The NHS catch-22: will bureaucracy beat reform?

3 May 2016

First an apology – again I am breaking my promise of a further blog on David Cameron’s policy legacy as Prime Minister. That will certainly return next week. One of the joys of this job however is to pick up some “word on the street”, however, which lends itself to an immediate post. (I know a blog on NHS policy is not very “street”. It’s the best I can do.)

The question is whether the NHS can now reform itself in line with NHS England’s (and the Government’s) ambitions and timescale. Not will but can.

Some are saying that the basic pressures on NHS leaders to keep services running are now so great that they don’t have time to engage in the redesign at the heart of the Five Year Forward View. The NHS confronts a catch-22. Leaders are so pressed by financial and performance issues that they don’t have time to seek the changes that will actually ease those pressures.

At one level this has to be taken with a pinch of salt. All managers have to balance the here-and-now with the future. The NHS challenge is so great that managers just have to find a way to find the time. As Kenneth Clarke said the other day of his own time as a reforming Health Secretary, the forces of inertia are strong but they can be challenged.

Nevertheless it isn’t only up to managers. The various health authorities can make their task much easier or much harder, by minimising the regulatory burden on managers or increasing it. A smaller regulatory burden will increase managers’ bandwidth and vice versa.

This is a good moment to remember what is easily forgotten, which is that NHS bureaucracy is vast and overwhelming. Stuart Rose picked up on this in his review of NHS management and leadership (July 2015) (which has also been somewhat forgotten). Lord Rose concluded that: “The NHS is drowning in bureaucracy” (p.30). He said that there were too many regulators, making too many demands for information. As a result management was distracted from the really valuable work: “Management itself is often far too tactical in its behaviour; there is not enough strategic thinking. Great commercial organisations tend to spend more time thinking about the future” (p.30). Lord Rose recommended a rationalisation of the data demands of regulators and oversight bodies, and a reduction in the numbers of the regulators themselves.

One of the ideas raised in Reform’s recent general practice research was that GPs are comparatively lightly regulated. Partly because of that, they have been able to build new “super-practices” that are an entirely different (and better) kind of organisation to traditional small practices. Some suggested that GPs would never have been able to make those changes if they were regulated at the level of hospitals.

Lord Rose pulled his punches. He could have added as problems the number of targets set by Government, still in place despite many pledges over the years to abolish them. He could have mentioned a Ministerial (and Prime Ministerial) attitude which still reserves the right to set direction for the NHS, for example the need to recruit more clinical staff. There is the clearest possible contrast with the Home Office, which has reduced the number of objectives faced by the police to one (to cut crime) and abolished targets on officer levels. (Speaking to Reform in 2014, Theresa May set out a new role for the Home Office now that it no longer aspired to run police forces.)

At the same time, the different professional regulations for the different parts of the NHS workforce are highly complex, baffling for the outsider and themselves a brake on change.

Like the proverbial boiling frog, the NHS has got used to the bureaucracy involved in running a part-nationalised set of organisations employing 1.3 million. A layman like Stuart Rose, without that experience, was rightly astonished. Initiatives such as transparency and Foundation Trusts set a better course but they haven’t stemmed the bureaucratic tide.

The political leadership of the NHS should be pro-management and anti-bureaucracy. At the moment, it’s the wrong way round. Could the NHS function with just one objective: to deliver high quality, high value healthcare? Does the commitment in the Five Year Forward View to “diverse solutions and local leadership” need to go much further, to a wholescale downgrading of central direction beyond that suggested by Stuart Rose? If the NHS needs space to change, this might be a good moment to do it.

Andrew Haldenby, Director, Reform

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