Interview by Andy Cowper, editor, Health Policy Insight
Michael Sobanja occupies exactly the position he wants to in NHS Alliance. It’s just not an easy position to define. In musical terms, he’d be the drummer of the band: nailing down the beat of the tunes to hold together the front-stage heroics of lead vocalist Michael Dixon and lead guitarist David Jenner.
I have a lot of time for NHS Alliance (please note: I’ve also worked for them on various projects, so happily admit to being favourably disposed – AKA biased - towards them). They fulfil a useful role to provoke debate without being knee-jerk confrontationoholics.
Their annual conference, which takes place next week in Manchester, is a lively event. While not on the same scale as the NHS Confederation’s (or perhaps as a result), people often say more interesting things there.
In 2005, then-NHS CE Sir Nigel Crisp pointedly failed to apologise for the fast-rescinded ‘Commissioning A Patient-Led NHS’ policy paper ordering PCTs to divest provision, laving then-Health secretary to do so. In 2006, David Nicholson told delegates to “make trouble for the NHS … root out bad deals and bad services” (some you win, David); and Sir Ian Carruthers said that “the NHS should spend less on management consultants at every point”.
2007 saw Mark Britnell’s Orwellian presentation of seven national world-class commissioning “must-dos” as four, telling delegates “we’re looking at more freedoms and sanctions for PCTs … the engine room of world-class commissioning will be practice-based commissioning. We’re building the system with you, not doing it to you”.
2008, and David Nicholson told the conference, "in my career as a NHS manager, we tried three times to get increased capacity to under-doctored areas across the country. What happened was that it failed three times. A cosy conspiracy of PCTs and general practice overcame it. This (move to polyclinics) was at the end of that process". Ben Page of DH pollsters IPSOS MORI revealed that 41% of people surveyed think the NHS should offer any drugs and treatments that work, no matter what the costs – and 31% think the NHS should offer any drugs and treatments even if ineffective, no matter what the costs.
We have a standard to meet here.
HPI: It’s often suggested that one result of the market reform mechanisms is that people in the NHS aren’t, in the words of the conference title, ‘all together now’. Is some adjustment needed?
MS: If taken too far, markets and competition can lead to adversarial behaviours, which don’t necessarily produce the best deal for patients.
I’ve said before that I think some competition can act as the grit in the oyster that makes the pearl, and so in my view it can co-exist alongside collaboration
I think health secretary Andy Burnham is getting there, talking in his recent Kings Fund speech about the NHS as the preferred provider, but I notice in David Nicholson’s clarification letter yesterday some very careful wording. It suggests that there is not necessarily the backtracking on competition, which many did start to think from Andy Burnham’s Kings Fund speech.
HPI: Talking about the NHS as a 'preferred provider’ has quite an explicit legal meaning …
MS: In essence, he said where NHS providers are not up to scratch, market testing is acceptable. Two things from this – one is who defines what’s up to scratch, and what is good performance.
The second is a question of the style in which market competition is undertaken. But I don’t see this as backtracking on the potential role for non-traditional providers, be they private, social enterprise, what have you.
I believe that where patients cross sectoral or organisational boundaries, there remains a great need for primary and secondary care clinicians to come together to determine appropriate care pathways, and particularly appropriate handling of transfers of responsibility. Handling these handovers is often an area where the NHS has abdicated responsibility and it could be argued has left the patient or carer to manage things.
So we need to achieve these notions of integrated care, but also of integrated commissioning.
HPI: Of course, the good performance question is simple. It’s whatever the Care Quality Commission tell us it is.
MS: The question of what’s good performance has several dimensions. One is clinical effectiveness; another is efficiency; another is safety (which I think of in terms of risk management); and the fourth dimension, if you can have one, is patient experience.
Some of those four in some circumstances involve trade-offs against each other. Cytotoxic drugs can be very effective but miserable for patients. One current clinical benchmark for managing diabetes is getting HBA1C levels in blood down to 7, yet some people with diabetes may choose to go higher than 7 because of risks of hypo attacks.
HPI: Can you explain what you mean about the style of market competition?
