do very much at all. The people who are in a position to do that are, in terms of the NHS hierarchy, some distance from those doing the planning. Children with mental health problems will – in many cases – have their mental health improved by relationships outside of the NHS. And if they do need NHS services, they will get them from mental health staff a long way from Whitehall.
There is then a false assumption that establishing the relationship between the document called ‘a plan’ and a change in the practice of staff working in localities all over the country is straightforward. For a plan to have an impact on practice it needs a secure and workable delivery chain between the two.
Politicians often refer to delivery as ‘levers to be pulled’. The Secretary of State for Health sits in their room and, having been committed by their party’s manifesto to achieving something, looks around for which lever to pull to make it happen. And there are a lot of levers – one is called ‘speeches’ – another ‘meeting with the CEOs of NHSE /I’. The problem is whether any of the levers are actually connected with something that has an impact on practice.
My own experience of this state of affairs began in 2001 when I became special adviser to the then Secretary of State, Alan Milburn. The Labour Party had just won a big majority on a manifesto of reducing NHS patient waiting times. Luckily for me Alan Milburn had been Secretary of State for 18 months or so and had helped to write the NHS plan a year earlier. By the time I came on the scene he knew that pulling any of the levers in his office had had little impact on waiting times.
We could – with a majority of 140+ – have passed a piece of legislation to mandate that “no-one will wait longer than 6 months”. But such legislation would not have performed a single operation to shorten waiting times. So we had to ask ourselves questions like “What exactly are the existing relationships between a room overlooking the cenotaph and an A and E unit in Lancashire?”
We were also very lucky that the Prime Minister had set up a delivery unit under Michael Barber whose task it was to work with a few Government Departments to create a delivery chain. During the previous 4 years Michael had helped to create a delivery chain between the office of his previous boss, the Secretary of State for Education, and the school classrooms where pupils were, or were not, becoming literate and numerate. He had created a delivery ‘chain’ between office and classrooms.
We realised that what we needed to put any of this new policy into practice was a delivery mechanism to exist between manifesto commitment and the members of staff delivering the services. Creating this delivery chain was not a straightforward activity. In reality what we found were enormous gaps in the chain. The first few links, between the Secretary of State and senior civil servants, were self-evident. But most of the senior civil servants had no method for getting their policies into the practice of staff in the NHS. All of that had to be constructed – and tomorrow I will try and show an example of what such a chain might look like for improving cancer survival rates in the present day.
Today though I want to stress test how NHSE/I shape up as organisations with the capacity to deliver better healthcare outcomes. Because if you don’t construct a new delivery chain, then NHSE/I is what you mainly have. They are, for the NHS long term, the default delivery mechanism.
NHSE works through CCGs and NHSI works through Trusts. If you privately asked the senior staff of CCGs whether they enjoyed their relationship with NHSE, fewer than 5% would say they did. If you privately asked the senior staff of NHS Trusts whether they enjoyed their relationship with NHSI the number would be about the same.
If you asked those senior staff how they would characterise the relationship with their performance management organisation – very few would choose the word helpful and most would choose words like telling, shouting and occasionally bullying.
This existing experience is important since the future reality for the NHS plan delivery chain is – by default – going to go through these organisations.
Which starts us off in a very bad place.
If you were then to ask CCGs about the main topic of their experience of performance management by NHSE it would be split between the spending of money and waiting time targets. The same would be true of Trusts’ experience of NHSI. Both money and waiting time targets are about reporting numbers.
Taken together this means that for nearly all CCGs and Trusts their experience of their performance management organisations is mainly about being told what to do about numbers.
If NHSE/I is to be the main transmission mechanism between the NHS plan and the real delivery of a changed practice, this is a difficult starting point. Because a changed practice will need – well – a change in a practice. It will not need performance management of numbers about existing practice.
For the NHS delivery chain plan to work, those actually delivering services will have to change some of their practices. A delivery chain that performance manages numbers about existing practice is not going to be very well suited to achieving this aim.