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Posts Tagged ‘top-down’

The Deputy NHS Chief Executive of England, David Flory, has written a stern letter to all NHS Chief Executives:

The commitment to ensure patients receive treatment within 18 weeks of referral is embedded in the NHS Constitution and is a fundamental part of the NHS Contract. The Government has recently reinforced this commitment. I have personally stressed the need to maintain delivery of RTT through the meetings that were held with you to “sign off” plans for 2011/12. There can, be no doubt about the importance of delivering improved performance on waiting times, particularly for admitted patients.

Stirring stuff. But then he goes and spoils it:

Against this background, it is unacceptable for performance to fall below the expected standards as it did in February and March 2011.

But February and March were the months when the NHS sorted out its long-wait backlog. Here’s the chart:

Watch the dotted line; it shows what’s happening to the waiting list backlog. Back in November, one in ten patients on the waiting list were waiting more than 18 weeks since referral. Then winter struck, the backlog grew, and at the end of January one in ten were over 19.4 weeks. Then in February and March the NHS sorted the problem out, admitting the longest-waiters and cutting the backlog down to pre-winter levels.

But the Department of Health weren’t watching the dotted line. They were watching the solid line instead. This shows the waiting times of the top 10 per cent of patients who were admitted. Clearing the long-wait backlog meant admitting lots of long-waiters, so in February and March the solid line went up, breaching the 18 week target level.

When, in all this, was the performance “unacceptable”? Surely not when the problem was being solved, in February and March? The worst performance was surely in December and January, when the backlog was allowed to grow? This letter is starting not to make sense.

And it goes on:

Recovery plans for the worst performing organisations were requested during the recent planning round. … I expect local support to be made available; contract levers to be applied in a robust way and for swift intervention where the necessary progress is not being made.

The “contract levers” he refers to are in the standard NHS contract. They include Schedule 3, Part 1, section 8, which provides for heavy financial penalties if Trusts admit too many long-waiters. So if a Trust has developed a long-wait problem, it isn’t allowed to tackle it by admitting lots of long-waiters. That’s like trying to solve over-indebtedness by limiting how fast people are allowed pay off their loans.

Surely the Deputy Chief Executive of the NHS in England cannot be encouraging Trusts to sweep their long-waiters under the carpet and ignore them? That would be truly astonishing, and yet… well, here is another shred of evidence.

On the very day he sent his letter, David Flory also published his report “The Quarter” which covers the same time period. On page 19 he lists the twenty-eight “Acute trusts with poorest performance on referral to treatment waits March 2011″.

There is a strange omission from this list of 28 recalcitrants. It is the Trust with the second-longest-waiting patients in England. At the end of March, 31 per cent of its waiting list patients were over 18 weeks, and 5 per cent were over a year. So how on earth did it escape the list? The answer is, this Trust wasn’t tackling its backlog. In March, only 5 per cent of its admissions were over-18-week waiters. That meant it achieved the headline target, and escaped the list of sinners.

Which Trust is it? It’s University College London Hospitals NHS Foundation Trust: the hospital where David Cameron promised not to lose control of NHS waiting times, just a few short weeks ago.  If the Department of Health wants to encourage Trusts to neglect their longest-waiting patients, it is going the right way about it.

There are currently eight measures of waiting times in common use at English acute Trusts.* Bizarrely, a Trust can meet six (and in the short term seven) of these measures, cost-free, by refusing to treat any patient who was referred more than 18 weeks ago.

The odd one out is the most important measure of all: the 95th centile waiting time for incomplete pathways. Of the eight, this is the only measure that looks at long-waiters who are still waiting. But with all those other measures floating around, how easy is it for Trust Boards to home in on the one that really matters?

After reviewing the published Board papers on 165 Trust websites, here is an answer to that question. It looks as if many Trust Boards are pretty much in the dark. Here’s the data:

I managed to find referral-to-treatment (RTT) monitoring data on 91% of non-FT websites and 49% of FT websites. Probably the others examine the data in private session. So the following stats are based on the 111 Trusts’ performance reports that were published, all of them covering data periods in late 2010-11.