MS: To improve patient care, we need to encourage collaboration and avoid adversarialism - particularly between primary and secondary care.
When I look at effective and mature commercial activity, people tend to get into long-term arrangements with partners. They manage those deals fairly aggressively, but they cover the entire supply chain. Once into a relationship, they work very closely with partners, especially to bring products to customers.
Land Rover and Unipart struck a 10-year partnership arrangement. Initial negotiations were very blunt, direct and each party was trying to get the best deal. But once they were into the relationship, you would not have seen them arguing over bits and pieces round the edges.
HPI: What’s the practical application of all this in a system of payment by results (PbR) and patient choice?
MS: PbR is clearly not results without the commissioning for quality and innovation (CQUIN). But even at that level, both parties – commissioner and provider - must work together to manage demand and activity flows. That has to involve secondary care and primary care clinicians, even if the latter are not the commissioner.
In choice, it’s always difficult. The NHS was founded on notions of the public good and utiltarianism, where you subjugate individual preferences to the common good.
Introducing individual patient choice, and suggesting to everyone they can get their needs met, runs a risk that the least articulate people with perhaps the greatest health needs receive the poorest service.
Add to that issues about efficiency and the role of the taxpayer as stakeholder, having to manage with finite budget, I think you can’t meet every individual’s preference.
So we need all parties in system to collaborate to provide the best service for patients overall.
HPI: But Julian Tudor Hart’s Inverse Care Law already proves that the least well-off get the worst services.
MS: The NHS was without markets from its creation in 1948 until the first Thatcher market efforts. One criticism you could make is that it sometimes seemed to be organised more for those working in it than for those who receive service.
The evidence I’ve seen on inequalities in health and outcomes is that both have become worse, not better, over the last decade. So the way we’ve pursued marketisation of the NHS hasn’t produced the results I think most people want – of reducing inequalities
I don’t think that necessarily makes commissioning, and market mechanisms faulty in themselves. I think what’s been wrong has been the style in which they’ve been conducted.
HPI: It ain’t what you do, it’s the way that you do it?
MS: Yep. Likewise, the issue of management and clinical engagement. Critics who talk of ideas ‘reeking of management’ and ‘management by diktat’ have suggested that we need a return to consensus management.
I remember one hospital where we worked in a management team of one doctor, one nurse, and myself the manager. When that arrangement works well, it can work really well. But when it’s bad, it gets appalling because nobody wants to admit to any deficiency
To overcome that risk, we need responsibility, accountability and authority. Critics claim that leas to authoritarian styles of management, which I would refute. Managers need to take people in their teams along with them, and get best use of those individuals’ management and skills.
HP: What does that mean in practice for managers in PCTs?
MS: You say that almost as an alternative description to a manager in primary care. I’m not sure a PCT is in primary care – their role is to improve the health of their population within their fixed budget, commissioning both primary and secondary care.
What it means is that PCT managers must be leaders, co-ordinators, and generators of enthusiam for common goals towards which people can work towards, rather than people who say, ‘this is the plan - follow me’. We need to get notions of leadership from behind as well as from the front.
HPI: David Colin-Thomé (DH’s primary care ‘czar’) recently said of PBC, “The corpse is not for resuscitation! Progress has been patchy, and there doesn’t seem to be much traction. PBC is not taking off in any systematic way, it’s not seen as a major vehicle for change, to deliver on QIPP (quality, innovation, productivity and prevention).”
MS: If you look at PBC’s growth since it started in 2005, it’s been slower than I and many people would have liked. The recent surveys, especially that by the Kings Fund and NHS Alliance, found there’s still a strong appetite for PBC (about 70% support it), but it’s partly a question of being clear what we’re talking about?
PBC many not be universal, but that does not mean that some form of clinical budget-holding going forward is inappropriate or something to be dismissed. I think the policy direction for PBC is as strong as ever – there’s a greater need for the NHS to manage clinical budgets in the financial ‘cold climate’.
HPI: Are hard budgets for PBC inevitable?
MS: The problem with this is, again, definitions. Delegated PBC budgets from PCTs (where their arrangement is in the PCT’s gift and if they choose not to delegate, they don’t have to), have to go.
