It’s Time for a Few Good Punch-Ups in the NHS

Pritpal S Tamber

December 7, 2012

Some reflections on the speakers at the Cambridge Health Network's Christmas event

The National Health Service in England needs a goal, and a plan on how to get there. Its local leaders should be appreciated more, not constantly pilloried. Primary care is on the brink of failure and needs to truly understand its role within integrated care. And we all need a few good punch-ups to get the right kind of debates going.

So say senior figures of the NHS who met at the exclusive Cambridge Health Network’s Christmas Event. Four of the senior figures were challenged with offering a “short, fun little ditty – their Christmas wish for the health sector in 2013”, as Pam Garside, one of the founders, described it. The audience was then invited to comment and ask questions.

Mike Farrar kicked things off with an impassioned plea for more recognition of the hard work delivered by local NHS leaders, especially chief executives.

This was perhaps not surprising given that he runs NHS Confederation – an organisation that represents NHS Chief Executives – but a recent survey published in the Health Service Journal does suggest that CEOs are feeling pressurised in ways that are not healthy. Many describe a “bullying culture” with one going as far as saying: “A climate of fear pervades the NHS, driven by ruthless governance and accountability regimes that have little interest in achieving anything other than the avoidance of blame.”

Farrar’s specific fear for 2013 is a backlash against managers in light of the findings of the Francis Inquiry into failings at Mid-Staffordshire NHS Foundation Trust. Although the Health Secretary has promised that the recommendations will not add to the bureaucracy faced by managers, Mike’s fear is that statutory regulation of managers will be “another opportunity to pillory managers”.

Up next, complete with flashing alien tentacles (I kid you not), was Stephen Thornton, the Chief Executive of the Health Foundation, an independent charity that looks to improve care in the UK. The tentacles indicted that he was from outer space, the vantage point from which he described how the NHS intends to operate once the government reforms are implemented. At speed he named all the bodies being introduced and how they allegedly fit together. Bewildering is the only way it can be described. “People on the ground are hugely confused”, he warned.

David Bennett, sadly, left his comedy tentacles at home (I hear they’re massive), but the Chief Executive of Monitor offered two positive predictions for 2013. Firstly, although he thinks we’re about to see greater fragmentation of services, he believes this will drive more transparency and hence the desire for more rigour and collaboration. Secondly, he believes we’ll see real progress in the much-needed reconfiguration of services, although he didn’t really say why. Tellingly, he felt that both these positive outcomes would be by accident rather than design.

Transparency featured repeatedly in the fourth and final speaker’s “ditty”. Nick Seddon, the Deputy Director of Reform, a charitable think tank that suggests better ways to deliver public services, hopes to see more openness about such services. In the same breath, however, he worried that the huge amount of government talk about openness was part of the “Law of Inverse Relevance” – the less you intend to do about something, the more you have to keep talking about it – made famous by the satirical television show, Yes, Minister.

Seddon also pointed to the need for a mature discussion about the use of human capital. Delivering health care is personnel-intense but discussions about the better use of people often get emotional – not surprising when it often means pay cuts and redundancies. One group grasping this nettle is the NHS South West Consortium, a group of about 20 NHS Trusts who have decided they’re tired of waiting for national pay negotiations and are clubbing together to decide what salaries to pay across the region. Seddon hopes the Consortium succeeds despite union claims of it being a cartel.

Among Seddon’s other hopes was an echo of Farrar’s request of a proportionate response to the Francis Inquiry, that we might actually do something with the recommendations in the Dilnot review of the funding of care and support and that the failures in south London teach us that incremental improvements to health care are not what we need. He hopes that 2013 will see more outside players innovating in care, perhaps leading to a few good punch-ups – or “disruption” as clever business people call it.

Questions from the audience almost immediately focussed on integrated care. Barbara Young, the Chief Executive of the charity Diabetes UK, asked the speakers if they thought integration would ever happen, especially as she believes ministers have started to understand that the policy levers they’ve developed “aren’t attached to anything”. In reply, Bennett hoped that we’d see more experimentation in integrated care in 2013, although Farrar made the point that somehow our definition of integrated care does not include primary care and that this needed addressing; “Pilots that ignore primary care will not work”, he warned.

This focus on primary care seemed to chime with the audience with a small flurry of comments about “the need to take responsibility for the poor quality of general practice” and the strangely unchallenged assertion that “general practice will fail within a few years’ time”. As heads nodded in agreement we drifted into the familiar waters of having to learn from successful integrated approaches in Valencia, through Kaiser Permanente, and in Scotland. We docked at “weighted capitated budgets administered through primary care to deliver integrated care” and the discussion looked set to close in an all too familiar place.

Thankfully, there were newer voices in the audience (at least new to me). One audience member asked why no speaker had mentioned the promise of digital health. Her fear was that the promise of digital is all too often reduced to using video conferencing as a way to “see” your GP, and the inevitable press reaction to it. One member asked why the discussion only focussed on healthcare when the future has to be about health and avoiding the need for care. Another member said the NHS needed a goal that extended beyond electoral cycles and a development plan for how to get there.

As the Yuletide wine beckoned, I couldn’t help feeling there is a lot of anger in the system. From Farrar’s plea for less pillorying of managers, Thornton’s worries about confusion on the ground, Bennett’s caveat that his positives would be by accident rather than design, and Seddon’s fears of the Law of Inverse Relevance, it seems that 2013 might be ripe for a few good punch-ups. Good. Glove up.

Competing interests: The Cambridge Health Network commissioned this post and approved it before publication. No material changes were requested as part of the process and I think they’re sending me a small token of thanks in the post. I have no other competing interests in relation to this post. 

This post was first published on my original blog, Optimising Clinical Knowledge, and co-posted on BMJ Blogs.

Pritpal S Tamber

I’m a doctor who trained as a medical editor and publisher and now researches and consults on the link between community power and health equity. My interest in community power started when I was the Physician Editor of TEDMED and is explained in My Perspective. I also work as a freelance medical editor and publisher for organisations that want to write high-quality articles and a strategy for their publishing and promotion. Find out more on my About page.

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