The most popular measure monitored was the longest-standing one: the admitted and non-admitted RTT percentage within 18 weeks: 82 per cent of Trusts monitored this.

Next most popular was the admitted and non-admitted median RTT wait: 39 per cent of Trusts.

Then admitted and non-admitted 95th centile RTT wait: 35 per cent of Trusts.

Bottom of the list was the most important measure of all: the incomplete pathway 95th centile RTT wait (invariably accompanied by the incomplete pathway median): monitored by only 25 per cent of Trusts.

Happily, many Trusts also presented data that is not nationally specified, to help their Boards understand their backlog pressures. So if you count up all the Trusts that present data on either the number of patients waiting, or the longwaits, or the over-18 week backlog, or any combination of the three, then that covers 58 per cent of them.

Which means that nearly half of Trusts gave their Boards no information about those patients who were still waiting.

nearly half of Trusts gave their Boards no information about those patients who were still waiting

Does this matter?

It is entirely possible that Trusts were giving their Boards all the information they needed in private session. We have no way of knowing, although most Trusts provide such voluminous performance reports in public that it would perhaps be surprising if even-bigger reports were handed out in private.

What we can rule out is the possibility that, if a Trust doesn’t mention long-waiters who are still waiting, that is because there isn’t a problem. To take a real-life example, here are all the published 18-week performance measures for a Trust with a significant and growing long-wait problem:

The covering paper for this Trust’s performance report contains no commentary on 18 weeks. So if you were, say, the local MP, or even a non-executive director at this Trust, you might assume from this data that everything is alright on 18 weeks.

And yet the underlying picture shows that everything is not alright. The analyses that follow were prepared by us from Department of Health data, and not included in the papers given to the Trust Board. The next chart shows that lots of patients are already waiting more than 18 weeks after referral (look at the dotted red line):

The time trend shows that things have been deteriorating rapidly since last summer (look at the dotted red line again):

I understand that Trusts are in a difficult position, when the “system” is monitoring so many waiting times measures, and when so few of them are particularly useful. On the other hand it is surely worth remembering that, if the waiting list is kept under control, then all the other measures will follow.

So would it not be better for Trusts to focus attention on the measures that really matter, and relegate the other parts of the scorecard to an appendix?

Or, put another way, if the waiting list is blowing out then why not say so?

 

* The median and 95th centile waiting times for admitted, non-admitted and incomplete pathways, plus the percentage admitted and non-admitted within 18 weeks.

(This post first appeared in HSJ blogs)

At the end of July the NHS Chief Executive wrote round with the new Service Reconfiguration rules. His letter formalises the four straightforward tests that the new Secretary of State wants applied to every proposed service reconfiguration:

support from GP commissioners;

strengthened public and patient engagement;

clarity on the clinical evidence base; and

consistency with current and prospective patient choice.

Unfortunately the straightforwardness ends there, and the letter immediately runs into the heaped sands of inherited bureaucracy. The four tests involve commissioners, the public, patients, and (tacitly) the providers concerned, so it is unsurprising that these feature prominently in the letter. You would expect there to be some other process, given the risk and money involved in reconfigurations, but is it really necessary for local commissioners to involve all of the following? In order of appearance in the letter the cast list is:

• Strategic Health Authorities (SHAs)
• Local Authorities (LAs)
• Local Involvement Networks (LINks)
• Office of Government Commerce (OGC) Gateway
• National Clinical Advisory Team (NCAT)
• Independent Reconfiguration Panel (IRP)
• LA Health Overview and Scrutiny Committees (HOSCs)
• Cooperation and Competition Panel (CCP)

The involvement of so many bodies invites a number of criticisms. It is centralising and weakens local decision-making. It delegates complex judgements to bodies who may be expert in their subject but unfamiliar with the local particulars. It causes delay. It confuses the process, and thereby pushes blame back up the system to the Secretary of State. It is expensive.

