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Much more than a Mandate
- November 4, 2013 posted by Andrew Wilkinson
The announcement of Simon Stevens’ appointment as the next Chief Executive of NHS England has ended a period of uncertainty over the future leadership of the health service in England. While much commentary in the days since his appointment has focused on his likely leadership style, a more fundamental issue remains at stake – the question of how independently he will be able to chart a course for the NHS.
Away from the publicity around the new Chief Executive, a power struggle has been playing out between the Department of Health and the organisation that Mr Stevens is soon to lead. Back in July, the Department opened a consultation on proposed changes to the Mandate to NHS England. The final version of the Mandate will be due for publication imminently.
Despite its technocratic-sounding title, this consultation is of far greater strategic importance than most. Having created NHS England as an autonomous body charged with the day-to-day management of the health service through the Health and Social Care Act 2012, the Mandate represents the Department’s main lever of control over English health services. It stipulates objectives for NHS England to achieve through its stewardship of £110 billion of public money.
The first Mandate to NHS England was a relatively uncontroversial matter. In the spirit of the Act, it set overarching, multi-year objectives for NHS England. A more interventionist Ministerial team at the Department has, however, shown its propensity to exert closer control of the health service in this year’s proposed Mandate refresh, which included a number of more detailed measures, reminiscent of the planning frameworks of old. Some, such as the emphasis on the vulnerable older peoples’ plan, bear decidedly political fingerprints.
NHS England was, naturally, displeased at the Department’s attempt to turn back the political clock, not least because it ignores the clear intentions of the Act. At its July Board meeting, serious concerns were raised about the financial implications of the new Mandate targets, and fears have been expressed on the ability of NHS England to undertake longer-term planning when changes to Mandate imperatives could occur in line with the electoral cycle. Such interference defeats the point of creating an autonomous body to manage the health service – and does so after only a few months of its existence.
The publication of the refreshed Mandate will therefore reveal the victor in this very public test of strength between NHS England and the Department, with the cards stacked in favour of the latter. As he takes up his role in April, Mr Stevens might well find that he leads a substantially less autonomous organisation than the one that appointed him in October, though it seems unlikely this will come as a surprise to such a seasoned operator.
Great appointment, big challenge
- October 24, 2013 posted by John Murray
The news that Simon Stevens has been appointed to succeed Sir David Nicholson as Chief Executive of NHS England will be greeted by a mixture of jubilation and relief.
Speculation had been growing that the government and NHS England were aligned on Simon’s appointment and when Mark Britnell announced last week that he was not a candidate the die seemed cast.
The jubilation surrounding the news flows in large part from his exceptional qualifications for the job. Simon Stevens’ career began in the NHS and he has strong first-hand experience of NHS management. His time treading the corridors of power will also be invaluable in such a highly political job. Finally, and by no means least, NHS England is a commissioning body pure and simple, working with largely independent providers, primarily by virtue of their foundation trust status. Simon’s experience in United Health should help him and NHS England mediate this new kind of relationship in a way which older hands familiar with the days of command and control have perhaps struggled to address.
The relief relating to the appointment reflects the fact that the cupboard otherwise looked frighteningly bare, with most of the obvious candidates having ruled themselves out long ago. Simon Stevens’ willingness to take what must be a substantial pay cut is also striking, while his decision to dock himself an additional 10% in year one reflects an unusually political mindset.
So a very welcome appointment but a massive challenge on several fronts. Public discourse tends to concentrate on the steadily growing financial pressures facing the NHS as stable funding meets rising demand. Simon Stevens may, however, find that his first task is to sort out the internal workings of NHS England, with often great staff variously exhausted, demotivated and demoralised and a matrix structure still struggling to work.
Fashion that flatters to deceive
- October 9, 2013 posted by John Murray
I have written in the past about the malign influence of confectionery pricing, which makes it very difficult to buy one chocolate bar when the unit price of three is so much cheaper.
The clothing industry has been guilty of a matching misdemeanour in surreptitiously reducing clothing sizes for garments of a given dimension. I have had a 34 waist throughout my adult life. Some years ago, a shop assistant taking my details for a made-to-measure suit made the suggestion (rejected) that we quietly build in an extra inch for the arrival of middle age spread. Today, off-the-peg clothing does the job for us, no questions asked. As a consequence, I am miraculously back in “32” inch jeans, last encountered in student days. My wife, a life-long size 12 has done even better and can contemplate buying size 10 in some shops – only suitable for people of almost Twiggy-like proportions in her youth.
It might be said that all of this does no harm but the mind is very good at registering the evidence it likes while dismissing the rest. Consequently, ignoring the evidence of the scales becomes a little easier when your clothing size remains the same. Furthermore, using reliable sizes as a check on weight is in many ways far preferable to neurotic scale-watching, as daily fluctuations of a pound or two shouldn’t worry us if the clothes still fit.
