Some of us that have worked in and around the NHS for years are getting very worried. Not just about the mismatch between aspirations and funding but because of a malaise deep within the NHS itself – the culture might be one word for it.

Particular concerns come from those of us who examined the STPs and are now looking at plans for ACS/ACOs; and separately but connected – the sudden outburst of plans to outsource NHS services to wholly owned companies.

Parking for now the wisdom of these moves what raises concern is the appalling way the NHS is going about trying to force changes through.  The lack of any robust governance, refusing to consult, badly written documents and obviously implausible plans just being voted through by apparently sensible people.  We even have the Chief Executive of one of the major NHS quangos admitting on his exit that they were managing plans they knew were bonkers.  The NHS leadership and the Ministers can’t even agree on basic issues such as the extent of “additional” funding.  Those same leaders also admit that the system is unable to deliver what it is “Mandated” to do.  Full speed into the iceberg.

Why are people signing up to things they know won’t work?

What on earth is going on?

A select band had the misfortune to look in detail at the STPs.  We have also recently had the task of evaluating plans from multiple Trusts to set up wholly owned companies.  Our immediate reaction is exasperation at just how poorly prepared these plans are (with a few notable exceptions).  The NHS appears to have lost the skills required to write Business Cases and to be able to subject these to proper evaluation and change control.  Many Trusts turn to “consultants” who give them cut and stuck reports of poor quality and limited value which they slavishly follow – what happened to due diligence?  The shelves full of guidance and the endless reports on lessons learned and common causes of failure are simply gathering metaphorical dust.

And let us not forget the infamous Strategic Projects Team that for many were the consultancy of choice; ironically they were not procured through any competitive tendering despite their enthusiasm for markets and competition.  They advised Trusts on magic plans and it took years for them to go from winning awards to being forcibly wound up.  The NHS does not learn

With the wholly owned approach the driving force is now wrapped in the age-old NHS saga – we are being put under pressure, something must be being done, this is something, we are doing it.

When we had at least some form of strategic oversight (through Strategic Health Authorities) there were some with the skills and the clout to push back on the more daft plans that came to their attention.  No more.

Developing the STPs was a master class in how not to develop plans for a whole system change programme.  Keeping things secret, anonymous leadership, refusing to consult organisations that were claimed to be partners, wasting millions on private sector advice to do the obvious was bad enough.  What was worse was that when what were claimed to be plans finally emerged they were pants.  The level of quality varied from poor to awful (OK with 2 or maybe 3 exceptions).  Already analysis by various reputable groups has shown how totally inadequate these plans are.  So they lost the word plan from the title!

Now, yet again plans that have serious financial risks and which require thousands of staff being moved out of the NHS are being pushed through without a Business Case, without having conducted any Options Appraisal, with a refusal to publish the documents and with decisions about spending our money being taken in private  and with a refusal to consult with staff representatives.  Why is that even allowed – what oversight is applied to these Trusts who say they have been given the go-ahead by the Regulator!

So how is this possible?  Where are the system leaders challenging autonomous dysfunction?  Where are the Non Executive Directors who ask tough questions?  Where are the Trust governors who refuse to sit back and allow stuff to get forced through?  Where is the oversight of commissioners?  And even – what happened to common sense?

Maybe we know the answer.  It is back to that word culture.  In the NHS the toxic culture of bullying with all that implies is rife.  Successful NHS leaders do what they are told, even when they know it won’t succeed.  In fact for many, their tenure is so short they will have moved before failure occurs.

So what of the latest wheeze, to let the NHS lead on setting up Accountable Care Organisations responsible for the planning and delivery of the care needs of large populations?

Well, based on the above no STP/ACS/ACO should be permitted if it has leadership drawn from the NHS.  It is time we found proper leaders, willing to engage and consult, able to speak their own minds and there to genuinely represent the best interests of the patients and public.


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  1. Alex Scott-Samuel says:

    This diagnosis is necessary but not quite sufficient. The bullying culture which 10 years ago led to mid-Staffs and is currently leading to the fragmentation and dismantling of the NHS in the form of the AC0s, is an archetypal feature of patriarchal neoliberalism.
    Let’s be clear: it was Blair, Milburn, Stevens, Nicholson and their successors who generated this culture in the ‘noughties’ and it is May, Hunt and Stevens who generate and maintain it now. Just as the latter have ruthlessly performance managed cuts, rationing and privatisation, so prime minister Corbyn and SoS Ashworth must equally ruthlessly performance manage solidarity, equality and the rebuilding and renationalisation of our hurt and damaged NHS

    1. Richard B says:

      The evidence from my own experience and of the many colleagues and friends who have worked at a senior level in the NHS for the last 40 odd years does not support this nostalgia for the golden age that never was. Management by shouting at people goes back a long way in the NHS.
      Still either way there is a current problem adding to the major concern over the impact of totally inadequate levels of funding.

      1. Hannah says:

        Can’t agree with your managerial friends here, having helped write the Unite motion that gives the union’s backing to the NHS Reinstatement bill and over 20 years clinical experience talking to colleagues on this subject

    2. dougwright says:

      Thank you Alex; I agree with what you you are saying. The question is what do we do next? We chould stand NHS candidates in next year’s local elections because Corbyn (whom I support) and Ashworth should be telling Labour Councils/Councillors to oppose ACOs. We are going to lose the NHS forever.Why not now try something different?

  2. Doug Wright says:

    I am tired of asking questions at CCG’s/Board of Governors/Council Scrutiny meetings etc and being fobbed off. How can we ensure that the general public get to know what is going on in our NHS? Perhaps we should seriously consider standing in local elections against ANY Councillors who don’t oppose Accountable Care Systems.

  3. Anonymous says:

    Sue the bastards.
    There is no legislation, no plan, no money and no evidence.
    The law may be an ass , but its not stupid.

  4. nivekd says:

    Due diligence? In Wirral the Council, in developing its own version of the horrors in collaboration with the CCG, turned for due diligence to PWC. Cue hysterical laughter.

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