Category Archives: NHS Management

Following the Judicial Review in London in July, NHS England quietly launched its promised public consultation on the Integrated Care Provider (ICP) Contracts on 4 August. The consultation closes on 26 October.  If the appeal granted at the other Judicial Review called for by 999 Call for the NHS in Leeds is successful, this ICP contract may yet be unlawful, but it is nonetheless essential that we respond to the feedback.

The ICP consultation document is a daunting read for most of the public. However, Health Campaigns Together (HCT) has provided expert answers to all 12 points in the public feedback document. 

HCT’s aim in providing these answers is to prevent flawed plans being adopted. They are seeking to prevent long-term contracts being signed that will undermine our NHS. This is in order to preserve any hopes of achieving a genuine integration of health and social care as public services, publicly provided free at point of use – and publicly accountable.

 

A reminder on what’s happened so far: There have been two judicial reviews on the Accountable Care Organisations and these Integrated Care Provider (ACO/ICP) contracts. And the courts found in favour of the NHS. But one of the campaign groups, 999 Call for the NHS, has now been granted permission to appeal. 

This is some very good news. But it also means NHS England is consulting on an ACO/ICP contract that may be unlawful. 

NHS England knew full well that an appeal was a possibility. Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the ACO/ICP contract. The consultation says that the Judicial Reviews had ruled in their favour. This consultation runs until 26 Oct.

 

We all know that this ICP consultation needs to be combatted and stopped. But in the meantime, here’s all the information you need to fill in the consultation feedback.

As stated, the judge in the London NHS Judicial Review said that the ACOs (now ICPs) should not be enacted until a lawfully conducted consultation was held, and any eventual ICP contract would have to be lawfully entered into.

Since then, NHS England have moved swiftly and stealthily into gear, and you will find their monstrous ICP ‘consultation’ document at this link.

And here is Health Campaigns Together on the subject at this link.

As you see, the consultation document includes 12 points for feedback and Health Campaigns together has provided suggested responses to these points – very good responses too, I think. You’ll find them at this link.

When you’re ready here is the direct link for public feedback to the document, just copy and paste from the Health Campaigns Together link above.

As stated, there is a move afoot to get the consultation suspended until after the appeal granted to the 999 for the NHS has been concluded, but it’s very important to counter what will definitely be lots of responses from the allies of NHS England. Otherwise they will be able to hail the result as a democratic mandate.

Health Campaigns Together say that it is OK to copy and paste HCT’s responses into the feedback boxes on the questionnaire, although if possible, it would be good if respondents could add a few tweaks of their own.

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National Health Service (Co-Funding and Co-Payment) Bill

2017-19

Type of Bill:

         Private Members’ Bill (Presentation Bill)

Sponsor:

         Mr Christopher Chope

Progress of a Bill

House of Commons

First reading, Second reading, Committee stage, Report stage, Third reading

House of Lords

First reading, Second reading, Committee stage, Report stage, Third reading

Consideration of the Amendments

Royal Assent

This Bill is expected to have its second reading debate on Friday 26 October 2018.

This Bill was presented to Parliament on Tuesday 5 September 2017. This is known as the first reading and there was no debate on the Bill at this stage.

Details of the Bill

National Health Service (Co-Funding and Co-Payment) Bill (HC Bill 37)

A

BILL

TO

Make provision for co-funding and for the extension of co-payment for NHS services in England; and for connected purposes.

Be it enacted by the Queen’s most Excellent Majesty, by and with the advice and consent of the Lords Spiritual and Temporal, and Commons, in this present Parliament assembled, and by the authority of the same, as follows:—

1.    Amendment of section 1 of the National Health Service Act 2006

  (1)      The National Health Service Act 2006 is amended as follows.

  (2)     In section 1 (Secretary of State’s duty to promote comprehensive health  service), in subsection (4)—

           (a)   the words “the making and recovery of charges is expressly provided for by or under any enactment, whenever passed” become paragraph
                  (a), and

                 (b)   after paragraph (a), insert or

                 (b)   the charges form part of an agreement in England for co-funding or co-payment.

2.  Other amendments of the National Health Service          Act 2006

  (1)       The National Health Service Act 2006 is amended as follows.

  (2)      After section 12E (Secretary of State’s duty as respects variation in provision of  health services), insert—

                                       ““Co-Funding and Co-Payment

  12F                Co-Funding and Co-Payment: England

  (1)            For the purposes of this Act, co-funding of NHS care shall be permissible in England when NHS-commissioned care is proposed to be partly funded—

                     (a)         by a patient, or

                     (b)      on behalf of a patient

  (2)           Co-payments permitted by virtue of this Act shall, in England, include payments made through co-funding as provided for in subsection (1)

 3             Extent, commencement and short title

  (1)          This Act extends to England and Wales.

  (2)          This Act shall come into force at the end of the period of two months after the day on which it receives Royal Assent.

  (3)          This Act may be cited as the National Health Service (Co-Funding and Co-Payment) 2018.

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What can it be like to lose the life of a loved one to an institution?

Clinical care is currently running the risk of burying its head in the sand of less than adequate regulators, and being dehumanised in a swathe of bureaucracy.

It struck me recently that the 6Cs of nursing, which arose from NHS England’s “Compassion in practice”, can be, to some extent, applied to patients as well as clinicians.

 

[graphic source]

The 6Cs are: care, compassion, competence, communication, courage, and commitment.

One of my issues is that, while the 6Cs are elegantly branded and themselves slickly marketed, they can, at worst, trivialise what are important issues for the entire health and social service. The issues are inherently more complex than might first appear.

I’m not one of the brigade who believes that everything in healthcare can be measured. One of the problems I have with the adage, ‘If you value it, measure it’, is that you can do inadvertent damage by measuring the wrong ‘key performance indicators’, or skew the discussion unfairly in a particular way.

Arguably, the 6Cs are the sorts of things which ‘you recognise when you see it’, and the same sort of thing can be said for some long term conditions such as dementia and frailty. But merely eyeballing the issues may be necessary but not sufficient. What is the right level of a competence? What would you rate as ‘good enough’ in the standard of clinical care you’d expect from a Specialist Registrar, such as #BawaGarba?

As it happens, I have been thinking a lot about how ‘courage’ applies to healthcare, not least because I have just written a book, jointly and equally with Rebecca Myers. We both had complementary but not identical views about courage in healthcare, from the perspectives of being a service user/patient, leader, manager or clinician.