So expect further reform, as the Coalition Government sets to work simplifying and localising decision-making in the NHS.

Something else is odd, though, and this goes to the heart of the Secretary of State’s new approach. The covering letter says:

The Secretary of State has also made it very clear that GP commissioners will lead local change in the future.

If the Secretary of State wants a market in healthcare, then surely this is going in the wrong direction? In a normal market, customers don’t design products; companies do. So healthcare providers should conduct the market research and consult the stakeholders, and if that goes well then they can design and take the business risk on developing new service configurations.

To be fair, the Secretary of State only walked into his office a few weeks ago, and cannot be expected to reform everything all at once. But, as the evolving policy on service reconfiguration shows, he will have his work cut out to achieve more straightforward and local decision-making in the NHS.

The White Paper was like diving into a British lake: a cold shock, a rush of blood, a feeling of disorientation, and yet all somehow very invigorating and healthy.

The SHAs are being abolished, and they will not be missed. I hope that now all the stories of bullying, extra-legal activity, and jobs for the boys will come out. The SHAs filled a gap in the organisational chart of top-down control, but in practice they neither insulated Ministers enough for Ministerial comfort, nor showed enough willingness to place Government policy above local issues to be genuinely useful to them. Soon they’ll be gone.

The abolition of PCTs has been deftly done. Now that so many PCTs are coterminous with local authorities, many people expected functions to transfer over. Health improvement is a natural transfer. So is the join with social care. Handing commissioning to GPs is also natural; in fact GPs have always done the commissioning because they refer the patients. What’s left? An untidy bag of statutory duties will need sorting out, but they are not enough to justify the PCTs’ existence. So off they go.

What emerges at local level is very different from the longstanding model of monopoly hospital toughing it out with monopsony commissioner. In its place we will have something more like a normal market, with many independent commissioners (the GP consortia) buying care from a much smaller number of hospitals. This is very much to be welcomed.

So what could go wrong? Plenty of course, and it will.

Quality will inevitably become much more variable around the country. So expect a lot of complaints about health inequalities and postcode lotteries, even as overall quality improves.

There also will be complaints about the funding formula, because as it is applied more locally, funding will become more variable. The strength of the assumptions being fed into the formula will start to look shakier on close local scrutiny, and the most likely result will be a simplification of the formula and a reduction in funding variation, amid loud complaints from the biggest losers.

Some hospitals will struggle to achieve Foundation status, and some Foundation trusts will flounder (as is happening already). As noted in an earlier post, many hospitals would work better if their monolithic structures were broken up, to separate the different clinical, operating and property functions within them. As with GP commissioning, this would be no more than a reflection of reality: consultants have always been clinically autonomous, and so it would make sense to rediscover their heritage and become organisationally and economically autonomous again too.

Some GPs will struggle with commissioning, especially in the early stages. But a penumbra of independent-sector services will emerge to provide the specialised services they need. This penumbra will not necessarily be big companies from overseas; their chances were better when they had big government to talk to. No, the GP consortia will be much smaller outfits, and will deal easily with boutique companies (like gooroo) providing very well-targeted expertise for the local situation, with each GP consortium remaining in control as customer.

The separation of GPs’ personal fortunes and their commissioning budgets will be crucial, and difficult. GPs will be establishing out-of-hospital services for conditions like diabetes, COPD, and cardiology, referring patients to those services, and profiting from providing them. It will appear that they are pocketing their commissioning budgets in the process, and there will be sufficient wriggle room in the application of the tariff to blunt protestations that they are simply competing on a level playing field. Handling this blurring of boundaries between commissioning and providing will probably be the commissioning regulator’s biggest challenge.

The regulators will face constant temptation to extend their powers and intervene more. Every scandal and every failure will bring calls for Ministers and the regulators to “do something”. These temptations to recreate SHA-style powers through the regulators will need to be firmly resisted if GP Commissioning is to flourish and providers are to become more responsive. The heavier the hand of regulation, the more everyone will look to the regulator instead of to the patient.

