The National Health Service is at the centre of political debate again. Some people want no change. Others demand root-and-branch dismantling, or talk vaguely of reform with little real idea of what they want to do. In this paper last week, Ian Birrell offered a highly personal prescription, setting out a cogent agenda that apparently makes politicians nervous; it is, however, in tune with the views of many of the NHS leaders I work with. While the NHS is undoubtedly getting better, there is a great deal of room for improvement.
We need to focus on the delivery of healthcare rather than abstruse debates about social insurance or Singaporean health savings accounts. Competition is undoubtedly a major driver for change and the introduction of independent surgical centres into the NHS has had a significant impact. But 60 years of central control, a limited supply of doctors compared with most other European countries and increased specialisation in medicine means it is difficult to create real competition.
A large amount of the work of the NHS is providing care for people with long-term conditions who have a relationship with their provider and are part of a complex system. This means that rather like retail banks, the service has to be very poor before people consider switching. So, in parallel to choice there needs to be rigorous attention to the quality of care and integration and co-ordination between providers. The commissioners of services and GPs have a crucial role in making sure this happens.
To really work, competition needs to have a direct impact on front-line staff, but in the past most staff have been insulated. Managers get replaced, but the rest continue in their posts. So creating a culture that focuses on delivery of the service is harder than in, say, retail. And where competition and choice does operate it takes time – often longer than policy-makers can wait in their electoral cycle. It may also produce results the public find unacceptable, such as the closure of much-loved hospitals. This creates a dilemma for politicians and managers who feel they must do something, a compulsion at its greatest where there are scandals and high-profile failures.
Another key problem is the expectation that politicians will micro-manage, and that they will do something every time a problem flares up. This has created a culture of looking up for instruction, an ethos that those at the top know best, which means people in the health service shy away from innovation and avoid taking risks needed to improve services.
How we move on from politicians being caught in a trap of being expected to act only to be blamed by the media is not at all clear: there is an expectation of accountability. The move to put more providers at arm's length through the creation of Foundation Trusts was an important step in this direction. But perhaps we all need to be braver, and stop expecting politicians to be the fall guys for everything.
Do we also need more transparency? Certainly, there is much to do to improve measurement in healthcare. However, surprisingly, the evidence suggests that patients do not extensively use published quality information to select hospitals where it is available. The real effect of publishing information is to engage the professional competitiveness of clinicians rather than influencing patient choice. This gives a vital clue to where the real driver of change might come from: namely, the desire of the medical profession to offer the best possible service in competition with friends, colleagues and rivals. Sadly, the enthusiasm of professionals for improvement has been squashed by the top-down direction of the last 30 years.
The pleas for more managerial freedom and better quality management are absolutely right. I know many fine NHS managers, although the quality of middle-tier management is variable. However, I wonder why anyone, particularly talented clinical staff, would want to go into healthcare management when it is such a vilified profession? This needs to change. We need to challenge the assumption that management in healthcare is just a worthless overhead. Much of what goes wrong with patients' experience of healthcare is to do with systems that do not work as they should and fixing these is a managerial task.
Mr Birrell proposed a manifesto that would go a long way to driving improvement. But many of the solutions to the problems people experience with the NHS are in the hands of front-line clinicians, and of managers not politicians. The service ethos, for example, cannot just be mandated from Whitehall. We need to focus the attention of front-line staff and managers on the real business of healthcare, rather than the requirements of policy-makers, the check lists of regulators and other necessary distractions. We need to discuss care, compassion and the experience of healthcare rather than just engage in a dry and sterile debate about funding systems and reform.
The author is policy director of the NHS Confederation, which represents people from all areas of the health serviceReuse content