As it happens, I am still not entirely sure of what the exact definition of courage is. What I do know is that the #BawaGarba case rumbled on, such that the GMC felt it appropriate to bend over backwards in removing a senior junior Doctor from the register of medical professionals. That was courageous, as it was a pretty ubiquitously unpopular decision in the light of organisational learning and ‘just culture’. One can only also imagine the huge courage needed to the parents of the child, or #BawaGarba herself in the face of a media and regulatory lynching.

When writing this book, I myself had substantial health problems. During last year, during the stress of my personal independence payment being refused despite being clearly physically disabled with mobility problems. I had a haemorrhage in my eye.

This meant my visual acuity went from cloudy, to ‘counting fingers’ to only seeing light, over a period of months.

I had an eye operation on January 25th 2018, but unfortunately I soon afterwards had a post-operative bleed, which meant my vision rapidly worsened. I then had a ‘repeat’ operation, called a vitrectomy, which cleared up my vision, meaning I can type this piece on my laptop computer with the affected eye without any difficulty.

Whenever I would hear people who are blind on LBC talking about their disability, I’d think, ‘That could be me’. In fact, despite being on the medical register currently, I had never viewed the patient experience through that prism. But it is very educational, if you believe me like me that the NHS should be comprehensive, universally available and free at the point of need or use.

Because I could not see, I actually fell over on a book in February 2018, which meant I had been rushed into hospital in the back of an ambulance inhaling Entonox like a pregnant mother in labour pains. I had dislocated my shoulder, and was in agony. At 2 am, the Specialist Registrar could not reduce the dislocated humerus bone back into joint, and at 9 am I was in theatre, under a general anaesthetic (which I had never had before).

At roughly the same time, my mum was admitted to hospital, living with dementia, but experiencing a horrific delirium. This is an emotional experience which will have a lasting effect for me forever.

All of these ‘patient experiences’ were deeply emotional. They’re not the sort of experiences which would be box office in a conference, such as promoting the joys of self management, or saying how wonderful the ‘dementia friendly communities’ kite mark is.

But nearly going blind mattered to me. Being in agony due to my shoulder (still healing) made me realise my own vulnerability. And when I used to go into hospital to see mum asleep (hypoactive delirium), I would wonder when or if she would ever wake up; she did, and massively improved when discharged out of hospital.

About 11 years ago, I suffered a cardiac arrest, and then spent six weeks in a coma due to meningitis. Actually, it brought my alcohol dependence syndrome to an end, but those were definitely the worst days of my life (and had a worse effect on others.) The thing is, I had no ‘feeling’ for what it was like to have any of these conditions as a junior doctor or medical student.

Whilst I do not subscribe to the idea that you have to be living with a condition to practise in it clinically, I think there are advantages of having sympathy, even if not complete empathy, with a patient’s experience as a doctor. Kay Redfield Jamieson, professor of psychiatry at John Hopkins, has openly written and spoken about her experiences with bipolar affective disorder.

So when I read terms such as ‘affected by dementia’, I find it quite trite to be honest. It’s really marketing. I could be ‘affected by dementia’ in the same way I am affected by herpes labialise, a cold sore, on the top of my lip, or ‘affected by a verruca on my big toe’.

Being both a clinician and a patient/service user is a highly emotional experience, and one thing I learnt from doing this book, essentially which I learned from Rebecca, is that courage is not solely a personal trait, as a lot depends on your vulnerability and strength within the rest of the system.

Take, for example, the courage Dr Chris Day must have had in challenging whistleblowing protection for patient safety, essentially himself as a whistleblower, putting him at total odds with the medical profession, who as usual protected themselves but not Day. The corpses of careers of people within health and social care are, unfortunately, widespread, and, if ‘lessons have been learned’, things can only get better?

Courage, like the other 6Cs, may trip off the tongue, but certainly does merit scrutiny. Whilst it can be very positive, giving you the strength to face an operation, it is telling you might need to have extraordinary amounts of it waiting for example on a hospital trolley in a corridor with chest pain.

 

@dr_shibley

 

 

 

 

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By  Ian Kirkpatrick, Andrew Sturdy and Gianluca Veronesi

Few topics have provoked as much debate and controversy in many western societies as the growth in public spending on management consultants. In the UK’s public healthcare sector, the National Health Service (NHS), this spending more than doubled from £313 million in 2010 to £640 million in 2014. Understandably, it is under constant scrutiny and there are considerable pressures to cut the use of management consultants, but spending remains high.

Management consultants provide advice on strategy, organisation, financial planning and assist with the implementation of new information technology. Frequently, they promise significant improvements in efficiency. According to the main industry body in the UK, the Management Consultancies Association (MCA), for every £1 spent on consulting fees, clients can expect £6 in return. However, as shown in a study we conducted recently, published in Policy & Politics, the use of management consultancy in English NHS hospital trusts is more likely to result in inefficiency.

A key question centres on why public sector (or indeed any) organisations use management consultants. On the one hand, it is clear that the growing size and complexity of the NHS has generated a demand for expert advice and support which cannot always be provided in-house. However, critics argue that management consulting firms have fuelled unnecessary demand through sophisticated selling techniques and backstage deal-making with politicians (the so-called ‘revolving door’). A recent example is the development of ‘Sustainability and Transformation Partnerships’ in the NHS which are said to have ‘created an industry for management consultants’.

To date, it has been hard to evaluate these competing claims about the value of management consultants. According to David Oliver, most NHS organisations have been either unable or, for political reasons, unwilling to engage in formal evaluation, resulting in an absence of ‘rigorous, peer reviewable, transparent data’. In this regard, our own study breaks new ground.

To estimate consulting use, we collected data on ‘consulting services’ expenditure from the Annual Reports of acute care hospital trusts in England for four years (2009/10 to 2012/13). In 2013, the 120 hospital trusts included in the sample had a cumulative cost of hiring management consultants of nearly £600 million. This meant an average annual expenditure on consultants of around £1.2 million per trust (although this varied from zero to £5.6 million).

Using pooled time series regression analysis, we looked at the relationship between this spending and the efficiency of each hospital trust over time. The results of this analysis were undoubtedly revealing. While in some cases spending on management consultants did improve efficiency, overall consulting use generated inefficiency, thus making the financial situation of clients worse. In monetary terms, these losses were not great – on average £10,600 for each hospital trust per annum. However, this is in addition to the £1.2 million fees already paid annually to management consultants on average by each trust for little or no gain.

To conclude, these findings suggest that while efficiency gains are possible through using management consultancy, they are the exception rather than the norm, as one would legitimately expect. Overall, the NHS is not obtaining value for money from management consultants and so, in future, managers and policymakers should be more careful about when and how they commission these services. More thought could also be given to alternative sources of advice and support, from within the NHS, or simply using the money saved on consulting fees to recruit more clinical staff.