The only potential benchmark I can find as to how far this process has gone relates to a shop called Evans. In earlier times, the store was called Evans Outsize and, if memory serves me correctly, was specifically intended to provide elegant clothing for women of slightly more ample proportions starting at size 18. Today, Evans starts at 14 and goes up to 32.
I doubt the world of high street fashion will ever confess the magnitude of the deception they’ve perpetrated and it seems unlikely the clock can be turned back – too depressing – but it would be good to know that this particular kind of inflationary deflation has run its course.
A litmus test for Jeremy Hunt
- September 17, 2013 posted by John Murray
When Mark Carney was appointed Governor of the Bank of England, George Osborne went out of his way to claim credit for landing the best candidate for the job, bar none.
When Sir David Nicholson announced that he was stepping down as the Chief Executive of NHS England, Sir Malcolm Grant, its Chair, lost no time in claiming that the job was even more important than that of the Bank’s Governor, emphasising the need to cast the net worldwide in the same way.
The conundrum at the heart of the appointment is the desire to combine fresh leadership with the knowledge and skills needed to navigate the complexities of the NHS, often portrayed as whale-like in shape but made of myriad small fish. This conundrum may have been simplified by the speed with which most of the obvious candidates then ruled themselves out of the running. In consequence, candidates practised in the NHS arts are now thin on the ground, perhaps opening the way for a more radical appointment better fitting the world post-Francis.
The big fly in the ointment is money. It seems likely that several senior departures preceding Sir David’s announcement were at least in part precipitated by the lure of better pay and less political exposure. Andrew Lansley’s Health and Social Care Act was intended in part to ensure that the boss of NHS England rather than the Secretary of State should feel the heat for failings over which he or she in truth has little or no control. Combined with an annual salary in line with Wayne Rooney’s weekly earnings, this makes for a less than seductive proposition, with global appeal probably close to zero. The only countervailing factor might be personal ego but while a strong ego is indispensable for a job of this kind, too much tends to prove a fatal mix for individuals who must from time to time bend the knee to their political masters.
As time goes by, the rule that public servants should earn little or no more than the Prime Minister becomes steadily more corrosive of their quality. It doesn’t seem to have deterred George Osborne from finding what was necessary to secure his preferred candidate. Malcolm Grant doesn’t have that latitude in health but Jeremy Hunt should show his mettle and secure the right package for one of the most important jobs in public life. The alternative could be a re-tread in Sir David’s mould but maybe without quite the same grip!
Has the NHS become unaffordable?
- August 6, 2013 posted by John Murray
The NHS spending freeze is set to continue beyond the next General Election and, bearing in mind that even a freeze is seen as preferential treatment by other government departments, the vultures are circling predicting the demise of taxpayer-funded care free at the point of delivery.
The received wisdom in quarters sceptical towards the NHS is that we are at the top end of what taxpayers are prepared to pay and that the inevitability of increased expenditure will need to be accommodated by, as a minimum, the introduction of more charges for NHS services (eg for GP appointments) and a diminution in those services (eg for more cosmetic procedures) with the private sector stepping in to pick up the slack. More radically, many would like to see the replacement of the NHS by insurance schemes, probably with state support for the most vulnerable.
This kind of outcome is perfectly possible given the essentially political nature of the decision. Whether it would make sense is, however, highly debatable. We know that even after the massive injection of cash under the last government the NHS remains one of the cheapest health systems by percentage of GDP in the developed world and one of the very few to offer universal coverage. We also have good reason to believe that the NHS should be capable of delivering those services much more efficiently given its strategic reach and buying power.
The main reason for doubt concerns the NHS’s ability to convert that potential into the scale of savings required, which dwarf anything better procurement alone could deliver. In particular, the NHS struggles to re-configure services as a result of an unholy and mutually reinforcing alliance between elected politicians and their constituents, which portrays any proposals for change as a direct attack on the NHS rather than a means of securing its future.
The BBC and the NHS were both products of an enlightened but paternalistic age. The BBC remains a major institution but no longer retains the dominance in broadcasting that the NHS possesses in healthcare. As a result we have seen much more choice in broadcasting but have we necessarily seen better value? Certainly there is a cornucopia of sport available nowadays on Sky but the related subscription is more than three times as expensive as the much berated BBC licence fee, which still delivers an astonishing range of viewing for all but the most dedicated couch potato.
Healthcare is not broadcasting – it’s much more important than that. But there are comparisons to be drawn between the funding models for the BBC and the NHS. If nothing else, we should look very carefully before we jump out of the NHS frying pan. One way or another, we will have to pay for the healthcare we want as a country. A well-managed NHS may well continue to provide the least worst model, especially if politicians can be persuaded to desist from knee-jerk reactions to necessary change in the way services are delivered.