As the feelings of disorientation wear off, and as the detail of these changes becomes clearer, it will start to feel as if there are more problems than solutions in these changes. However, a decade from now, I think we will all look back and wonder how we ever tried to run the NHS as a management hierarchy, defying the reality that doctors were autonomous all the time.

Some years ago, when Gordon Brown was Chancellor, I met his right-hand man Ed Balls at the Treasury to talk about waiting times. It is difficult to imagine now but, back then, inpatients waited up to a year for their operations. Ambitious Ministers wanted to cut this radically.

I advised that a 9 month target would be easy to achieve at minimal cost, but a 6 month target would require substantial extra resources to cut the size of the waiting list. When I stressed the costs involved, I was surprised to find that Mr Balls was unruffled. But of course, back then, I had no idea just how much extra resource they were willing to commit.

Soon after our meeting, the Labour Government opened the spending floodgates and poured money into the NHS, announcing that they effectively wanted to abolish waiting lists. A brutal performance management regime was created with monitoring, threats, naming and shaming. As NHS expenditure trebled from its 1997 level, capacity expanded, waiting lists came down, and the 18-week referral-to-treatment waiting time was (with only a few exceptions) achieved across England.

A report by the Nuffield Trust shows that both money and pressure were necessary in achieving 18 weeks. England achieved short waits, but Scotland, Wales and Northern Ireland did not (despite spending more money and having more staff). In short, both blood and treasure were spent; lots of it. The 18-week target was hard-won.

Times have changed. The money has run out, and a new Government has been elected to clean up the mess. At the Department of Health, the new Secretary of State has wasted no time in shaking things up with a new Operating Framework for the NHS.

The changes to the 18-week target caught the headlines. They are “a very risky message that waiting no longer matters”, said Lord Crisp, a former NHS Chief Executive. “There is now a real risk that there will be a slipping back on the big improvements in waiting times of the last 10 years”, said Chris Ham, the King’s Fund Chief Executive.

So what does the new Operating Framework actually say? The key passage is:

18-weeks waiting times

7. NHS organisations have made significant improvements in access to elective care. Average waiting times now need to be reduced, in line with international experience. Accountability to patients and greater information transparency, through patient choice and the move towards GP-led commissioning, should now make long waits unacceptable. Performance management of the 18 weeks waiting times target by the Department of Health will cease with immediate effect.

8. To maintain progress during 2010/11:

• commissioners should maintain the contractual position and GPs and commissioners will want to ensure that any flexibility to improve access reflects local clinical priorities; and
• referral to treatment data will continue to be published and monitored. Commissioners will want to use the median wait as an additional measure for performance managing providers.

9. Patients’ rights under the NHS Constitution will continue, as will the accompanying legal requirements to ensure that providers are achieving the waiting time rights. We are considering to what extent amendments are required, and if so, we shall carry out a full consultation in due course.

So the brutal performance management regime has come to an end, to the relief of Chief Executives who feared the phone call if the target was breached on their watch. In its place are the NHS standard acute contract (with financial penalties of up to 5% of total elective income for breaching 18 weeks) and the NHS Constitution pledge, backed up by the Waiting Time Directions 2010 (which require PCTs to “take all reasonable steps” to arrange an earlier appointment if a patient complains she is waiting too long).

These measures have the potential to be firm, if they are actually implemented locally. However the experience of the past suggests that, when the going gets tough, too often the easiest option for both commissioners and providers is to let the patients wait. We shall have to wait and see how well this hands-off approach works.

What are we to make of the waiting time statistics mentioned in the revised Operating Framework? First it talks of the need to reduce average waiting times. Average waiting times are directly proportional to the size of the waiting list divided by the rate that patients are added to it (assuming casemix remains constant). So in practical terms that means that waiting lists must rise no faster than referrals. A sensible measure.