Of course, when drawing this conclusion, it is necessary to strike a note of caution. From the available data, it is not possible to explain exactly why management consultants are having such a negative impact on efficiency. Part of the problem may be their lack of in-depth understanding of healthcare organisations or disruption caused by having too many consulting projects. However, some responsibility for inefficiency should also sit with politicians and NHS managers who make poor procurement decisions and then fail to implement the advice (even the good advice) they receive. These caveats suggest that more research will be needed in future. Nevertheless, our study is a useful first step in strengthening the evidence base and challenging the myth that management consultants generate efficiency in the NHS.

This article was originally published on Policy and Politics and is republished with permission

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Mad Management: Leaders (not) learning the lessons of history, especially in the Public Sector 

“Good morning, good morning!” the general said, when we met him last week on the way to the line.

Now the soldiers he smiled at are most of ’em dead, And we’re cursing his staff for incompetent swine. 

“He’s a cheery old card”, grunted Harry to Jack as they slogged up to Arras with rifle and pack . . .

But he did for them both by his plan of attack.

This was Siegfried Sassoon’s bitter poem about the World War I battle(s) of Arras. By this time 700,000 British men had died: equivalent to wiping out Sheffield and Hathersage. It is the Arras 101st anniversary this month. In fact, the plan was so bad that Sassoon amended the last line to read “But he murdered them both…”

Rightly, we need to remember and honour all those who died; but we also need to understand why they died in such numbers at Arras and how this ultimately led to the defeat of the British at the second battle of the Somme a year later – and to learn some lessons. The Lloyd George government had been steadily draining the fighting men from the front, leaving exhausted veterans of the first battle of the Somme to carry the burden instead of being reinforced. By the end of 1917 the fighting force had decreased by 7 per cent. The infantry alone was 80,000 short, and was projected to be close to half a million short by October 1918. Then came the second battle of the Somme, 100 years ago this year.

Guess what? From March to August that year 544,000 troops were somehow found and sent to France! The war ended in November. By this time 700,000 British men had died: the equivalent of wiping out the populations of Sheffield and Hathersage. Many, many of the deaths were unnecessary, caused by the outdated “plan of attack” and staff incompetence, and by government interference.

Does not this sound like a forerunner of our infamous Austerity policy? Admittedly the horrific scale and utter tragedy of the war bears no comparison, but the dynamics have some real parallels with today, especially in the withholding of resources (Treasury finance) and treatment of much of our workforce in the private sector, and the NHS and Social Care. Note, I am talking of the employees, not the customers or patients. First of all, the Treasury has systematically starved the public services of funding, for no other reason than the Chancellor could. This policy clearly displayed the contempt Osborne holds for the British people, as does Cameron. It is the act of a bully, as befits a Bullingdon alumnus.

We know what the impact has been for Sheffield. David Blunkett, now chair of the Partnership Board said in the Sheffield Telegraph last year that “austerity has dealt a terrible blow to our area”. Too right, and austerity continues to deal terrible blows to the one institution that we are most proud of, the NHS, achieving above average outcomes, with below average funding and below average staff numbers.

It was estimated to require £30 billion by 2020 to meet predicted demand, leaving it £2.45 billion in the red, while record numbers of nurses are leaving and GP practices closing down. There is no valid reason for this. It can only be that government wants it to fail, then, a bit like that doyen of the business world, Sir Philip Green, Jeremy Hunt can sell it for a pound to a USA health company. In the meantime, just like the workers in the gig economy or on zero hours, those in the NHS are increasingly insecure, underpaid and demoralised. And, we are talking about 1.3 million dedicated people.

This is our Somme, with Jeremy Hunt way, way behind the lines plotting the strategy, and, as Siegfried Sassoon wrote: “He did for them (all) with his plan of attack”.

How do the private and educational sectors meet the challenge David Blunkett has laid down, i.e. to regenerate and grow Sheffield? Well, I believe there is a step before we can work together as he urges us to do, and that is first to put our own houses in order. Do we pay our providers and suppliers on time? Have we minimised waste in our production and delivery systems, or are workers constantly having to rework and correct, just the way the government has done on almost every new plan it devised, from IT failures in the NHS, Defence and Welfare to Universal Credit to privatising probation services.

The May Council elections will be an opportunity to remind them. If not then, then do not expect any rise in productivity or increase in cooperation. Herzberg pointed out 60 years ago in his famous study on motivation: if people don’t feel they are paid enough, or are supervised badly or feel insecure then they will underperform. This means that unless these basic conditions, called Hygiene Factors, are fulfilled, you can forget about trying to apply Motivation Factors for productivity.

The second challenge is: To pay our staff enough, and give them some sense of security and belonging. For far too long too many firms have been disloyal to their staff, for example, Sports Direct and the banks. This is an opportunity to change that. I suggest that our universities blaze the trail with no more zero hours contracts.

First published on the JCAshby blog

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Trusts around the country are setting up wholly owned companies to deliver services so they can take advantage of taxation changes this allows.

This great VAT saga shows the NHS at its very worst.    Bullied from above, local managers believe the hype from consultants.  They can’t write a proper business case but still launch a project in secret, refuse to consult with staff, totally mislead the staff and public about the real intentions, refuse to give information claiming everything is commercially confidential and plough on regardless – all with the active collusion of a Regulator that is supposed to stop such poor behaviours.  Those involved continue to refuse even to respond to FoI requests.  Questions in both Commons and Lords get stock answers saying this has nothing to do with Ministers – it’s local decision making – nothing to see here.

Unison has been active in opposing the outbreak of wholly owned companies for 18 months.  On the face of it this represents money for nothing – the same staff doing the same job in the same way with the same managers but with “savings” in £millions from tax changes.  No increase in productivity, no innovation, no efficiencies at all – just a tax scam.  The staff loose out by moving out of the NHS and become collateral damage, but this does not matter as they are not nurses or doctors – that may come later.

Tactically the Trusts also get to break out of the national pay and conditions and can pay new staff and even promoted old staff on worse terms and conditions.  This alone should set red lights glowing somewhere.

Oh,  and two fingers up to any local plan about working together, collaboration and that guff – this is every Trust for itself – they even all claim that they will be selling services to each other.

And big issues like the consequences of transferring ownership and control over public assets to a private company (even one which for now is wholly owned) have simply been ignored or lied about.

