“Laser-like” focus – the best strategy for a Secretary of State seeking to improve an inter-connected NHS?

Politics and anxiety drag most Secretaries of State for Health and Social Care into making detailed interventions in the NHS.

Given that £150 billion of taxpayers’ money is being spent, and that the NHS is often the public’s number 1 priority, I think it would be very strange if they didn’t. If they didn’t feel responsible for all that public money and public service endeavour and failed to act on that responsibility, we would, quite rightly, say that our representative democracy wasn’t working. The public would be outraged, and they would be right to be.

So, the question is not whether but how they should carry out this responsibility and, of course, whether they do so in a way that will realise the goals they are trying to achieve.

Sometimes they choose to modify the law. The Lansley reforms enacted in 2013 created an organisation that was to be independent of the Secretary of State. This law set up the NHS Commissioning Board. But the organisation barely existed. In a fit of extreme hubris on vesting day it elected to call itself NHS England. Whilst self-importance was the main reason for the name change it helped that whilst the vast majority of senior staff and board members had never commissioned anything very much, many of them had run NHS provision. So, let’s call ourselves something we know a bit about. (This is how the original aims of organisations are undermined and become something else).

Whatever it was called it was not a creature of the Secretary of State. The Lansley Act and arguments around it made clear that this was a new idea – to remove it from direct political direction. (Many of us raised more than one eyebrow at the time and muttered ‘good luck with that’.)

However, the 2010 intake of new Tory MPs would have argued, inside and outside the House, that this new separation of NHS executive power from politics was a vital departure for the NHS. This would have included the new MP for Northeast Cambridgeshire – Steve Barclay.

We can assume that on 25 October 2022 when Steve Barclay was reappointed Secretary of State, he would have identified the need to cut long waits as an important target and would have had a laser-like focus on achieving that that aim.

He will already have noted, as he read himself into his new brief back in July 2022 that NHSE had already begun the process of cutting staff numbers in both its own organisation and various other bodies that had been folded into it. The overall aim being to cut 6000 jobs.

By October the ‘new’ Secretary of State would also have recognised that getting rid of 6000 central managers would be a good political outcome.

However, assuming that an election is coming in Oct 2024 he would then have had just 24 months in which to cut long waits and would be expecting everyone to concentrate on that – especially NHSE staff.

Yet here we are – 9 months later in June 2023 – and still much of the activity of NHSE staff is being taken up by either their own or other’s personnel issues. If Steve Barclay is very lucky this process may be finished by October 2023.

12 of his 24 months will already have slipped away.

Central staff cuts may or may not be a good thing but not if your laser-like focus needs those members of staff to achieve something else.

Another area thrown into sharp focus last winter was the need for more hospital beds. More beds to get us through the winter of 2022/23 might have been a worthwhile ambition ten years earlier when something sensible could have been done. Like building the locations for these new beds.

Creating new beds just ahead of the winter in which you need them is less likely to be useful.

Systems and trusts were encouraged to staff thousands of additional ward beds in the run-up to last winter to try and ease emergency care pressures.

But, in just a few weeks, where do you find extra beds? Apparently from other parts of the hospital. So many of these additional beds are not in proper ward spaces. Some are located in gyms and others in areas used for physiotherapy and other forms of rehabilitation.

Inevitably this crowds out the space for rehabilitation, and if there is less space patient rehabilitation slows down – which in turn pushes up the length of patient stays in hospital, knocks on costs, and increases the chances of readmission.

This came to light towards the end of last month.

The Chartered Society of Physiotherapy (CSP) shared results of a new survey with HSJ in which 45% said the situation had got worse since winter, half said nothing had changed and 3% had said it had improved. In February, after campaigning by the CSP for the spaces to be restored, the health minister Lord Markham acknowledged the problem and said government would “write to all NHS CEOs about the issue”. This has not happened.”  HSJ 25/05/2023.      

The problem with having a laser-like focus on specific NHS issues is that everything is related to everything else, especially the flow of patients through hospitals. To achieve anything of real importance you need to have laser-like focus on it all.