The underperformance of the UK pertaining to healthcare outcomes has generated much support for ‘Healthcare Reform’ (Radix paper No 16, July 2020).
Covid 19 and, more recently, international financial problems have admittedly played havoc with healthcare systems worldwide, but the unalterable fact is that NHS outcomes have compared unfavourably internationally for many years prior. There have been several well-intentioned NHS reforms over the many years, most radically by the Thatcher and Blair governments, but with little sustained impact.
From my observation, unless there is a fundamental change in the culture and style of NHS leadership, architectural or methodological reform is doomed to failure. A point made but not emphasised in the recent Hewit Review.
Crucially, past reforms hardly invoked the headquarters function, presumably as NHS problems were perceived to reside elsewhere. Headquarters at any level must quintessentially lead the shaping of governance to reflect a new social entrepreneurship culture.
Begging the questions, why in the preceding decades has the role of the headquarters never been challenged? And how has the present culture developed? The NHS’ admirable principles were most publicly expressed in the NHS constitution and are often heralded as its culture. Self-evidently that’s not the case as evidenced by increasing negative patient and staff feedback, now coupled with widespread industrial unrest.
I suggest NHS culture emanated from the strong authority culture of its two most visible professional groups – medical and nursing. That cultural dominance is worldwide, but the NHS has compounded the pervasive clinical culture by state ownership within the UK’s centralising political ethos.
The nationalisation model served the country well in the post-World War 2 chaos but arguably has outlived its purpose. Its focus is scarcely on the customer. For the NHS as for the political class, we should heed the words of the late Philip Gould: “Progressive politics must find a way of integrating the schism between the individual as consumer and individual as citizen”.
NHS management style was classically administrative in defending the status quo until the Griffiths report (1983) heralded a managerial age within the NHS. But managers including those of a clinical background largely succumb to the antiquated concept of top-down control.
The best managers in my experience retain the necessary control by ‘letting go’, a scarce skill.
Frustratingly existing NHS leadership is predominantly recognised and valued as being in the gift of formally appointed managers. Reform must ensure a leadership role is fostered, facilitated, and supported for all staff. Without an all-encompassing, positive, enthusing, participatory leadership, what hope is there of a sustained NHS renaissance? ‘The function of leadership is to produce more leaders, not more followers’ (Ralph Nader).
Some suggestions to turn polemic into action?
At the individual level, ALL positional leaders must be chosen not only for their technical knowledge and skills, but also for personal attributes. Past behaviours reveal much.
Throughout all organisations, an identification and support of existing and aspiring system leaders to ensure they own a participatory, collaborating, enabling, adaptive ethos. Adaptive, so essential yet so uncommon, to move speedily into centralising, enabling authority but only in response to a crisis – exemplified by the excellent NHS response to the pandemic. Lay leadership of organisations need to be well chosen to ensure the change in ethos.
Fundamentally, the financing model must also be reformed which should even benefit those who proclaim the current statist model. A long-ago Secretary of State equivalent described the system of finance in the NHS as one that ‘endows everyone providing, as well as using it, with a vested interest in denigrating it’.
Social insurance, widespread in much of certainly western Europe, in comparison offers a more flexible inclusive financing yet underpinned by social fairness. Arguably, because it is not framed by a rigid ideology, it has led to a more pragmatic approach to the delivery of healthcare.
‘What matters is what works’, should be the guiding principle of the underperforming NHS, and the French system for instance is informative. Ultimately, of course there is a caveat; ‘Research on different health and social care funding models found there is no single, commonly preferred solution to achieving sustainable revenues’ (Health Foundation 2017).
In conclusion, some pithy suggestions to facilitate and hopefully embed culture change in the NHS:
- A sound governance of which devolution and trusting relationships are key principles – in contrast to the compliance focused traditional NHS hierarchical governance approach. A useful mantra is: “We need relationships underpinned by contracts, not relationships defined by contracts”.
- Essential governance prerequisites are the acceptance of subsidiarity, two-way accountability between NHS organisations, and at least the partial devolution of NHS budgetary responsibility.
- All well-managed organisations set targets. As an alternative to top-down commissioning and performance management, provider organisations should set their own goals and targets which will be publicly available thereby publicly accountable. A transparent approach will lessen the temptation to set unambitious targets, and publicly available information may create a soft competitive edge to ensure more ambitious targets. The key role of commissioners would be supporting the process and ensuring public accountability, and thereby necessarily lessening their size and complexity.
For such a necessary reform we require, nay demand, political leadership. We really cannot wait beyond the 2024 general election to avert an NHS existential crisis.
