In my last post before Christmas, I want to reflect on one of the consistent themes of the feedback that I have received recently about the content of this blog.
This can be summed up in the phrase “Given how dreadful everything is how do you remain so optimistic?”
The feedback I receive contains variations on this theme – perhaps the most lyrical being, “You have the audacity of hope” (which I blush to say the internet informs me is the title of Barack Obama’s 2006). So let me reflect a bit on this.
This year’s thoughts about improving NHS performance sprang from a breakfast event at the King’s Fund in December 2022. They were publishing a report commissioned by the DHSC a year earlier on the question of why waiting times had come down in the noughties and gone up ever since.
They had asked me to speak at the breakfast, so I read the report and before appearing phoned them up and asked, “You do know that this report argues that some of the things I was involved in, as Alan Milburn’s, John Reid’s and Tony Blair’s Spad actually worked??”. (Being asked to speak on the report had been a bit of a surprise because in 50 years of work I had never been asked to comment on a piece of research that said I had done anything at all useful.)
But at the breakfast I realised, looking round the room, that nearly everyone had been very young in 2001 – the year we began implementing our NHS Plan. To them, it was ancient history.
This didn’t just mean that the changes I was a small part of had happened a long time ago. More powerfully it meant that most people in the room felt that the way in which the NHS worked in late 2022 was how it always had.
The current NHS systems of finance, regulation and performance management were just there, and any changes would have to take place within existing parameters.
Over the last year, this has been the most significant lesson I have learnt.
Whilst there are a few people on the radical right who argue that the basic principle of the NHS (paid for out of national taxation, free at the point of delivery, with equal access for all) is wrong and needs abolishing. They really do believe that very big things can be changed. But for most people that want to save and revive the NHS, their belief about the size of changes that can actually be reformed is limited.
So, the reason I am more optimistic than most, is that when I look at some aspect of the way in which the NHS works, I think “How do we change that?”, and “this”, and “that”, and “that”. Then I start to discuss with others how that might be done.
But many of those I meet – in many different groups – go very quiet at that point because they don’t believe these things can really be changed.
Of course, one of my main reasons for thinking a much larger number of things can be changed is because, for a few years in the noughties, I was working with a government that did just that. And because, on nearly every occasion, when we started to work through how to make the changes, many people said “you just can’t do that”.
So, since the spring, one of the issues I have been working on has been to develop different funding flows either within the NHS or between the NHS and other public services – such as social care. This is not just a technical issue (though it is important to get the technical issue right) but it is also one that potentially changes the ways in which different services work together to increase prevention. It involves considerable change.
For some this is a set of changes which are beyond the possible. The current financial system works like gravity – it just is.
And often in these moments I find myself using my personal experience as a teaching aid. In 2002/3 I was part of a group of people that constructed a part of a new funding programme. We introduced “payment by results” when most people told us it would simply not work. They argued that the problem was that if we created such a new system, it would destabilise hospital finances.
Which was of course an intended consequence. Not too much instability, just enough to change behaviours.
Now, having created one payment system to get results I stand by the experience. It is entirely possible to create another payment system to get different results (say more secondary and tertiary prevention).
I believe the same is true for many of the reforms we made in the noughties. Creating semi-autonomous trusts that had less central performance management was just “never going to happen”. Then the Foundation Trust legislation and movement began and – whilst Labour was in power – it thrived.
If we could do that for trusts in the 2000s, we can do it for ICBs in the 2020s.
The point is NOT that the change that was done before must be replicated. It is that the change that was done before encouraged different behaviours and that change at that level cannot just be proposed as a’ policy’ – but can be implemented as a practice.
The reason I believe, more than most, that change can happen is because I’ve been involved in something similar before.
But for me it also goes back a bit further than the noughties.
My first degree was at the London School of Economics (1966-69), where I was taught by the great post World War 2 Fabians who had played a big role in creatng the post-war welfare state. We did spend some time studying the theory of social policy but mainly what we did was to examine social policy as a set of practices. If you morally wanted an outcome which levers would you pull to bring it about?
It was all about change, and they taught me that whilst understanding how to bring about change was only an idea – if you did it in practice you could be part of bringing it about.
As a teenager I was taught not only that change was possible but that we had some form of duty to bring it about.
And going back even further my Dad was part of the generation whose university was being in the armed forces in World War 2. As a part of that generation, in an army of non-commissioned officers, he learnt to run things.
After the war – in 1948 – he started work as a clerk for the Ministry of National Insurance. 15 years later, when I asked him why he went there, he was quite clear “It was to create socialism”.
Now in my mind we didn’t get to socialism but getting employers to pay their National Insurance stamps for their employee’s benefits – that was a real outcome.
And that’s sort of how I got to the title of this post. I think most of us are too privileged to allow ourselves to be pessimistic.
Have a good break and see you in the new year.