Facts as opposed to the lies, are slowly emerging.  To take one well documented example. Late in 2016 a Trust did preliminary work with outside consultants on going down the wholly owned companies route.  In December 2016 in secret the Board agreed to go ahead using a particular model solution pitched to them by the consultants.  They did not look at the overall strategy involved and failed to look at other options.  This offer was too good to be true and others had done it; so why not?  The “Business Case” to the Board was laughable being a few pages of platitudes and 63 pages of tax advice.

The Trust worked on in secret, despite being under a very clear duty to engage with the staff on a decision which affected hundreds of them.  Eventually, late in 2017, they had to come clean and start TUPE consultations, but they consistently refused in every forum to consult or engage with staff on what was being proposed – they would only talk about the consequences.  They knew their whole case was entirely bogus.

In public the Trust simply avoided telling the truth.  They maintained throughout that what they were doing had to do with somehow professionalising the facilities management services.  Strangely the Trust had never reported its concerns with these services before they were sold the VAT dodge.  They never engaged with staff to see how they could improve services at all.

The Trusts maintained the fiction that this was nothing to do with tax as they had been instructed to do.  They gave a presentation to staff which had a dozen slides but none of them even mentioned VAT or tax. They signed a secrecy agreement with the consultants they used.  But because information was coming out of other Trusts doing the same thing, but slightly more honestly, they were caught out anyway.

After enormous pressure from Unison the Trust finally revealed at least some of its documents but only after it was already implementing its decision.  What the documents showed was what everyone already knew – the savings almost all came from changes in taxation.  Savings from other sources such as reducing pension rights or bringing in a two tier workforce were tiny in comparison.  This was and is all about tax. All about a Trust in severe financial straights doing anything to make savings.  Doing what it was told.  It was more afraid of external intervention for not trying hard enough than it was afraid of the outrage from its own staff.

Utterly dishonest from start to finish.  But with active collusion from NHS Improvement – the Regulator which knew exactly what they were doing and why, even if they now refuse to release the information and ignore FoI requests.  We know from parliamentary answers that NHSI signed off the deal.  We also know the relevant CCG opposed it and appealed to the Trust not to go ahead – yet again the lie is that everyone was in agreement.

A disgrace from start to finish.  Staff disillusioned, staff relations soured for years to come, further fragmentation of the NHS and a wholly uncertain cloud over the future ownership and control of vital NHS assets.  And NO SAVINGS.  Anything saved in one place is lost to the exchequer in another – its our money and we get no benefit at all.

No Board that agrees to this kind of subterfuge and secrecy is fit to stay in place.  But they will.

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This is blog is not a rant—well not too much of a rant. It is an expression of serious frustration about the way the NHS is run and about the willingness of some senior NHS managers to become complicit in something near to dishonesty.

Everyone at the frontline knows the NHS is running on empty. The more perceptive know that more money for the NHS alone will not improve services for patients. But—and this is perhaps the unpopular “but”—NHS senior managers ought to accept their share of the responsibility for the present crisis because they have colluded in pretending the NHS can deliver the impossible. Does anyone believe that NHS managers have “spoken truth unto power” about limits of NHS productivity?

The importance of public servants confronting ministers with uncomfortable truths has a long tradition. Long before Sir Ivan Rogers used the phrase, a 2015 FCO blog said:

“The UK Civil Service doesn’t have an official motto—but if it did, it would almost certainly be: “speak truth unto power.” It’s a maxim that’s in the blood of good civil servants, even if they know that it won’t make their lives any easier. The best politicians learn to cherish civil service advice which points out the flaws in their arguments. The worst surround themselves with sycophants who create a micro-climate which wraps a warm embrace around their worst tendencies.”

But, who speaks truth unto power in the NHS? When do NHS managers draw lines in the sand about what is realistically achievable in response to NHS England or NHS Improvement? Rarely, and often only at the (premature) end of a career.

The STPs are the latest set of “plans” where NHS mangers have been asked to promise to deliver the impossible. In response the NHS is signing up plans which are more fiction than reality. Privately, NHS senior managers know that STPs are totally undeliverable for a series of interlocking reasons.

First, they know that the NHS does not have effective change management procedures. Every small change has to be negotiated and agreed in detail with all stakeholders before it can get the green light. Thus every CCG, every truculent local authority, and every NHS Trust holds a veto to stop change happening. That stops controversial plans happening for years.

Secondly, politicians can block change. Time after time, local managers are overruled by senior NHS staff to avoid political embarrassment.

Thirdly, even if changes could be agreed locally, the capital needed to deliver effective changes is not available. Managing change is expensive, new buildings cost money and must be built before old ones are sold, and a measure of double running is inevitable. Capital money to fund STPs is spent plugging existing deficits. The iron rule of public service—you can only spend the same money once—seems to have been lost.

So why is the NHS repeating a failed planning process? Because it is told to. Scratch the surface, and many will reluctantly admit that the management culture of the NHS is close to dishonest. NHS England or NHS Improvement tell commissioners and providers what the plans are required to deliver. Once the targets are set, it is not acceptable to say that a plan to create financial balance or deliver 95% A & E performance “cannot be done.” It is equally unacceptable to say “It cannot be done without substantial capital investment, money for double running, and political will to deliver a series of unpopular changes.” NHS officials come under intense pressure to produce plans that confidently predict the undeliverable and most bow to that pressure.

The plans get signed off and the “system” confidently tells ministers that all will be well, all will be well, and all manner of things will be well. But, of course, now we know that all will not be well without substantial new investment in health and social care or if standards are substantially lowered. But, no one in the NHS is allowed to say that.

The NHS in England is in the mess it is today because of systemic overpromising and underfunding. That is primarily the fault of politicians. But, NHS management culture must bear its part of the blame. NHS managers, with some honourable exceptions, have colluded with politicians to tell them what they wanted to hear, and then demanded those under them produce plans to make good on those promises. Is it time to change the NHS culture by having courage to say what can and cannot be achieved with current resources?

This was first published by the British Medical Journal

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The Department of Health (DH) is to create a new property company to replace the two that currently exist1 nearly four years after the intention was first announced. The move is understood to be one of the recommendations of Sir Robert Naylor’s forthcoming report on the NHS estate.

The current position came into being as an afterthought to the now much derided Health and Social Care Act 2012 “reforms”, with a new DH owned company, Propco, solving the problem of who took over billions of pounds of property (such as primary care centres, clinics, community hospitals and offices) after Primary Care Trusts (PCTs) were abolished.

