The Re-Re-Re-Reform of the NHS

1. Why reform-itis......irritable bowel syndrome in policy? Ideology: 'public service reform' – 'new' public management; market; privatisation? Normal politics: centralise success and devolve problems? UK/English structures: “because they can” (but...different in Scotland, Wales, N.Ireland...) The Re-Re-Re-Reform of the NHS

2. Ideology • Ideology versus Evidence • At best, we have had policy-based evidence, not evidence-based policy.....usually we have had evidence-free policy.....and at worst we have had evidence-inverting policy (eg the Lansley reforms/Health Act, giving buying power for hospital care to GP-led local purchasers (I use the word deliberately....not commissioners!) • So when it does not work, we start again...and again

3. Normal politics • Secretaries of State want a monument • Policy is sexy; implementation is dull (Taylor; Hyman....on New Labour...but applies to most) • 'New' public management as opposed to 'old' public administration based on outputs, objectives, managerialism, 'systems'.....so susceptibility to “fads, fashions and foolishness” (Marmor) • Buck-passing to lower tiers and 'kiss up, kick down' is the flipside to objective-setting and accountability (ask Auld Nich aka David Nicholson)

4. UK/English structures • Fastest law in the West (except for New Zealand) • Centrally-funded NHS (unlike Sweden)...so turning the financial spigot off and on is in the government's hands....and the same with the policy streams pouring out increasingly... • But same in some other countries (and England has reform-itis more than rest of UK)...so it is culture as well – the 'po-mo' culture of a policy a moment (New Labour should have realised that policy has a life and is not just for Christmas!) • Yet biggest and worst re-disorganisation under the Coalition: “Never Again” will we need re-organisation, said Lansley (after this one!).... see Nick Timmins revealing book with that title

5. Current Reform • Diagnosis one third-right; prescription almost wholly wrong • Diagnosis: New Labour's reforms were costly (half-right), bureaucratic (half-right) and too statist/not market-oriented enough (wrong) • Note New Labour's successes - little, if anything, to do with the market: much-maligned targets brought real successes for patients; some clinical areas improved (cancer; stroke)......half of the 'extra money' (2000/Wanless onwards) went on real things

6. Prescription • More market BUT evaluations of Thatcher market (no benefit) ignored and Blair market (minor benefit, if any, at huge cost) spun • GP 'commissioners' BUT evidence suggests the opposite (AND indeed real planning/commissioning will have to be done at higher level ie Regional offices of NCB) • External regulation rather than strategic (internal) planning and performance management....BUT banking sector? railways? Mid Staffs et al?!

7. Radical or routine? • Upheaval but not new....... PCC before: GPFH 1993-7 TPP 1995-7 PCGs 1998-2001 PCTs 2002-2005 PCTs II 2006-2012 PBC 2006- ?

8. Radical or routine? Cont. • We've had market before: 1991-97 Internal Market: price competition, with adverse effects on quality (Propper et al), where it operated; mostly didn't (ie cost without benefit) 2006- date Blair Market:some see minor benefit (Copper et al; Propper et al) but this is contested AND small compared to cost

9. 'Garbage Can' Theory of Policy • Politics; 'Policy Solutions' (Advocacy); and Problems: separate logics...decision-points • Panics or busi-ness; Ideologies or obsessions; Media-filtered problems....... each reform episode! • Reform is arational, sometimes irrational....rarely rational (if that means securing consensus on problems then designing solutions using evidence)

10. What should we be doing? • Recognising pluralism – voters, doctors, managers etc have different priorities amongst the same values. That is not wrong or changeable. • Recognising tensions between and among objectives: quantity versus quality (despite 'guru speak') targets, quality/safety and finance

11. Lessons from Mid Staffs • Mid Staffs neither 'one bad apple' nor typical...a warning of how national, regional and local policies and cultures can combust • Not a condemnation of all targets but of target-itis and Stalinist enforcement; Ministers blame over-eager attacks on kulaks and grain horders; Nicholson blames people for carrying out his orders; SHA blames external regulators, its predecessors and successors and local Boards....'kick down'

12. Lessons from Mid Staffs cont. • FT enforcement to blame? Auld Nich and Antony Sumara in Staffordshire....a story of blunderbuss rather than rapier (job cuts) • Francis naïve re scapegoating: letting those at the top off scot-free is de facto to scapegoat those lower down the food chain • By keeping Nich to save their blushes at their centrifugal reforms, Ministers have betrayed Francis on Day One (DoH self-protection)

13. So, is the market the answer? • Problem: if care, compassion and altruism have been lost, then it can't be the answer... BUT some (Milburn et al) look for hotel-ratings in a market-place as the answer. • Statism and the market are two sides of the same coin • Altruism, professionalism and performance management need to be combined

14. Some suggestions • Regional, not local, democratic control • Sparing use of key targets to steer not bully • Patient and staff voices restored/amplified...not more bureaucratic reform of PPI but one quality/safety regulator listening to them (Francis) • Choice without market (bureaucracy) • Health and Wellbeing/Public Health as wider remit, with democratic control, with NHS as unequivocally about health CARE not wider health...at least honest?

15. Meanwhile....incompetent government • Lansley's disruptive White Paper, July 2010 • Terrible Health Bill Mark 1, 2010/11, so 'pause' • Lords needed to improve almost-terrible Health Bill Mark 2, 2012 • Incompetent (or deliberate?) Section 75 regulations • So need to be rewritten (Norman Lamb) • What next?