But then it asks commissioners to monitor median waiting times. This means that if you take all your patients, and sort them in order of their experienced waiting times, then the middle one (50% of the way down the list) has the median wait. Is this a sensible measure? Consider this: if 20% of the patients are urgent, and the rest are broadly seen in turn, then the median wait (the 50% wait) will be close to the maximum wait. But: if 70% of the patients are urgent, then the median wait will be very short because it is experienced by an urgent patient. So monitoring median waiting times makes little sense at first sight.

It gets worse. Let’s say 55% of patients in, say, plastic surgery are being admitted as urgent patients, so your median wait is in the urgent zone and very short. But you examine the casemix carefully and find that some routine patients are being misclassified as urgents, which is clinically unjustified and causes other routines to wait longer. So you put this right, obeying the contractual guidance that:

9.3 Providers are expected to follow recognised waiting list management practice such as taking patients of equal clinical urgency in turn.

So now only 45% of these patients are being admitted as urgents, which is a more accurate reflection of the casemix. But your median waiting time has increased dramatically, because now it reflects typical routine waiting times instead of urgent waiting times. Improving your scheduling has sent median waits in the “wrong” direction.

So on 18-weeks, the new Operating Framework can be criticised on two grounds. Firstly the lifting of central performance management is likely to cause the target to slip once the financial squeeze takes effect; at worst, maximum waits could rise by one week every week. Secondly, the suggestion that commissioners should monitor median waiting times reflects ignorance of scheduling dynamics; I would suggest that if a centile is to be monitored then it should not be the 50th, but a high one such as the 90th centile. That would reflect more accurately the provider’s success at managing scheduling.

It isn’t a trick question. Surely any major public service should have high-level objectives? Especially one that has been around for half a century and spends £100 billion a year.

But does it?

If you go to the NHS website you will find “core principles”, not objectives as such. When the NHS was founded in 1948 they were:

• That it meet the needs of everyone
• That it be free at the point of delivery
• That it be based on clinical need, not ability to pay

In 2000 these were extended by the Labour Government of the day to:

• The NHS will provide a comprehensive range of services
• The NHS will shape its services around the needs and preferences of individual patients, their families and their carers
• The NHS will respond to the different needs of different populations
• The NHS will improve the quality of services and minimise errors
• The NHS will support and value its staff
• Public funds for healthcare will be devoted solely to NHS patients
• The NHS will work with others to ensure a seamless service for patients
• The NHS will help to keep people healthy and reduce health inequalities
• The NHS will respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

We can tell that these are principles, rather than objectives, by asking ourselves a simple question: could we tell if the NHS failed to achieve them? The answer is: not easily.

In 2010 the same Government published the NHS Constitution, which contains “Seven key principles”, “underpinned by core NHS values”. Although there are overlaps, they are different from the core principles listed above. The Constitution principles were:

1. The NHS provides a comprehensive service, available to all
2. Access to NHS services is based on clinical need, not an individual’s ability to pay
3. The NHS aspires to the highest standards of excellence and professionalism
4. NHS services must reflect the needs and preferences of patients, their families and their carers
5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population
6. The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources
7. The NHS is accountable to the public, communities and patients that it serves

… and the core NHS values were:

• Respect and dignity
• Commitment to quality of care
• Compassion
• Improving lives
• Working together for patients
• Everyone counts

Hmm. We aren’t any closer to something crunchy. What about the more operational guidance produced by the NHS? Does the annual operating framework contain any objectives?

Indeed it does. The current operating framework contains 18 “existing commitments”, for example:

A maximum wait of one month from diagnosis to treatment for all cancers”

and 63 national “vital signs” in three tiers of priority, for example:

NHS Breast Cancer Screening Programme will be extended to all women aged 47–73 by 2012

Much crunchier, but suddenly we’re deep into the detail. These are really sub-objectives created on the basis that, if you achieve them, then they will contribute to your overall objectives. The operating framework does direct us to the 5-year plan for the NHS which “set out a five year vision for the NHS and should be read in conjunction with this NHS Operating Framework which operationalises the first year of that vision”… and so we are straight back to the “vision” again without finding any high-level objectives in between.

