Celebrate our success
By Dr Michael Dixon
Twelve years and a General Election in the near future make it a good time to take stock for the NHS and NHS Alliance. Starting with the past, let’s pause for a second and celebrate our successes.
For the NHS, a considerable and necessary increase in funding has led to much reduced secondary care waits and vastly improved care for patients with cancer and heart disease. The NHS Alliance television team tell me that the opinions of people on the street, speaking about the NHS, were almost universally positive this year. It is a far cry from years past!
Meanwhile, NHS Alliance has also gone from strength to strength. We have established a new culture of frontline managers, clinicians and non-execs working together. We are bringing Primary Care Trusts and practice based commissioners together as well. Our messages of clinical leadership, localism and effective commissioning are now part of popular rhetoric. Primary care has raised its game. It can no longer be ignored. Indeed, we are now the key to survival in a challenging economic climate.
Right now the NHS stands at a crossroads in so many ways. As we await an election, people tell me of a feeling of “policy impermanence” with ministers and director generals of commissioning seeming to change almost as rapidly as the weather. There is an ever widening disconnect between the high ideas, the discussions and the resolutions in Whitehall and those who are struggling to deliver their best for patients at the frontline of the NHS.
Clinicians, in particular, appear to be alienated. Forget leading, far too many are not even engaged! Commissioning, in the sense of radical redesign, is the exception rather than the rule — even after nearly twenty years of trying. That enormous energy, enthusiasm and inventiveness for improvement that exists at the frontline is too often sapped by rules and regulations. In short, whether you are a manager or a clinician, a group of practices or a PCT, you are probably succeeding in spite of the system. All too rarely because it supports your aims.
Times of turbulence, indecision and impermanence are also times of great opportunity. Times are bad financially but primary care now becomes ever more important as the answer to how we create a more cost effective, more efficient, fairer and healthier NHS. The World Health Organisation, no less, has produced the evidence for that.
So it is time now for us to be a little more bullish about the things that we have championed over these past twelve years. NHS Alliance has just published a challenging document titled “Sustaining the vision: how the NHS can survive the financial crisis”.
We have also launched a dialogue with patients and people titled “Whose NHS is it anyway?” One minute politicians tell us they are going to spend more and more on the NHS. The next, it is a macho battle to see who can introduce the biggest cuts. From now on, we want to inject a little commonsense into the debate. From now on, those who are commissioning, providing and receiving care at the frontline are to be part of the difficult decisions that need to be made.
The Future
David Nicholson, Chairman of the NHS has frequently asked primary care to “make trouble”. We must follow Nicholson’s advice. Because you and we are all victims of a most fundamental dysfunction in our current system. A dysfunction that continues to block all progress. It is really a disconnect. In three parts. Between the centre and the frontline, between secondary and primary care and between manager and clinician.
I may be wrong, but I believe that these disconnects started with changes introduced following a report for the NHS by Roy Griffiths, then Chairman of Sainsbury’s. This created a fierce, forceful and top heavy managerial hierarchy all the way down the NHS system. If it was ever right, it is certainly no longer fit for purpose today.
Because what we have created is an autocracy of senior managers at the top of the NHS. Detached from the rest of us lesser mortals, particularly the clinicians. Many if not most of this ruling elite have come from the acute sector so it is little surprise that hospitals remain “the senior service”. The consequence is all sorts of expensive and ineffective councils, boards and initiatives that do too little to support or meet the concerns of ordinary patients, clinicians and managers at the frontline of primary care.
What does this system achieve? It means that ministers and senior managers on the bridge of the NHS are able to press buttons labelled “restore financial balance” or “reduce secondary care waiting times” and things happen. The button labelled “increasing clinical engagement, ownership and leadership” doesn’t work because there is no connection to clinicians. They are not part of this managerial hierarchy. They were not meant to be. Meanwhile, the button labelled “localism” is permanently stuck. Localism is, by definition, something that a centralist system cannot deliver and no wonder that David Nicolson, in spite of best intentions, still finds everyone looking upwards not outwards.
So it is no surprise that frontline clinicians and patients get ignored, an excellent “Out of Hospital” policy and White Paper never gets implemented, managers and clinicians continue to distrust each other and the NHS and its patients get a bum deal. No surprise, to be more specific, that personal care and continuity are insufficiently valued and that the work of patients and clinicians is interrupted by everything ranging from inappropriate central targets to overcomplicated forms. After all, this was a system based on the retail trade and designed for selling baked beans - not the complexities of personal care and relationships. Consequently, we measure and performance manage things that don’t matter and clinicians fail to voice, effectively, things that do. Perhaps this is why poor care continues to go undetected. Albert Einstein said it all - “Not everything that can be counted counts. And not everything that counts can be counted”.
That is why we must now dismantle this system. We must allow clinicians and managers to lead together at all levels from primary and secondary care, with 360 degree performance appraisal at every level - just as we discussed last year. To create a centre that is connected and accountable to the frontline – every bit as much as vice versa. Practice based Commissioning, World Class Commissioning, clinical leadership, radical service redesign, a cost effective NHS – none of these things will ever really happen until clinicians, practice based commissioners and PCTs are fully connected and fully emancipated within the NHS structure at all levels. In future, leadership must be “owned” by all of us.