When Propco was set up there were concerns and issues and the suspicion that this was just a vehicle for privatisation or an asset sell off. Many of the properties were occupied wholly or in part by non-NHS bodies. Social enterprises (largely formed by former NHS community services staff) raised concerns that the change would add further complexity to the management of the estate, stalling the ongoing rationalization of existing property assets. They noted that new leases would have to be prepared with additional expense and management arrangements would become more complicated having overall a destabilising effect on local health economies.

Propco became NHS Property Services and its recent decision to move to market rents has caused a lot of problems. In July last year it was reported that commissioners remain locked in protracted negotiations around how much they will pay for buildings rented off NHS Property Services because of data problems. A senior Clinical Commissioning Group (CCG) finance officer told HSJ the principle of the move was understandable, but raised concerns that the implementation was being “botched”. NHS England director of financial control Steve Wilson informed CCG finance directors in a letter dated 15 June that there had been “a number of data quality issues” with NHS Property Service’s data highlighting earlier concerns that the setup of Propco had been compromised2.

For me locally there are problems with Health Centres facing extra charges and a community based organisation, born out of the Local Authority and NHS working together, suddenly being asked to pay huge increases in rents and charges; which I have taken up on their behalf.

But my wider concern is about the aims and objectives of the new property services company. Is this incarnation an attempt to be supportive of the NHS and its Sustainability and Transformation Plans (STPs)? These STPs are the great hope for our NHS, implementing the Five Year Forward View. Or is this new company just a route to a sell off more of the extensive NHS estate; or is it an income generator getting in the rents and charges. And why not bring in all NHS properties and include management of the many large PFIs (maybe better expertise could renegotiate better deals)?

This confusion about aims and objectives was highlighted when the original Propco was set up. In its March 2014 Report, Investigation into NHS Property Services, the National Audit Office pointed out that the objective “to hold property for use by community and primary care services AND deliver value for money” (emphasis added) was not clear.

This is important because just about every STP has pointed to estates as one of 3 or 4 key enablers of change. So does Newpropco have the role of facilitating these STP changes, or is it about maximizing income or receipts? Are decisions to be made locally, or by Newpropco, or through joint working? How will Newpropco staff be expected to work with localities – at present there is little or no local presence or knowledge.

So far the objectives of Newpropco have not been published but a DH spokesperson has said “The ability to invest in the highest standards of patient care, delivered in the right buildings and facilities, is a priority for this government. The creation of a new NHS property organisation will help to identify unused property to generate funding for reinvestment in the NHS whilst driving down estate running costs and creating opportunities to deliver new homes across the country.” Very laudable but not very specific on how potentially competing aims are balanced.

To add confusion last October, Simon Stevens the Chief Executive of NHS England told HSJ that NHS England was exploring the possibility of NHS organisations keeping their land sale receipts to invest in new services, rather than surrender them to central government.

This tension between running a property company and managing properties on behalf of the best interests of the operation of the care system is probably not resolvable.

I await with interest what Ministers will say about the setup of Newpropco and the Naylor Report when we see it. We must all hope this venture goes a lot more smoothly and with a much clearer strategy than the last attempt. It would also help if it operated in a more open and transparent manner like the NHS is supposed to be and not behaving like a commercial company in disguise.

1 NHS Property Services (Propco) was set up in 2012 to take over the ownership and management of property previously owned by organisations, such as primary care trusts, which were abolished by Health and Social Care Act reforms. It runs 3,500 properties, including offices, primary care and community health facilities. Community Health Partnerships (CHP) was established in 2001 to manage the DH’s interests in local improvement finance trust companies. LIFT is a scheme for public-private community property developments.

2 This is acknowledged now as many tenants have no proper leases or even agreements of any kind to cover rent and charges. Information was never properly collected on start up.

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The publicly funded, free at the point of use NHS has been described as the UK’s ‘national religion’. Its significance in our national consciousness underlined by its prominence in the opening ceremony of the 2012 London Olympics. Even Mrs Thatcher – whose government enthusiastically privatised many public enterprises such as telephones and utilities – maintained a rhetorical commitment to its ideals. Ongoing sensitivities surrounding the financing and management of the NHS are nicely illustrated by the current debates surrounding the Labour Party leadership contest, with ‘privatising the NHS’ used as a stick which to beat Owen Smith.

In spite of this rhetorical appeal to public-sector purity, a form of marketization was introduced into the NHS as long ago as the 1990s and continues to affect the NHS today, having been maintained and extended by the Labour governments of Blair and Brown. Usually called a ‘quasi market’ because patients do not have to pay when they use health services, NHS agencies are instead allocated money by the government which they spend on behalf of their local populations. Since the latest re-organisation of the NHS under the Health and Social Care Act 2012 (HSCA 2012), these ‘commissioners’ or ‘purchasers’ are known as ‘clinical commissioning groups’ (CCGs), and are led by local general practitioners (GPs), with the help of professional managers.

Although the NHS is still funded out of taxes and is still free at the point of use, hospitals and other providers of healthcare are constituted as semi-independent entities. These are known, confusingly, as ‘trusts’, even though they have nothing to do with the legal definition of a trust, and, although wholly state owned, they are expected to compete with each other for patients. The quasi market is structured so that the amount of money each trust earns should depend on the number of patients it treats. The idea is that market forces (i.e. competition) will encourage improvements in quality of care and improve value for money.

Yet this competition between state-owned providers does not tell the whole story of NHS competition. Alongside NHS trusts, successive governments (including New Labour) have encouraged non-state organisations to enter the quasi market and offer care to NHS funded patients. This includes for- profit firms, and also various forms of third sector organisations, such as social enterprises and charities. This is the ‘privatisation’ against which many are currently campaigning, taking the view that the HSCA 2012 has made a fundamental change to the NHS by attempting to enshrine the need for competition in law, and widening the opportunities for for-profit companies.

And so over the past two-and-a-half decades, the structures of the NHS and the rules governing its operation have undoubtedly shifted in the direction of greater marketisation. At the same time, there has been ongoing debate about the extent to which this marketisation has also permeated the mind-sets of NHS managers and healthcare professionals. One view is that there is a lack of fit between the enduring underlying values of the NHS, such as the focus on individual patients and seeing the NHS as a common enterprise (as celebrated in the Olympic opening ceremony), which encourage collaborative approaches, and the formal rules of commissioning which push for greater marketisation of relationships in the health system. Other researchers have found that the longstanding ‘clan’ culture in the NHS, bonded by loyalty and tradition, has been overtaken by a ‘rational’ culture bonded by competition and emphasis on winning market share.

