Another Secretary of State pushes determinedly, blindly on with NHS reforms, deluded in the notion that they alone can solve the great mystery of health.
My message is: no matter how well intentioned, your policy making is doomed to fail, as others have failed before you. May I humbly suggest another solution?
The NHS is now into its 30th year of perpetual reform (perhaps we should hold an anniversary party?). Yet it is still in need of reform. At what point do the politicians wake up and conclude that, in the way they go about it, it is irreformable?
Our ‘heroes’ in government – it happens to be Conservative but could have been Coalition, New Labour, or Jeremy Corbyn – drive determinedly on with their reforms, confident they will succeed this time because it fits with their ideology, or it washes whiter, or it comes gift-wrapped from a captive think tank, or because ‘we are better than our predecessors’.
The New Scientist examined the neuroscience of these sort of political beliefs:
“All told, the uncomfortable conclusion is that some if not all of our fundamental beliefs about the world are based not on facts and reason – or even misinformation – but on gut feelings that arise from our evolved psychology, basic biology and culture. The results of this are plain to see: political deadlock, religious strife, evidence-free policy-making and a bottomless pit of mumbo jumbo.”
Political decision-making is fallible. Politicians can come up with any policy they like because the system allows them to. The only effective check on flawed policy is the House of Lords. But this only applies to legislation, and then is rarely used and can be circumvented. Public pressure may tell occasionally – from a media campaign to a riot. Equally occasionally, an independent rigorous report may emerge years after a policy’s initiation concluding on its ineffectiveness, and it is changed.
But the vast majority of decisions are either taken in private without recourse or are whipped through by the majority party.
Did you know that no criteria exist with effective enforcement to assess a policy’s quality? You’d think a rigorous, formal policy assessment would be in place, asking questions like, will it work? How? Who will it affect? Have its unforeseen consequences been checked?
And what will it cost – everyone not just the exchequer, including travel to receding A & E departments?
The NHS is one of Labour’s great post-war achievements – a massive improvement and, for a time, the envy of the unprejudiced world. Now Labour is unable to countenance the prospect of a new NHS, no matter how tired or lame the old model is.
The Conservatives have too often wanted to remove this large lump of the state. Consequently they are not trusted with a change of model. Indeed Prime Minister Margaret Thatcher had to reassure Britons in 1982 with the promise that the NHS is “safe in our hands.” But true Conservatives would be much happier if the NHS disappeared altogether: it has been a success deeply embarrassing to their beliefs. With the consequence that Labour defends this ailing institution even more fervently.
The two big parties lock horns over its reform but never join hands to consider its successor. So we are stuck with an institution that will never catch up with better functioning models despite how hard anyone tries.
The electoral system pits these jaded heavyweights against each other – neither having come to terms with the modern world – and they wrestle: pulling the NHS this way and that, removing bits, gluing some back on, replacing parts with prosthetics – or contractors as they are termed, using starvation as an appetite-suppressant, smothering it with procedures and managers, and of course, dipping into those sometime quack cure-alls of marketisation and privatization.
Trapped by their history, the parties are stuck in their ideological backwaters, unable to look to best practice overseas or to reconceive a health service for the 21st century.
The NHS is another victim of ‘Zigzag government’. Typically, as soon as a new government arrives then anything its predecessor has done is ‘wrong’ and jettisoned and a new orthodoxy takes hold. This lasts for a while then, again typically, some jettisoned policies return.
The NHS is now experiencing exactly the same underfunding that occurred in the 90s as Thatcher’s world concluded. Gordon Brown arrived and restored the funding to functioning levels….. but went too far, such that by the end of his term money was pouring in only to be appropriated by top management for, um, eh, top management. Excess austerity became the new normal once more and the patient is skinned again.
In a two party state without the stabilising influence of other parties always in the canoe of state, each party in power makes the mistake of assuming that their beliefs will endure for the foreseeable future.
I know former ministers who’ve described the reality of seeing their ‘ground breaking’ reforms shelved after a few years, when they’d thought and hoped they’d stand the test of time and change the system.
In reality, these are practiced for a limited period, only to be declared false gods by their successors. Small state, big state. Hard on welfare, soft on welfare. Private sector good, public sector bad. Public expenditure good, public expenditure bad.
As citizens and consumers we benefit or suffer from the cumulative output of these regimes, the aggregate, not the separate parts. The moving average of successive governments’ results comes at a high cost in wasted taxes and blighted lives. First past the post voting in which a single party gets absolute power for five years to force its prejudices on the majority is no way to produce a great health service.
All that time, effort, and money being consumed in argument and ‘reform’ which could have been used on medicine.
