Managing the NHS: An Unhealthy Attachment to Top Down Control

Dr Tony Hockley writes…
Today’s blog for Politeia by Gerald Malone and this week’s keynote speech on the NHS by Jeremy Hunt display the frustration that ministers feel in dealing with the leaders of the medical profession. Since Bevan’s hurried deal with the doctors when the NHS was created, ministers have found themselves having to pussy-foot around the unions in seeking improvements to NHS service.

Over the years ministers have had to rely on a few bold pioneers around the country to push forward with new ways of working on behalf of patients and hope that these might slowly break the established orthodoxy. Jeremy Hunt spoke of how the priesthood of the NHS will try to rubbish and silence such heretics if they push too boldly in updating the ‘national religion’. Incremental change rather than a change of path is the only successful way forward. But it is a frustrating path to follow. Hunt is the first Health Secretary to openly acknowledge the tendency for ministers to declare an NHS decentralisation but to take central control at the first sign of trouble. It will be interesting to see whether he will now resist this temptation.

In the 1990s ministers often referred to GP fund-holding as the ‘grit in the oyster’ that was enabling a grassroots shift in the focus of the NHS, leading to a Primary Care Act based on the notion that it would allow local experimentation and diversity. Twenty years later a few pioneer providers in the NHS and overseas are providing that grit, as well as a tiny degree of non-NHS competition for NHS contracts. Over time these may change the provider-focused culture of the NHS, but it is by no means guaranteed.

Hunt has announced a healthcare equivalent of the Air Accidents Investigation Branch (AAIB), to push the NHS forward on safety. Part of the strength of the AAIB, however, lies in the competitive nature of the airline industry, and that fact that its users will easily shift from a provider that is seen to be unsafe. Airlines can and do disappear from the market as a result. Airlines nowadays have no option but to take this to heart and focus completely on their customers and their safety. It is hard to imagine how NHS providers can adopt a similar focus without a much more active role for its users and for alternative providers. Save for the experiment with ‘personalised budgets’, however, a reformation of the funding system still seems an unspeakable heresy.


Gerald Malone writes…
More planes crash at weekends when flown by unqualified pilots. Outrage. Public demands qualified pilots fly planes at all times. Pilots cave in. The end.

And so should flow the narrative of the absurd row over whether or not the NHS delivers a top quality service seven days a week when statistics show the probability of death measured at 1 for a Monday admission soars to 1.75 on Sundays. NHS ‘pilots’ (consultants) are, courtesy of Tony Blair’s 2003 capitulation to the Neanderthal BMA, entitled to leave the cockpit at weekends. And they do.

But not only admissions are affected. At weekends ICUs and high dependency units often have depleted manning or close completely. Patients are shunted back towards where they receive an inappropriate level of care. Outcomes for expensive procedures carried out during the week are compromised; not only bad for patients, but a waste of money.

Hypocrisy. This is the same BMA that trawled through my office in the mid 1990s incanting, ‘Consultant-delivered care’. Then, to shore up their work-load, their agenda was to do it all, lead from the front and keep junior doctors firmly in the rear. But it made sense. I mostly agreed.

Jeremy Hunt has reminded them of that obligation. An outraged public should shame them into delivering.


Dr Tony Hockley

Dr Tony Hockley is a Visiting Senior Fellow at the Department of Social Policy at the London School of Economics & Political Science. He is Director of Policy Analysis Centre Ltd and the co-author of Politeia’s Working Systems: Towards Safer NHS Nursing (2014) and A Premium on Patients: Funding the Future NHS (2010).

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