Marketisation and management culture in the NHS

To find out if NHS culture is changing, our recent research investigated the views of managers about competition in the NHS after the enactment of the HSCA 2012 to examine the extent to which marketisation has become an internalised feature of NHS commissioning practices, and explore how far this is actually changing the NHS in any fundamental way. We investigated the views on competition of senior managers in both providing and commissioning organisations in four local health economies in England; focusing on managers is key to detecting any ‘real’ shifts in the NHS culture, because they hold the power of either translating structural changes into changes in behaviour or hampering such changes.

We found evidence that marketisation has become embedded in the thinking of some NHS managers, however, rather than a wholesale shift in attitudes, this seems to reflect creative incorporation of some market principles into everyday commissioning work – and such work still mostly seems to favour collaborative rather than competitive approaches.

Commissioners and providers (including non-state providers) found the rules introduced by the HSCA 2012 confusing, hard to follow and potentially contradictory. Instead of a shared understanding of the rules, there was a shared sense of confusion, leading to divergent interpretations and organisational responses. A lack of clear policy direction and changing policy emphasis were also noted as the government made a series of policy announcements which appeared to change the direction of competition policy in the NHS without actually repealing the legislation promoting competition.

There also existed a whole spectrum of underlying opinions about the place of competition in the NHS. Although most interviewees preferred collaboration as a main method of solving local service delivery problems, especially in cases of complex service transformations, this was not the only attitude encountered. Some pointed out the benefits of competition when used in a non-prescriptive, creative way. This suggests that, notwithstanding the strong commitment to a ‘public’ NHS amongst NHS patients and staff, some NHS managers have internalised the idea of a more pluralistic NHS. In the face of contradictory and ambiguous rules, participants were preoccupied first of all with preserving their own organisation’s interests and identities.

Overall, this suggests that, whilst in general NHS managers remain committed to co-operation and collaboration, two and a half decades of marketisation have introduced pockets of pro-competitive thinking. The outstanding question is how the changes which are starting to occur in NHS managers’ attitudes will affect our NHS; will the common NHS identity expressed by Danny Boyle at London 2012, which has successfully supported the delivery of care to all citizens regardless of ability to pay, withstand this shift in attitudes?

Note: this paper draws from research published in Public Administration and co-authored with Dorota Osipovic (lead author), Elizabeth Shepherd, Lorraine Williams, Marie Sanderson, Anna Coleman, Neil Perkins and Katherine Checkland.

It was first published on the British Politics and Policy blog

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Predictions that the NHS is facing disaster have been issued so often that people no longer pay much attention. This time there is unanimity. Even normally government friendly experts are in agreement, and for good reasons.

Since 2010 the NHS budget has been almost static, while the UK population has increased by two and a half million and is predicted to grow by 440,000 a year over the next ten years, with a growing proportion living longer and having more longterm illnesses.  So it is no surprise that NHS hospitals in England look likely to have overspent their 2015-16 budgets by £2.5bn and that even so care quality is now seriously declining. There is also an acute shortage of GPs; CCGs are announcing cuts in the range of treatments they will pay for;  waiting times for treatments, including for cancer, are rising;  hospital wards are understaffed; beds are also unavailable because too many are occupied by patients who can’t be discharged because of cuts to social care provision. And Monitor has told seriously overspent trusts to ‘reduce their headcount’. The Kings Fund normally gives cautious support to government policy but on 7 April its Chief Executive, Chris Ham, finally broke with precedent and in effect told the government it was in denial in maintaining that services can be maintained and even improved when funding per patient is already too low and is planned to drop fairly rapidly over the next five years:

“NHS leaders have never felt this target was credible and are now wondering when the emperor will be seen to have no clothes. Many feel as if they are living in a parallel universe in which they are striving to sustain existing services in conditions of adversity while politicians promise improvements in care that cannot be delivered with available resources. ”

In other words, without a major increase in funding the NHS as it presently operates cannot continue; but a major increase in funding is ruled out by the government’s austerity strategy, and most of the practicable savings from salary freezes, delayed maintenance, etc, have already been made.

In response the Chief Executive of the NHS in England, Simon Stevens, has proposed

  1. major improvements in disease prevention (or health promotion) and
  2. a radical transformation in the way health services are organised, in the belief that this can make services better as well as cheaper, improving productivity by as much as 3% a year by 2020-21.

His 2014 paper, A Five Year Forward View, estimated that to maintain services of the same quality as in the past, by 2020-21 the NHS in England would need £30bn a year more than the government was planning to give it. (The basis of the predicted gap has been questioned, but not in a way that suggests it has been overestimated – it could even be greater.) In November last year Stevens got Mr Osborne to agree to provide £8bn of the £30bn a year needed by 2020-21, with some of the increase coming early enough to cover the cost of adopting the ‘new models of care’ on which the hoped-for productivity improvements depend, and which are currently being trialled at 50 ‘vanguard’ sites around England. The remaining £22bn per annum gap predicted for 2020-2 was to be closed largely by these improvements.

Until the experiments have had time to be tested and evaluated we can’t know whether they are really capable of improving (or even maintaining) care quality while also saving major sums of money, let alone within five years. To judge from Chris Ham’s intervention, even sympathetic experts don’t think they are. ‘There is now no prospect’, he writes, ‘that efficiencies on this scale can be achieved by 2020/21.’ He thinks that much of the ‘front loaded’ £8bn new money extracted from Mr Osborne and intended by Simon Stevens to pay for costs of shifting to new models of care will be swallowed up in paying off deficits. Moreover it is not clear that the ‘vanguards’ which are trying out new forms of integration between primary, secondary and community health care – and in some cases also social care – are being independently evaluated. And there is no prospect that new measures to prevent illhealth could have a significant impact in reducing the need for health care by 2021, even if the government were to adopt them as a matter of urgency, which it so far shows little sign of doing.

But since, without a radical change in the government’s austerity policy, services are threatened with collapse, it is easy to see why most people in the health policymaking circuit initially supported Stevens’ strategy. Now, however, they are being asked to put their money where their mouths are and implement his central idea, in an extraordinary exercise in collaboration outside and across the unreformed but discredited apparatus created by the 2012 Health and Social Care Act. NHS England’s document, Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21, published just before Christmas last year, calls on ‘local health systems’, consisting of ‘clinicians, patients, carers, citizens, and local community partners including the independent and voluntary sectors, and local government through health and wellbeing boards’, to ‘work together to develop robust plans to transform the way that health and care is planned and delivered for their populations’.