Walking without direction
- July 24, 2013 posted by Andrew Wilkinson
NHS England has launched its flagship strategy review, the Call to Action, published to significant fanfare. Major health organisations responded immediately to the rallying cry, with seemingly broad consensus on the need to articulate a vision for a modern health service, centred around the needs of patients, with care delivered in a range of settings, as close to the home as possible, while balancing localism against the need to secure world class clinical outcomes.
Of course, it remains to be seen how successfully the call will result in action on the ground, but it might be worth taking a moment to focus on just one facet of the health service that demonstrates both the urgent need for clearer direction and the practical difficulties in achieving this – the plight of NHS Walk In Centres.
Walk In Centres were introduced in 2008/09 and are intended to provide non-urgent care for a range of minor ailments for both registered and unregistered patients alike, without the need for a pre-booked appointment. In theory, there are a number of advantages to this model. Centres open outside office hours can represent a more convenient route to care for working people, while unregistered patients may be more likely to see the doctor before a health problem gets worse. As such, Walk In Centres should help relieve pressure on A&E departments, a salient consideration given the current pressures on A&E services across the country.
In practice, however, problems abound. Walk In Centres have been closing across the country, prompting Monitor to run an investigation in May this year. There have been concerns that their cost is not sufficiently justified by the extent to which they have alleviated pressures on A&Es.
Visiting a centre, patients might have reason to feel confused. A series of brand new plasma TV screens in pride of place at a centre in Tower Hamlets suggest recent investment – but display the message that waits of up to four hours can be expected. Indeed, only two doctors are practising on a busy Saturday.
The contrast between new investment in an understaffed facility seems to cry out for clear direction from commissioners flowing from a strategic view of a modern health service, clearly articulated by NHS England.
The stakes are high for the Call to Action, but if it can enable greater common sense in the deployment of NHS resources, patients stand to benefit enormously.
Keeping mental health in mind
- July 16, 2013 posted by sarahm
When Stephen Fry recently revealed he attempted suicide in 2012, the public reaction was not only one of shock and concern – we also admired his bravery in speaking out. Of course, this is not the first time the actor and comedian has spoken publicly about his battles with cyclothymia (a form of bipolar disorder). Nonetheless, it was salutary for many of us to hear just how close Fry got to the edge. His actions forced us to reconsider
how we talk (or don’t talk, as the case may be) about mental health.
The importance of mental health has certainly been recognised in the transition to the new NHS commissioning environment. The Health and Social Care Act stipulates that mental health problems are to be treated as seriously as physical health problems; mental health is to be “on a par” with physical health. Clinical Commissioning Groups are required to demonstrate their capacity to commission for improved mental health outcomes as part of their authorisation process. The National Outcomes Framework now includes a notably stronger emphasis on mental health, with a new indicator to measure the success of the Improving Access to Psychological Therapies (IAPT) programme, which offers a range of NICE-approved interventions for people with depression and anxiety. IAPT is showing promising early results as it is rolled out around the country and there is clearly a desire to improve the patient experience of mental health services more generally.
Yet despite improvements to service delivery in recent years, shaking off the stigma of mental ill health remains an unmet challenge. Scroll through the comments section of any online article about mental health and you will see what I mean. As Fry puts it, whether such comments are “ill-natured, ill-informed, ill-willed or just plain ill, it’s hard to say.”
Thankfully, there is good news. The Government has announced that £16 million will be spent over the next four years on the Time to Change initiative, which aims to challenge mental health stigma and discrimination. With recent figures from the Office for National Statistics highlighting that nearly a fifth of adults in the UK have experienced anxiety or depression, the need for a cultural shift in the way we view mental health has never been more pressing. Time to Change and other similar programmes are a good start, but clearly more action is required if we are to see lasting change in attitudes towards mental health.
Encouraging people to talk to someone in their darkest moments will always be difficult. But challenging stereotypes and stigma in the public domain will surely help to create a more comfortable environment for people to reach out for help if and when they need to. Perhaps the most striking response to Fry’s revelation came from Alastair Campbell, who asked “To those asking what Stephen Fry has to be depressed about, would you ask what someone has to be cancerous, diabetic or asthmatic about?” Perhaps we will know there is progress when the first question is no longer asked.
Communiqué win heralds amazing weekend
- July 8, 2013 posted by John Murray
Just as we know lightning in the form of bad luck is perfectly capable of striking twice and more, so the stars occasionally come into perfect alignment and everything seems capable of going right.
After entering the Communiqué Awards last year and winning in the best healthcare policy programme category, there was much debate about whether we should try again in 2013 and in what category. In particular, the Communiqué Awards are incredibly demanding in terms of the quality and quantity of material you need to submit with your entry and therefore not to be undertaken lightly. Nevertheless, we decided to go for best small consultancy and were absolutely delighted to be successful again.
