Previously I explored the levers of reform that we used between 2001-2010 when working with the NHS to reduce long waits. Today I want to emphasise that these were not simply interesting policies developed to bring about change, but that each of them, being new, met with some resistance from those who would have preferred to carry on without them. These levers disrupted the status quo with a range of incentives that some in the NHS found difficult. Those seeking to implement them therefore needed a series of strong arguments to make and win the case for reform.
This is probably true of changing anything – be it a book club, a primary school, a football team or a factory. Many people in most organisations feel that the way they already do things is the ‘right’ way – so why change them? To change doesn’t just need new ideas but also a compelling argument to persuade people to do something they haven’t done before.
Institutions are often likely to respond to reform by insisting that their existing ways of working are fine, and that the reforms are too different. They are odd and outside of their world experience . Granted this may be true of a book club but when people in an institution of the size and importance of the NHS strongly believe that it is exceptional and operates outside of the sets of relationships in which these changes will work – the “It won’t work here’ response – you will need a very good set of arguments to persuade them that it will.
These were.
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- New payment systems (payment by results)
- Patient choice
- Creating a new independent sector
- Relative autonomy creating Foundation Trusts.
- Developing a quality regulator
Each provided change issues for the NHS as it was, and needed strong new arguments for change. How were these established?
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- Payment for results (payment by activity) argued that it was right to pay those organisations that did more work more money for doing it. At the time (and subsequently when this was dropped in recent years), this was treated by some in the NHS as a very weird and transgressive idea. Yet it is something that is certainly considered normal in most other areas of society. It’s pretty normal for wage earners to get paid more money when they do overtime. Since the late 1980s it had been pretty normal for schools that have more pupils to get more money. It’s true for most professions. Lawyers, accountants etc. are paid more for extra work. So, when some in the NHS argued that this was odd, one of the main counter arguments was to ask them to look at their own lives and the world they lived in. What was so different about the NHS?
- In 2002 we introduced patient choice. If you had been waiting for 6 months, initially for heart treatment, you could choose to move to a different provider who could treat you more quickly.
Some in the NHS said this would not work because patients wouldn’t know how to choose. Our argument pointed out that people who apparently couldn’t chose between hospitals did, in other aspects of their lives, make quite difficult choices all the time. They could even choose the Government. But apparently it was beyond them to choose whether they wanted to go to a hospital where they could be treated more quickly. Of course they could, and of course they did. If you needed heart treatment, choosing to go somewhere where you didn’t have to wait as long wasn’t really too much of a problem. Our argument was the normal nature of choice. Those who opposed it felt that NHS acute care was somehow different. - Last week I set out the argument for making a new market with independent sector treatment centres (ISTCs). Again, for some in the NHS the use of the private sector felt like a betrayal. Our argument for this intervention began with those NHS patients who were being treated at ISTCs. Were they pleased to get free treatment more quickly? What do you think?
- In Parliament, the introduction of legislation to create Foundation Trusts (FTs) created an enormous row. Giving better performing organisations more freedom over their work practices and their money was felt by many to be a differentiation too far. It was argued that it was unfair to those that were not trusts. This was a long and bitter argument and for many running the NHS the legal fact that they can’t tell FTs what to do is almost incomprehensible. Yet really, in the wider world that is our society, is it all that weird to give better organisations more control over themselves?
- We started the process of creating a regulator for health and social care. This took several false starts culminating in the establishment of the current Care Quality Commission (CQC) in 2013. Again, there were those that said it would just not be possible to make judgments about such complex institutions as hospitals and that differentiating between good and bad was somehow wrong.
One of the main overall aims of all of this was to develop further differentiation between different institutions in the NHS. The aim was to recognise that some were better (and some were worse) than others and reward them accordingly. There was and is a model of the NHS that disagrees with this differentiation, that wants to see the NHS as a single undifferentiated institution – all one. This was the major fault line of the argument.
My main point here is to expect opposition if you want to construct a programme of reform. Expect arguments for the status quo and be ready to mobilise arguments against them.