For this purpose England has been divided into 44 ‘local health systems’, each of whose ‘footprints’ covers, on average, 1.2 million people, three or four local councils and some 5 CCGs. Each of these ‘local health systems’ is called on to produce, by the end of June this year, a Sustainability and Transformation Plan covering the next five years.

The first requirement is that CCGs and providers must – somehow – cut their expenditure and stay within their budgets in 2016-17; and then, by keeping all providers’ books balanced for the following four years, and by making satisfactory responses to a long set of questions set out in the guidance, local health systems can earn access to centrally-controlled ‘transformation’ funding which will allow them to make changes to service delivery while ‘maintaining and improving’ patient safety and quality over the years 2017-21. The incentive to comply is that local health systems whose Sustainability and Transformation Plan s fail to secure an overall financial balance in 2016-17, or which fail to meet enough of the other requirements spelled out for them, will not get any transformation funding – which will from now on be the only additional funds available.

What this has meant for many trusts, according to one hospital trust finance director, is pressure to manipulate their accounts to appear to be in financial balance, or at least facing a lower deficit than they really are, because Sustainability & Transformation funding would be given only to those trusts that agreed to meet the control total and other conditions including access targets. In evidence given to the Public Accounts Committee in February he or she stated that

“My own organisation has been working hard on its draft 2016/17 plan since October 2015 and we predict a sizeable deficit for 2016/17. But, the regulator’s control total is for a deficit some £5-10 million lower than what the Board currently considers it can realistically and, more importantly, safely achieve… The regulators have provided no explanation as to how they arrived at their control total for my Trust… I have already been in contact with the Financial Directors of almost a dozen other acute trusts, all of whom have “control total” gaps in their draft 2016/17 plans of between £5m and £20m. My real concern is that Boards are being pressurised into accepting a 2016/17 control total that they do not yet have plans to achieve”

As for the questions Sustainability and Transformation Plans have to answer, they come in a form that makes it clear that not doing what they call for is not an option. Not all of the measures look like an improvement in care so much as ceasing to offer it (for example: ‘How will you achieve a step-change in patient activation and self-care? How will this help you moderate demand and achieve financial balance?’) or transferring work to unpaid family carers (‘How will your area ensure that people with learning disabilities are, wherever possible, supported at home rather than in hospital? How far are you closing out-moded inpatient beds and reinvesting in continuing learning disability support?’). But many of the new service models look sensible, indeed obvious, and especially those that envisage a future that, in the words of the Five Year Forward View:

“dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment. One that no longer sees… services fragmented, patients having to visit multiple professionals for multiple appointments… organised to support people with multiple health conditions, not just single diseases. A future that sees far more care delivered locally but with some services in specialist centres where that clearly produces better results” (Five Year Forward View p. 7)

But how far these aims can be achieved by new models of service delivery that also reduce expenditure is open to serious question. The guidance makes it clear that saving money is now primary – as the King’s Fund puts it, the post-Francis era of concern for quality and safety is over. But Sustainability and Transformation Plans must also contain proposals for improving care; yet even the King’s Fund says that ‘It is inconceivable that the NHS will be able to achieve both financial sustainability and large-scale transformation within these financial constraints’. The demands made also sometimes seem absurd, given the limited powers and resources available at local level and the lack of a correspondingly serious policy at the national level (e.g. ‘What action will you take to address obesity, including childhood obesity?’). There are in all 60 such questions (including sub-questions).

Moreover the idea that the diverse collection of local organisations and people who make up a ‘local health system’ can together produce– by the end of June – practicable plans that offer meaningful answers to even half of these questions seems so unrealistic as to almost make one wonder whether it is seriously meant. After all, ‘local health systems’ are not in fact systems. No legal or other structures link the organisations and individuals involved, there are no procedures for determining how disagreements are to be resolved, they largely lack planning expertise, and all the people who are expected to collaborate in producing Sustainability and Transformation Plans already have heavy workloads. And while the six organisations that have jointly issued the guidance (NHS England, NHS Improvement [Monitor and the NHS Trust Development Authority], Health Education England, NICE, Public Health England, and the CQC) presumably have the power between them to require the local NHS bodies concerned to do all the things asked of them, this does not apply to local councils, which are responsible for social care and are also included in the ‘local health systems’. Councils can no doubt be leant on by the Department for Communities and Local Government, but the whole process has a markedly extra-legal character.

The fact that ‘local health systems’ are now being given ‘guidance’ (which was code for ‘instruction’ inside the pre-2000 NHS) also signifies what was already clear from the Five Year Forward View, that improvement is no longer expected to result from competition between providers in a market (competition is not mentioned), but from CCGs, providers and local authorities responding to orders from the centre. The same point is clear from the fact that all NHS foundation trusts as well as trusts are now to be subject to ‘financial control totals’ managed by the DH and the Treasury as a condition of having access to any additional funding – definitively abandoning the idea, which has been central to government thinking since 2003, that they are independent businesses. Rather than acknowledging that that idea has failed comprehensively, and amending the law, the government has chosen to leave the Act’s dysfunctional structures unchanged and give ‘localities’ the task of dealing with the contradiction between its rhetoric of improvement and the increasingly inadequate NHS budget. This means that the resulting decision-making is governed by no statutory rules: it is not clear who will be accountable for the results in terms of service provision, or the accompanying redeployments of public funds, or the conflicts of interest and opportunities for fraud which the process is liable to generate. As a minimum the process needs to be made open and accessible in a way that doesn’t so far seem to be provided for in the Sustainability and Transformation Plan arrangements. Who is participating in each ‘local health system’, who they represent, how they are reporting back, where a record can be found of the meetings held and decisions reached – this information at least should surely be systematised and made public if the process is to be considered in any way democratic. Independent published evaluations are also needed of what the various new models of care have achieved in practice, in terms of both patient care and productivity gains.

Of course we are where we are, and perhaps sceptics will have a pleasant surprise, with the NHS emerging in 2020-21 transformed and improved, however unlikely it seems. But where we are is the result of political choices. One of these choices is to spend some two and a half percentage points less of our GDP on health than comparable European countries– 8.5%, compared with France’s 10.9%, Germany’s 11.0%, the Netherland’s 11.1%, and so on. This is a huge difference. Matching these countries’ present commitment to their health services would already mean an additional £40bn a year for the NHS. As Chris Ham points out, we are now almost back to the level of spending we were at before Tony Blair’s 2000 commitment to catch up with the European average. The first aim of the new planning process is ‘sustainability’, but what is truly unsustainable in the long run is providing a first-class health service on a third class budget. And the decision, on top of this, to be spending only £8bn a year more on the NHS in England five years from now, in the interest of shrinking the state, is another political choice, which has less and less support even among mainstream economists.