Is there anywhere else we could look? How about the legislation that governs the NHS, now consolidated into the NHS Act 2006. Its opening clauses say:

The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—
(a) in the physical and mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of illness.

…which has several qualifications in it, but could become an objective by changing the first line to: “The objective of the NHS is to secure improvement—”. Add an objective to spend within budget, and to secure local political agreement before making changes to services, and we are starting to build something like high-level objectives for the NHS.

Other areas of life have objectives. For a business it might be “maximising owner value over the long term by selling goods or services” (Sternberg); carefully worded, requiring plenty of sub-objectives to make it happen, but a high-level objective nonetheless.

It seems the NHS has chosen not to define its high-level objectives, preferring to leave a wide gap between vision and detail. Which leads us to the next question. Why?

Every year the NHS plans its future activity in great detail. And things never turn out that way. Why? And what should change?

Each year, information professionals in Trusts and PCTs devote enormous effort to the annual planning round. Activity for the coming year is described in intense detail, broken down by HRG, by calendar month, by specialty, between electives and non-electives of various kinds, and not least between each separate commissioner and provider.

Every year, the plans fail to anticipate reality. The finer the detail, the more inaccurate those details are. It’s nobody’s fault, because the demand for healthcare is largely random. But shouldn’t we be wondering what is the point of all this planning? And worrying, perhaps, whether any attempt to stick to such plans might be suppressing innovation and improved pathways of care?

This is an example of a point raised in an earlier post, which contrasted the conventional NHS conception of “strategy” (a kind of long-range plan) with Carl von Clausewitz’s conception of strategy as a way of responding to events in order to achieve an objective. So let’s start with the objective, and then look at the theories that might guide our responses to events.

The objective is fairly straightforward: for each Trust and PCT to balance its books at the end of the year, by planning activity to fit the budget available.

Simple as that. We don’t really care about the activity for Minor Ear Procedures in June, even though we may specify it. And the process we use to draw up our plans reflects our real priorities. Nobody picks through the detail, number by number, estimating from first principles exactly what each number should be. Instead we start with whatever happened last year, and apply some broad assumptions about demand, the tariff, shifts to daycase and outpatient settings, and some particular adjustments if we know that certain pathways are going to change. This is a top-down planning process, disguised in its presentation as being bottom-up. Perhaps, as expert providers of top-down planning services, we at Gooroo Ltd should hesitate to say so, but this is really not the best way to go about it.

A genuine bottom-up planning process would start by defining the bottom. HRGs? Months? I don’t think so. How about GPs? That’s more like it. If our theories about how to achieve financial balance include giving GPs greater control over finances, then the plans should be directly relevant to them. So commissioning GPs need to know in real time how their overall referrals and costs compare with their indicative budgets and with last year. If a particular area is ballooning out, they need to be able to spot it and address it. If an individual patient ended up costing many times more than expected, they need to spot that and challenge it. If a waiting list backlog needs tackling, then activity will need to exceed referrals temporarily. Note that this is not the same as increasing the level of planning detail; it’s about defining the objective at the right level and then being able to monitor and respond as time goes by.

If that is the intention, then where does that leave our planning process?

Firstly, it unhooks the commissioner plans from the provider plans. They do not need to reconcile. Trusts would plan in the same way as any market-driven business: anticipating likely trends and competitive effects, and looking for areas to expand or contract, to break into or withdraw from. If they cannot attract the referrals they were hoping for, then they need to adapt. They cannot expect any plans that commissioners may (or may not) draw up to translate automatically into referrals or income. In short, trusts would plan less and respond more.

Secondly, it pushes genuine monitoring and planning to GPs. GPs need to be equipped to do this, and given an interest in doing so (a big subject, and best left for discussion in another post), but they are certainly capable of doing it well. The role of PCTs in acute commissioning is then to act as a kind of bank manager, supporting GPs in setting, monitoring and balancing their budgets, providing the IT systems and central analysis they need, and helping to administer risk pooling arrangements.

