The NHS is going through another seismic reorganisation and the future of the IT agency, NHS Connecting for Health (CFH), is under question. Nobody seems to know where it will fit in the ‘future state’ or even whether it has any kind of role at all. Setting aside the half-arsed way that the government has gone about this reorganisation and the woolly-minded thinking that underpins it (I know, that’s setting a lot aside), a question has arisen about the re-branding of the organisation in order to ditch what is perceived to have become a discredited brand.
This is not new. Part of the legacy of Christine Connelly’s time as Department of Health CIO is that of brand confusion. CC was keen to incorporate NHS CFH into what she termed the DH Informatics Directorate, but found that she couldn’t because the lion’s share of the organisation’s staff are NHS employees. Although CFH is an ‘executive agency’ of the DH, in practice it operates as an NHS body and not as part of DH. So when it came down to it, the Technology Office happily rebranded itself as DHID, but the rest of the organisation remained as CFH in the absence of a clear steer from above.
A large part of wanting to subsume CFH into DHID was connected to the perception that the CFH brand had become contaminated, and on this score, there is considerable ‘form’. Historically, the Information Management Group (IMG) brand had been ditched for similar reasons and the NHS Information Authority (NHSIA) set up to replace some of its functions. The bolt-gun was applied to the metaphorical head of the IA for similar reasons as what was then NPfIT (National Programme for IT) came into being. Even CFH was cooked up in part because the NPfIT brand was starting to look rather tatty after only a couple of years in existence.
Now I want to make it very clear, I hate the name NHS Connecting for Health. Part of that hatred stems from the supposed origin of the name in a competition run at the time which supposedly evaluated a number of options. I don’t believe there was ever a real competition, and this was just a smoke-screen to make CFH employees feel they were all contributing to naming the new baby. I think the name was actually concocted at the highest levels with the very political intention of 1) avoiding any overt reference to information or IT lest it turn off NHS managers and clinicians; 2) get over the idea that we’re working to connect the NHS and what a jolly good idea that is. Frankly this is patronising tosh and anybody with half a brain in the wider service will see it for what it is, and very soon make the connection that CFH is about IT.
On top of that, it’s very true that the brand has become contaminated and that CFH has a very poor reputation across the NHS and with the national media – both specialist and generalist.
So why wouldn’t a rebranding help? Well for a start, the organisation does not have any kind of plan to address its manifold shortcomings, although the even bigger challenge is to carve out a viable niche for itself in the new NHS. So no idea what its role and purpose is, and no plan to tackle its shortcomings, which means no chance that this particular leopard will be changing its spots any time soon. That being the case, a rebranding right now would only serve to generate more cynicism in the service about the IT agency and lead to another contaminated brand that will need ditching in a year or two’s time. To bastardise Shakespeare: ‘a turd by any other name…’.
So what to do? I think the example to follow has to be Skoda. Not that long ago, this was a contaminated brand too – a national joke in this country and elsewhere, despite the firm’s enviable record in rallying and proud history of innovation and engineering skills from way back. So would it have helped to rename the company Adoks back in 1988, or would comedians have just tweaked the punch line to their crap car jokes? Probably the latter.
So instead, they set about changing the company: becoming part of the VW Group and rebuilding it around a couple of basic but well engineered products- the Fabia and Octavia – using VW technical platforms. It’s taken a long time, but twenty years later, nobody is telling Skoda jokes anymore unless they want to look out of date. And there are plenty of their cars on British and other European roads. Czech-mate I’d say.
So CFH should follow their lead – concentrating on a focused set of reliable products and services which it can use to build a new image based on a track record of successful delivery. Then in five years time, when perceptions of the organisation have been changed by actions rather than words, that is the time to consider changing the brand.
Friday 16 December 2011
Informatics - not so very NICE
In the HSJ a couple of weeks ago, Alistair McLellan wrote a very good article in praise of the leadership of NICE, rightly attributing a large slice of that organisation's success to the combined efforts of Andrew Dillon and Michael Rawlins.
The article got me thinking because many of the issues that McLellan raised as contributing to their successful tenure at the head of NICE are exactly those that have been absent from leadership in informatics. You could say the comparison is unfair because NICE was established on a very different footing to either the NHSIA or NHS CFH, but I tend to agree with McLellan that there are things we can learn from their approach.
Firstly, there has been continuity of leadership with both Dillon and Rawlins being in post for more than a decade. Not only that, but they appear to have a cast iron working relationship. We have had three informatics leaders in less than ten years, but each has adopted a different job title and sought a different working relationship with the DH and NHS. In all cases there has been a dislocation between informatics leadership (firmly on the DH side) and the delivery agency (less firmly, but in practice on the NHS side). This is still the case with Katie Davis, now the MD for Informatics.
Secondly, there has been little clarity of purpose, with even the initial four pillars of NPfIT being augmented with additional responsibilities and deliverables. As long as I've been involved there have been problems with basic portfolio management, with senior leadership failing to exert much authority over the organisation's business. The almost constant rounds of questionnaires and forms that programmes have been asked to complete documenting basic details like deliverables and costs seem to indicate not only a senior leadership with no handle on current activity, but also one with no organisational memory.
We have been through a couple of attempts to assert some basic ground rules with the DH, based on the (in my view) flawed assumption that the DH represents the 'head office' of the NHS and therefore the top of the business. It has also been assumed (again incorrectly) that DH officials understand that they need to formally commission the Informatics Directorate to deliver work and to back this up with business cases and funding streams.