A fully referenced version of this paper can be found on the Centre for Health and the Public Interest site

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Newly published research from Chris Bojke and co-authors estimates productivity growth in the NHS from 1998/1999 to 2013/2014. Total output of the NHS comprises both the volume of various services and their quality while inputs are approximated by total expenditure. Growth in productivity is then calculated by comparing growth in output with growth in inputs. Their main results are shown in figure 1, reproduced from the paper. Over the fifteen year period total productivity growth was 4.1% and under the previous coalition government productivity growth averaged 1.6% per annum.

bokje fig 8

Figure 1. Inputs versus outputs for the NHS. (From Bojke et al. (2016) CC BY-NC 4.0)

Early on during the coalition government the NHS was set a productivity challenge to find around £50 billion of productivity savings by 2019/20. This was equivalent to an increase in productivity of around 5% per annum, which was completely unprecedented at the time. Compare figure 1 to figure 2, which shows the targets the government was imposing. The new productivity data show that the NHS has not and is unlikely to achieve anywhere near this figure. Indeed, one of the cornerstones of the government’s healthcare policy, a 7-day NHS, is unlikely to be cost-effective and may further reduce productivity growth despite attempts to reduce labour costs through changes to contracts.

f1-medium

Figure 2. Inputs and outputs for the NHS up to 2009, with the orange circles representing the coalition government’s goal. (From Appleby (2012))

When it comes to overall changes in productivity it is not possible to disentangle changes in efficiency, improvements in technology, and economies of scale. Generally, new technologies are both more expensive and provide greater benefits, but their effect on efficiency depends on whether they are more cost effective than what the NHS is currently achieving with its inputs. Some research suggests that the cost-effectiveness threshold for adoption of new technologies is too high potentially reducing efficiency. However, healthcare providers may have disinvested from the least cost-effective technologies as their budgets contract, improving efficiency.

It is widely acknowledged that there are shortfalls in staffing in the NHS. Guidelines for safe staff to patient ratios are frequently not met. Bojke et al. show that labour inputs to the NHS, which account for 42% of all inputs, hardly changed under the coalition government. Staff inputs are not considered in the same way as technologies; it is not known what the “cost-effectiveness” of a doctor is for example. Increasing labour inputs can improve patient safety, thereby reducing patient harm and length of stay, while also potentially improving the efficiency with which healthcare is provided as staff are complementary inputs with other healthcare capital. However, investment in labour, unlike capital goods, takes place in a broader political context as the current junior doctor’s strikes demonstrate. This may lead to a suboptimal policy choice about investment in and remuneration of labour, a so-called ‘government failure’.

The question of what is driving productivity growth still remains. Bojke et al. note that “output growth appears to be more closely related to lagged input growth than current input growth”. This may explain why productivity growth is observed to be positive when input growth is low. Observed productivity growth may therefore be an artifact of reductions to input growth, casting doubt on the sustainability of further productivity growth in the future under current policy.

This first appeared on the Academic Health Economists’ Blog

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As it enters 2016, the NHS is not a happy organisation. It hasn’t been for some time but the problems and pressures that have gathered pace through 2015 are coming to a head.

A threatened strike by junior doctors is already a firm possibility but other issues are mounting by the day, ranging from cash‐strapped hospitals, allegedly underperforming GPs, shortages of clinical and nursing staff, poorly integrated health and social care, non‐existent or threadbare mental health services, the persistence of a bullying culture, to unforeseen cuts in public health funding that threaten to put further pressure on an already over‐stretched NHS. The list goes on.

The quick fix

It is tempting to pick these issues off one by one, reaching for the quick fix while also finding someone to blame for allowing things to reach such a parlous state. That would be a mistake and would fail to understand the forces that have brought the NHS to where it is today.

Taking the long view is a necessary prerequisite to finding appropriate solutions.

Key to this is understanding the politics of health. Conceptualising health as political and as the product of political action is integral to comprehending complex health systems and how they might be changed for the better. The problems of the NHS are not at the end of the day technical or managerial although they have their place.

All governments wrestle with a number of policy cleavages when it comes to health. These include the funding and organisation of health systems; the attempt to shift the emphasis from health care to health; priority‐setting and rationing health care; and the appeal of markets and choice and competition.

Public vs private tension

Running through each of these cleavages is a tension between the public realm and private realm that gets played out in discourses on the role and limits of government on the one hand, and on the role of individuals in taking responsibility for their health and in exercising choice on the other.

A persistent theme running through health policy in the UK since at least the early 1990s has been the ascendancy of the market in public services like the NHS. Governments of all persuasions have been seduced by the alleged virtues of markets and competition without appreciating their limits in areas of public policy such as health.

The seeds of the current UK government’s misconceived and unpopular NHS reforms introduced in 2013 by the then Conservative dominated Coalition government were sown by the last Labour government. This continuity in health policy has been a marked feature of the political landscape in England while the devolved administrations in Wales and Scotland have chosen to pursue a different path that seeks to retain the NHS’s public service ethos.

An underlying cause of much discontent within the NHS, including the junior doctors’ dispute, lies with the successive waves of reforms foisted on the NHS by all governments. The 2013 changes have attracted most criticism and resulted in an erosion of trust between NHS staff and politicians.

Anger

The deep seated anger felt by junior doctors is a manifestation of its growing frustration with the government’s stewardship of the NHS.

There is a widely held perception that the government’s real agenda is to dismantle the NHS as part of a wider redesign of the public realm. The feeling is that it is happening in other areas of public policy so why should health remain an exception.

For a government intent on pursuing a neoliberal agenda, institutions like the NHS and the BBC stand out as curiosities in the vision of a smaller state in which public services are largely privatised or outsourced.

Is there another way? Yes, there is always another way because that is the essence of politics. There are always choices. This does not mean a retreat into a mythical golden age for the NHS that never existed. But it does mean acknowledging that some activities end up in the public realm for sound reasons, not because they have somehow escaped the virtues of markets, choice and competition.

Politics is at the heart of all that happens in health policy. Making sense of the NHS’s current predicament, however puzzling, requires understanding the beliefs underlying policy makers’ choices and the interests they represent. It is these, and not some spurious scientism or notion of evidence, that is shaping and driving their choices.

If we are to engage with these issues and chart a different course for the NHS, we need a new kind of politics from that which we currently have. We know that neoliberalism kills. To counter such an ideology we need a new political economy of health. A public debate about health that puts politics centre stage is both necessary and overdue.

This was originally published on The Policy Press Blog

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