That is very different from the current planning process. But then again, it might turn out to have its uses, even beyond the early days of each new financial year.

The General Election is upon us, and on Friday this country may have a new Government. What should the next Health Secretary do with the NHS? Rob Findlay takes a look at some of the options.

“We won’t cut the NHS”, say politicians of all parties. But after years of rising budgets, everyone knows the coming financial squeeze is going to be painful. So what should the new Health Secretary do to balance the books, without hitting quality and access at the same time?

The main thing the new Health Secretary will need to get a grip on is demand: the big issue for PCTs and Trusts alike. PCTs cannot put a cap on GP referrals (and rightly so). But in the long run PCTs nevertheless have to pay for the all patients that GPs refer, whether they can afford to or not. This dilemma cannot be resolved by the PCTs alone and, as the finances dry up, some will find that they cannot balance the books.

Demand squeezes the Trusts too. Even though the tariff entitles Trusts to payment for the work they do, the NHS contract does not give them freedom to do unlimited amounts of it in any given year. If activity falls short of demand, then all the shortfall ends up on the waiting list and raises pressure on waiting times. Even if the new Health Secretary is minded to go easy on targets, they are unlikely (and would be unwise) to let go of waiting times completely. That means that Trusts are in the demand squeeze as well.

If Trusts cannot control demand, and PCTs cannot control demand, then who can? Conventionally the answer is: the GPs who refer the patients in the first place. But this gives rise to new problems, such as: how do you stop a (hypothetical) unscrupulous GP from lining his or her pockets by simple dodges like delaying Edith’s hip operation or cutting her prescriptions? That was the big objection to GP Fundholding back in the 1980s, and is likely to be the objection again now. I suggest that there are more interesting ways of looking at this problem, which include players other than GPs (notably patients themselves), and that the problems are indeed soluble. But that is a longer discussion that will need to wait for a future post.

For an organisation that is fundamentally about people, the NHS has an unhealthy obsession with buildings and organisational charts. This needs to change. Buildings and organisations are merely services that help front-line professionals care for and advise their patients. In that spirit, acute provision should move closer to the front line, as hospital consultants rediscover their heritage and become consultants again in the true sense. With theatre time costing something like £25 per minute, why do operating sessions so often start half an hour late, and would that still happen if the theatre was being hired out of the consultants’ own pockets? It is hard to deny that there is scope for improvement here, and the concerns about improper self-enrichment are far less pressing because the incentives would be the same as for any existing independent-sector provider. Most of the obstacles that used to stand in the way of more independent consultants have already been removed, including that of the NHS pension, so all that is now needed is a favourable political climate.

All this devolution to the front line would be held back, however, if top-down initiatives were not reined in. There are some obvious action points here: bringing the World Class Commissioning movement to a dignified close, decentralising decisions on IT investment and innovation, and refocusing SHAs into a more supporting rather than controlling role. Likewise the vast numbers of centrally-directed targets should be devolved to become local performance standards, so long as this process happens no faster than the devolution of financial control to the front line. I would make an exception of the 18-week target, however, and retain that as a national requirement in order to focus attention onto demand and pathway management.

Finally, the new Health Secretary should lead the NHS in taking a different view about the meaning of the word strategy. The NHS conventionally uses “strategy” to mean a kind of long-range plan, with all the objectives, the interactions between different players, and the intermediate steps mapped out and described in detail. Such strategies change frequently, which in itself suggests that this approach is not helpful. Instead (following General Carl von Clausewitz) “strategy” should be thought of as comprising: the overall objectives (e.g. better, cheaper healthcare); theories about how those objectives can be achieved (e.g. by devolving financial control to front-line professionals); and then those theories are used to guide both deliberate action and (more usually) the many and continuing daily responses to unforeseeable events. Again, this is a theme we will pick up in future posts, and it applies particularly to the planning process.