Some awards seem to guarantee subsequent obscurity but Communiqué has a good record of picking winners with a future, not least this year’s overall consultancy of the year, Aurora, who won best small consultancy only last year. We were therefore delighted that the judges, comprising clients as well as competitors (another strength of Communiqué), described JMC Partners as “an amazing agency”, expressing confidence in our “future growth and ambitions”. We now have to prove them right!
Our Communiqué win proved to be a prelude to a truly amazing weekend. Gnarled and weather-beaten, the Rolling Stones conjured up some very special magic in Hyde Park on Saturday, while Andy Murray’s victory at Wimbledon represented the height of gut-wrenching catharsis. We can only aspire to the Stones’ durability but clients will confirm that we are as unrelenting in pursuit of a result as Andy Murray at his most dogged.
Let’s talk about sexual health and local authorities
- June 26, 2013 posted by Sarah Fisher
As the realities of the reformed NHS begin to come into sharper focus many new, or newly powerful, organisations are being put to the test for the first time. One area where the stakes would seem to be particularly high is the commissioning of sexual health services, responsibility for which has been passed to local authorities. The rationale behind this is clear: local authorities’ remit covers many of the determinants of sexual health, including sex and relationships education and social deprivation, and to separate sexual health services from their context makes little sense.
Whether these changes will result in a more ‘joined-up’ approach to sexual health or not, the period of transition was always going to be uncertain, so recent figures that suggest falling condom use and corresponding increases in HIV diagnoses amongst gay men should raise concerns. This trend calls for strong and timely leadership on HIV prevention and any backsliding on the part of local authorities could prove damaging in health terms and for the budget of NHS England, which continues to commission HIV treatment as a specialised service.
Thrown into the mix is the fact that local authorities are political bodies, accountable to a public which may not always see the value of preventative and proactive sexual health services that are primarily used by young people. Not only are sexual health services potentially politically fraught, they are also expensive. Some estimates put the cost of the service at around £700 million per year, a substantial chunk of local authorities’ public health budget. Sexual health will also be vying for attention with other emergent public health crises, including obesity and drug and alcohol services.
All of this drives home the vital role that local authorities’ Directors of Public Health will play once the dust has settled. They will provide leadership on public health issues from a politically neutral perspective but may find themselves assailed from all sides, or as Dr Jeanette de Gruchy (Director of Public Health in Haringey) remarked recently: “it’s an unusual place to be as a professional, having an independent view within a political organisation”. Those with an interest in sexual health will hope that the Directors of Public Health prove to be powerful advocates for the people who rely on sexual health services. They may need to be.
Re-framing the debate on configuration
- June 6, 2013 posted by John Murray
Congratulations to the NHS Confederation, Academy of Medical Royal Colleges and National Voices for publishing their report on re-framing the debate on the configuration of NHS services – Changing care, changing quality – but the headlines on the Today programme promised tantalisingly more than the report delivers.
It is pretty much a given in NHS circles that fundamental change is going to be required to make the NHS a sustainable proposition during a prolonged period of rising demand and zero growth in real budgets. The seductive theory is that patients can get much of their care conveniently closer to home, with the costs far outweighed by the associated savings in the acute sector, enabling the NHS to keep up with advances in technology. A win-win situation if ever there was one, pace any punitive PFI terms and conditions which may be lurking in the shadows.
Parliamentarians are the fly in the ointment, in thrall to a morbid fear of even the slightest tinkering with local hospital services, triggered by memories of Dr Richard Taylor, elected as the Independent MP for Wyre Forest in 2001in response to such shenanigans. The report’s main prescription for greater success in the future is a locally driven approach to change, involving all interested parties and clinically led, making it easier for politicians to row in behind the resultant consensus.
All of this is eminently rational but seems likely to come a cropper all the same. In particular, history shows time and again that opponents of change tend to come late to the game, despite the best laid plans, and are far more vociferous than supporters, at which point politicians take fright. For example, the ground was assiduously laid for the reconfiguration of children’s heart services with the very strongest clinical and patient-related backing flowing from the Bristol Inquiry. All of which counted for nothing when the identity of the threatened services was disclosed or to bowdlerise a local MP in Leeds, if he had to choose between the opinion of experts and of patients in his constituency he’d choose his constituents every time.
So does this lead us to a counsel of despair? It might well unless the mindset of politicians begins to change. That will be no easy feat but perhaps the terms of the debate can be recast to lend a helping hand. In particular, as the new report says, the status quo is not an option. Consequently, opponents of well-founded change are effectively setting themselves against the future of the NHS as well. In short we need to give politicians the wherewithal to be on the side of the angels by supporting change in well-loved NHS institutions. It might also pay to give otherwise threatened hospitals a stake in change by dissolving the unhelpful distinction between primary and secondary care – but that’s for another day!
Views expressed are those of the author, not JMC Partners.