Editorial Thursday 13 February 2014: Chain reaction and the Comrade-In-Chief on change

Health policy via 18th-century philosopher Jean-Jacques Rousseau? Why not?

Yesterday, Health Service Journal carried a fascinating article flying a kite for the provider landscape to be reshaped into large chains.

The article is more than slightly opaque, but the thinking behind it deserves consideration. Every cliche and policy zombie is likely to be given its day in the run-up to next May's General Election. Chains of providers, your moment in the policy spotlight has come.

Chains may feel a bit S&M to some, but as I have previously noted, health policy is simply BDSM by other means. Chains also brings us to the French philosopher Jean-Jacques Rousseau's famous treatise 'The Social Contract', which opens with the arresting line "Man is  born free, and is everywhere in chains".

But how do we get to the idea of chains of providers? Sure, other countries do it - France has hospital groups, Germany has chains, South Africa has Netcare ... but this feels very much like HPI's trusty old friend, The Politician's Syllogism in action:
1. Something must be done about the provider sector.
2. Consolidating the provider sector into chains is something.
3. Therefore consolidating the provider sector into chains must be done.

See? The problem is solved. Politics For Dummies!

Except it's not quite that straightforward.

For one thing, we start from where we are today, with the 2012 Act legislating to prevent anti-competitive behaviour.

If there were to be a clearer example of anti-competitive behaviour than turning a diverse provider sector with long-established freedoms for more consistent performers into a few competing big groupings, then it would be to reimagine the NHS as one enormous mega-provider (which of course, is what it actually is).

Incoming NHS England CE Simon Stevens wrote about this for Reform, saying "the first paradox is that, despite the Sturm und Drang over the new Government’s decentralising health legislation, in practice the NHS is once again in a highly centralising moment. In time, the attempt to run the NHS as if it were one big hospital will inevitably again be superseded. Managing that transition – against the backdrop of continuing austerity – is going to require exceptional sophistication in policy design, political stewardship, managerial execution, clinical engagement, and public communication, if a crash landing is to be avoided".

And of course, now clinical commissioners spend £60 billion of the NHS's budget a year, such a change would massively diminish their real options for choice (or creative destruction, as some would have it).

In all seriousness, senior figures in Monitor are only looking at doing this if they think they can break the law fairly blatantly and spectacularly. My experience of senior figures in Monitor is that such an intellectual position is not where they are at.

On your Marx, get set, go! (or 'who's been running this NHS for the past seven years?')
There is much noise about the reshaping of the provider sector, with a contribution from the departing NHS England CE, Comrade Sir David Nicholson in yesterday's Telegraph.

The Comrade-In-Chief declares "the NHS needs to embark on a programme of transformational change to front-line care". Which is lovely.  I wonder who's been in charge of the NHS for the past seven years, and what they've been doing about this?

Comrade Sir David adds, "There are two big reasons why we need to do things differently. Firstly, the NHS has to transform the way it provides care in order to deliver better outcomes for patients". This, he adds, is because of an ageing population with long-term conditions. They obviously didn't exist in the past.

He goes on in this vein: blah blah blah money, blah blah blah living longer, blah blah blah. You get the picture, although you almost certainly wish you didn't.

We get more comedy from the Comrade: "Some will point out that we recently embarked on a major NHS reorganisation, which took effect only last year. But this government’s Health and Social Care Act focused, with good reason, on administrative structures". Right. Administrative structures were causing more inefficiencies than providers? Mmmmm.

You thought you'd had enough of the Comrade-In-Chief? Oh no you hadn't: "these next changes must focus on the practical ways we deliver front-line care in our communities, and they must be recommended, led and built by clinicians on behalf of patients, from the bottom up rather than the top down". [Cough] Lewisham. [Cough, cough] Bournemouth and Poole.

Nicholson asserts "we know centralised, large units, with concentrated expertise and technology, work best in providing the most effective care, so we need to ensure this approach is applied to other parts of the service, for people with very rare conditions, and for significant planned surgery".

Erm, do we? We know there is evidence around stroke, maternity and A&E provision. I had the impression that evidence was more equivocal for planned surgery. Nothing is said about the multi-decade failure to reconfigure paediatric heart surgery; an area where the evidence has been generally agreed for some long time. (Indeed, this failure dating back decades to the era of regional health authorities, and across a plethora of subsequent administrative schema. So the earlier suggestion that the 2010 iteration of administration required urgent reform is, let's be frank, balls.)

Anyway, back to chains. Why might that not work, apart from the hugely obvious anti-competitive bit?

There are lots of reasons. One of the implicit bits of magical thinking that seems to underlie the chains concept is the 'Great Manager' Fallacy, which proposes that troubled provider organisations (whose troubles are often longstanding) have, like that perenially-single friend, 'just not met the right woman/man yet'. This is very unlikely to be accurate analysis. NHS hospitals, particularly those geographically remote or running across multiple sites, are some of the most complex-to-manage organisations that exist.

There are more: if chains of providers are to be geographically close, then they will be on the receiving end of OFT/ Competition Commission attention that will make Bournemouth and Poole's unfortunate and expensive experience look like a walk in the park. If they are not geographically close, then many of the naive assumptions about cost savings that result from being managed as chains won't be there.

The provider sector has done mergers and acquisitions, to very mixed results. For those who affect improvements of the acquiree, like Nottingham University Hospitals and Heart of Birmingham, it takes years and lots of dedicated management resource. And often, it can fail spectacularly (South London Healthcare Trust a case in point of how the merger of three small troubled providers simply makes one enormous troubled providers.)

This is to say nothing of the implications of provider chains for governance. Do we think it would be a good idea for governance, clinical and financial, to be more remote from the delivery of such risky services as hospitals and other services provide?

So why chains? Why now and with such scant evidence they can do anything to address the NHS's problems of quality, outcome variation and cost-effectiveness? Could it have anything to do with this, I wonder? Perhaps this person knows?

Perhaps we should give the last words to Rousseau's second line from 'The Social Contract": "One man thinks himself the master of others, but remains more of a slave than they are".

Or if you want it in musical terms? Try this, or this, or this, or this ...