At the other end, you could have statutory requirement for PBCers and PBC clusters to be given budgets, which could even be allocated bypassing PCTs.
I think both extremes are equally unsatisfactory. Local arrangements must pertain to local circumstances. So it must be about PCTs and PBC budget holdsers working together, not either-or.
HPI: Did the lack of hard budgets delay or stymie PBC?
MS: What stymied PBC was its not being well-articulated in the beginning. Some PCTs saw it as turkeys voting for Christmas, and likely to diminish their role. Some clinicians did not see any personal or service advantages, and so didn’t get involved.
If the DH had articulated PBC as a partnership brinigng PCTs and clinicians together to define strategic priorities, means, allocations (including budgets and finances), and then agreeing how to performance-manage all that, I think we would be a lot further.
For too long, PBC’s been a “nice to do”; a sideshow as opposed to the central mechanism for achieving priorities and objectives.
For example, the centre’s approach around reduction of waiting times: the centre and SHAs could have asked, ‘how will you use PBC to hit 18 weeks?’ What happened was 2 separate questions: ‘1. how are you going to hit 18 weeks PCTs?’ Oh, and 2. are you doing anything about PBC?’. That was bound to make PBC second in queue for priorities at crunch time.
HPI: What’s the Alliance’s main message at the conference?
MS: All Together Now is meant to infer that we have to think integrated service, commissioning and provision, and to respond to the so-called cold climate financially in a collaborative approach across the different parts of NHS
We’ve also got to have a collaborative approach involving and engaging local communities, stakeholders and patients in making difficult decisions.
HPI: Which leads us to the London question – what if you explain the need to close things, and people still don’t want them to close?
MS: We can’t deflect the responsibility for making tough decisions onto fluffy consultation / engagement exercises. That doesn’t mean we shouldn’t consult and engage. I don’t think local communities or people are ignorant of the need for hard decisions and choices: as individuals, it’s how we all live.
It’s about going out and saying, ‘what can we do by local consensus?’ If a tough decision has to be made, it has to be made. That’s commissioning (or more accurately, decommissioning). Not everybody is going to agree as to every result all the time.
HPI: Is there significant change in the NHS Alliance ‘policy refresh’ you’re announcing, and if so, what does it represent?
MS:It’s back to the style in which we do things. We will say that it’s time to change the culture of NHS, not to play about with hierarchy and redraw new organograms.
At the heart of what we will be saying is a fact: cultural change is more difficult. We’ve spent over 10 years (and it’s not just been a Labour thing; the Conservatives before them were the same) addressing organisational structures as opposed to culture.
HPI: Can you think of any other public sector or public service body that’s changed ita culture staring down the barrel of reduced resources?
MS: I can’t think of any. We are looking at a decade ahead of lower resources than we’ve got used to having. Cultural change in the public sector is hard to implement and see evidence of: what we’ve seen instead has been growth of central strategies, hard-edged management and a lack of trust in the front line.
HPI: How do you see the Conservatives’ policy commitments (hard budgets for PBC, organic PCT mergers, independent board running the NHS) affecting primary care and changes you think are needed?
MS: One of their policy commitments is to ring-fence public health budgets - I get a bit worried by that, because I think you need to give people locally fixed sum to improve health and reduce inequalities, and allow them to choose how they spend it. Ring-fencing from the centre is a contradiction to localism.
A second key point is the independent NHS board (which is often called depoliticisation of the NHS). I think it’s difficult to see how you take small-p politics out of the NHS –how much public money to spend on what area and what might be national priorities are intrinsically political decisions. The danger is that these political choices disappear into smoke and mirrors.
The third issue, of hard clinical budgets, could give an immediate shot in the arm to clinical commissioning, but must be done carefully and couldn’t come in without hard lines of accountability to PCTs who may (and in London , should) be fewer in number.
As a direction of travel, it could go with the culture shift we’re talking about, but they need to articulate a lot more than I’ve heard so far to catch the imagination of people in the service. What they’re proposing could all happen but not necessarily change the experience of patients.