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Editor's blog 24 June 2008: More leadership, less management | Health Policy Insight
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Editor's blog 24 June 2008: More leadership, less management

Publish Date/Time: 
06/24/2008 - 13:09

Why it’s time for front-line leaders to hijack the moment and get involved in NHS reforms

Andy Cowper is the editor of Health Policy Insight (www.healthpolicyinsight.com)

The waiting for Lord Darzi’s review of the NHS is almost over. Speculation has grown and hints have been dropped.

Now all strategic health authorities have published their local Darzi plans, and the big picture is due at the start of next week. Call me a cynic, but some of it might conceivably be leaked to the weekend newspapers …

In true Burlesque fashion, a few bits of Darzi were exposed at the NHS Confederation’s annual conference last week in Manchester. There is to be greater focus on patient experience and outcomes. The importance of GP practice consortia-based commissioning will be re-emphasised. There will be some ‘earned autonomy’ and financial and regulatory freedoms for top-performing PCT commissioners, like those that foundation trusts enjoy.

GP-led health centres (which used to be called ‘polyclinics’) will not be imposed in a one-size-fits-all manner everywhere, but we are likely to see the piloting of virtual ‘integrated care organisations’.

Pilots of new initiatives are good: they let us learn things. The realisation that improving primary care in deprived or under-doctored areas is not necessarily always about new buildings is welcome. The BMA’s and Conservative Party’s campaigns against polyclinics have had effective, if often misleading, impacts. The Government’s presentation of the case for these changes in provision has been poorly made. There is a broader point here about current NHS reform.

Pushing, not pulling

When changing jobs, it’s generally recommended that you should be motivated more by the ‘pull’ factors of the new role rather than the ‘push’ factor of the current one.

Likewise, various recent reports (1,2) have noted the incoherence of the reform programme – despite Health Secretary Alan Johnson’s game attempt in his Confederation conference speech to sell them as an unfolding package, each building on the last and leading to the apex of Darzi.

If we remember that New Labour abolished GP fundholding just as research showed that it was starting to work, and that former NHS chief executive Lord Crisp didn’t even share 2005’s Commissioning A Patient-Led NHS with his director of workforce, this was historical revisionism on a grand scale.

And let’s not mention the NHS University.

There is a lack of a compelling story. The aims of reform have been poorly sold: they have simply been pushed down the system in the guise of ‘P45 targets’. Johnson noted in his speech that his predecessors in the job used an excess of rhetoric about technical mechanisms and means (like ‘contestability’ and ‘mixed economy’), without giving people a sense of the ends: better patient care, higher quality, and more efficient use of the finite NHS budget.

Most people need a story. We live our lives in a conventional narrative fashion: it’s not always linear, but no matter how good the healthcare, there’s always narrative closure.

It’s not all bad

Many aspects of NHS reform have delivered improvements. Without targets, it seems unlikely that waiting times would have been so dramatically - if expensively - reduced. Foundation trusts have remained in the top-performing group surveyed by the Healthcare Commission. (Come to think of it, we now survey trusts’ quality and release the information - inconceivable a decade ago.)

Even imperfect aspects of reform have had upsides. Neither commissioning nor payment by results is even approaching the finished article, let alone ‘world-class’. Yet they have driven attention to important variations in activity and outcomes, and facilitated conversations about changing patterns of provision and ways of working.

Underneath both are the use of data and the measurement of outcomes. Without them, no way would the 2008-9 Operating Framework include the introduction of patient-reported outcome measures (PROM).

Technical aspects are in urgent need of fixing. Commissioning is partly stymied by the need to unbundle the national tariff. Despite some successes like picture archiving and communication systems, NHS Connecting For Health is running years late, and some hospital products simply do not work.

Foundation trusts are not meant to sit there staring at their large surpluses of treasure, like Gollum from Lord Of The Rings. Both a competition regulator and a failure / takeover regime are urgently needed.

Hijack the moment

We’ve reached a point where top-down management strategies no longer feel relevant to real progress. This is a real opportunity. NHS chief executive David Nicholson keeps exhorting us to “stop waiting for permission … look out to communities, not up to Whitehall”.

The SHA Darzi plans claim to be local: so treat them as such. Or hijack them. For commissioning to work, it must be as locally rooted as possible.

If waiting for Darzi has exposed one thing about the current stage of NHS reform, it is that right now, we need leadership more than management. Clinicians in particular can seize a vital moment.



  1. Healthcare Commission and Audit Commission. Is the treatment working ? Progress with the NHS system reform. June 2008
  2. Kings Fund. Making It Happen. June 2008