Let’s take the previous major round of reforms started in 2012 by the then Health Secretary of State. This attempt received a scathing appraisal summed up in this article:
“Perhaps the pithiest verdict on the reforms came from Dame Julie Moore, head of University Hospitals Birmingham: “They cut it from 118 quangos to 234, and they reduced the levels of bureaucracy above me from three to 24.”
The article’s conclusions are spot on:
“It was, from top to bottom, a case study in how not to reform the public services: develop your plan in secret; devote no attention whatsoever to making a public case for it (or explaining its purpose and rationale); remove any shred of internal logic by accepting a series of compromises that go against the original spirit of the legislation; squander vast amounts of capital pushing the resulting botch job through; and then fire the guy responsible, even though for all his mistakes he may just be the only person who understands the reforms enough to make them work.
The lesson we seem to be taking is that you can’t trust any politician to make any reforms to the NHS whatsoever.”
The fallacy of politics.
Thirty years of continuous reform should set off the alarms that no matter how hard governments try, the model is not working and never will.
To state the blindingly obvious, we all need and want an excellent national health service, but its existing form cannot provide this. Wonky politics has produced a model which no matter how many attempts at tinkering with/battering it into submission won’t produce the required results. The villain here is our system of government. In terms of organisational theory a quarter of a century of making limited progress, despite repetitive and costly restructuring, demonstrates that the problem is the model of organisation, not the internal structure; and that it is time for a new one.
Public services around the world remind me rather of manufacturing industries before the Japanese got involved. They established ‘best practice’ to such an extent that, today, if your manufacturing is not world class you won’t be in business. As companies like Sony and Toyota started to export in the 80s, the rest of the world first felt the competitive squeeze, then cried foul, then explained away their success as the product of a foreign culture. Then the unprejudiced went to look and learn. What I term global ‘learning engines’ became established through management gurus, journals, professional associations, consultants, business schools etc. Most industries now have these means to acquire, disseminate and apply knowledge and best practice.
They exist already in medical practice. The protocol for treating a particular cancer is the same in Rio, Rotherham, and Riyadh.
But best practice acquisition is not practiced in public service organisation. It’s high time it was. Not so far away from our island isolation, are health models worth considering: ones designed for all, and not the high cost lottery of the US. Look at France as an eye opener. In its 2000 assessment of national systems, the World Health Organization found that France provided “close to best overall health care” in the world. Worth a look?
Or, the 2010 OECD report notes:
“Australia, Iceland, Japan, Korea and Switzerland perform best in transforming spending into health outcomes……….. There is no one-size-fits-all approach to reforming health care systems……..Adopt best practices from the many different health care systems that exist and tailor them to suit actual circumstances.”
Ah, good point.
In various ways these are all national health services, just not the NHS as conceived here.
The question then arises as to how we might get from today’s NHS to tomorrow’s, especially given all the past party political machinations and failure, and how distrustful we are of change.
Canada provides a model for considering, deciding on, and introducing such a major change to such a sensitive service. Its programme of extensive public engagement and deliberation on four potential health service models around 2000, involved all manner of accessing people: It started with an independently assembled fact and information base (without a spun statistic in sight, oh how sensible). The facilitator of that programme concluded a consensus emerged as much based on values as on hard data. He reported this to government, which accepted and implemented it.
The job of government here was sound delivery, not making the decisions. This is a really, really important point to get across to all those politicians who want to feel important but are crap at doing.
The Canadian government’s current stated purpose on health is to ‘hear what Canadians are thinking on a particular issue. The input obtained during these consultations helps form policies and legislation that reflect the concerns of Canadians.’ On something as important as health, Canada has been trying to make adversarial politics redundant as a decision making process. Could we, should we, dare to do the same in this country?
We live with the consequences of fallible policy making littered around us. Reforms based on the good ideas or whims of another delusional Secretary of State have not and will not work. Only consensual politics will end the political deadlock on NHS – and this means looking to best practice. Grown up politics rather than ideological zigzag. Now, there’s a thought.
I’ll be applying my knowledge of how government really works in future blogs. Follow me at edstraw.com for more on the detrimental nature of zigzag policies
Ed Straw
1880 words
Ed Straw is an organisational expert with 35 years of experience advising on the public sector, including health. He has stimulated/overseen wholescale reform including of Relate, Demos, the Olympics, New Labour, and Family Services in Britain, as well as advising on the development of the devolved Scottish Government and global companies.
He was for 20 years a partner at the professional services firm PricewaterhouseCoopers in management consulting. In 2014, he published Stand & Deliver: A Design For Successful Government. His pamphlets include Relative Values (Demos, 1996) and The Dead Generalist (Demos, 2004).