I believe that a lot of the woolliness around the fundamental relationships with both the DH and NHS arise from the lack of direct NHS knowledge in the senior leadership team. It's no surprise that at NICE both Andrew Dillon and Michael Rawlins are both long-term NHS people. Informatics on the other hand has had the dubious benefit of 'expertise' from the private sector where the relationship between corporate head office and wider organisation is far more straightforward.
One of the keys to NICE's success and acceptance has been that its guidance is not mandatory, thus avoiding direct conflict with NHS organisation's own decision making processes and autonomy. Contrast that with the heavy-handed and ill informed imposition of IT systems on an NHS with widely varying levels of enthusiasm and commitment.
Finally, there is something to be said for the personal style of the individuals involved. Neither Dillon or Rawlins at NICE are bigger than the organisation itself. They never became the story. Yet both are highly competent media performers striking a calm, measured and precise note in interviews. Again, constrast this with Richard Granger's pugilistic style and infantile management speak, or even Christine Connelly's tortured Scottish accent and excessive control freakery. Katie Davis apprears upbeat, but it remains to be seen whether she can project a more clear-headed and rational voice than her predesessors.
So the bottom line is, yes, informatics could learn a hell of a lot from an organisation like NICE. Unfortunately, there's no indication that those in authority in the DH have recognised this.
The article got me thinking because many of the issues that McLellan raised as contributing to their successful tenure at the head of NICE are exactly those that have been absent from leadership in informatics. You could say the comparison is unfair because NICE was established on a very different footing to either the NHSIA or NHS CFH, but I tend to agree with McLellan that there are things we can learn from their approach.
Firstly, there has been continuity of leadership with both Dillon and Rawlins being in post for more than a decade. Not only that, but they appear to have a cast iron working relationship. We have had three informatics leaders in less than ten years, but each has adopted a different job title and sought a different working relationship with the DH and NHS. In all cases there has been a dislocation between informatics leadership (firmly on the DH side) and the delivery agency (less firmly, but in practice on the NHS side). This is still the case with Katie Davis, now the MD for Informatics.
Secondly, there has been little clarity of purpose, with even the initial four pillars of NPfIT being augmented with additional responsibilities and deliverables. As long as I've been involved there have been problems with basic portfolio management, with senior leadership failing to exert much authority over the organisation's business. The almost constant rounds of questionnaires and forms that programmes have been asked to complete documenting basic details like deliverables and costs seem to indicate not only a senior leadership with no handle on current activity, but also one with no organisational memory.
We have been through a couple of attempts to assert some basic ground rules with the DH, based on the (in my view) flawed assumption that the DH represents the 'head office' of the NHS and therefore the top of the business. It has also been assumed (again incorrectly) that DH officials understand that they need to formally commission the Informatics Directorate to deliver work and to back this up with business cases and funding streams.
I believe that a lot of the woolliness around the fundamental relationships with both the DH and NHS arise from the lack of direct NHS knowledge in the senior leadership team. It's no surprise that at NICE both Andrew Dillon and Michael Rawlins are both long-term NHS people. Informatics on the other hand has had the dubious benefit of 'expertise' from the private sector where the relationship between corporate head office and wider organisation is far more straightforward.
One of the keys to NICE's success and acceptance has been that its guidance is not mandatory, thus avoiding direct conflict with NHS organisation's own decision making processes and autonomy. Contrast that with the heavy-handed and ill informed imposition of IT systems on an NHS with widely varying levels of enthusiasm and commitment.
Finally, there is something to be said for the personal style of the individuals involved. Neither Dillon or Rawlins at NICE are bigger than the organisation itself. They never became the story. Yet both are highly competent media performers striking a calm, measured and precise note in interviews. Again, constrast this with Richard Granger's pugilistic style and infantile management speak, or even Christine Connelly's tortured Scottish accent and excessive control freakery. Katie Davis apprears upbeat, but it remains to be seen whether she can project a more clear-headed and rational voice than her predesessors.
So the bottom line is, yes, informatics could learn a hell of a lot from an organisation like NICE. Unfortunately, there's no indication that those in authority in the DH have recognised this.
Friday 14 October 2011
Primacy of the patient - not the right approach
There has been something of a spirited discussion on the internal NHS CFH bulletin board on who should be considered to be the 'customer' as far as any national shared informatics function is concerned. This takes me back to the demise of the old NHS Information Authority in 2002-ish when I started writing an article that explored this very issue.
My point at the time was that the IA had in effect determined that 'the patient' was the ultimate customer and the needs of the patient ought to drive all decisions – although I'm not sure how explicit the process was that lead to this conclusion.
There is obviously some logic to this – the patient after all is the ultimate user of NHS services and since all tax payers are entitled to use NHS services free of charge, there is a very strong overlap between tax payers and patients. It's a fairly easy step from this proposition to saying that the ministers in the Department of Health, and DH officials more widely in effect have a popular mandate to articulate what 'the patient' and 'the tax payer' want.
Both the IA and the philosophy underpinning the National Programme for IT / NHS Connecting for Health were largely based on this fundamental principle. The problem is that in both cases, this does non seem to have worked terribly well in practice, and the reasons for this need some consideration.
The key problem as I see it is that the concept of 'primacy of the patient' is used by the centre as a pretext for foisting things on NHS organisations that they don't want or feel they don't need. Effectively, it's just a mechanism that ministers and DH use to give legitimacy to any kind of heavy handed, top-down scheme that they think the NHS ought to have.
More charitably and more importantly,it has also been used to try to impose change that makes sense at a larger geographical scale than the individual NHS organisation, but that has little benefit within those organisations. In effect, you're asking NHS organisations to implement some new system that does not actually benefit them, because it works better for the overall system, whilst simultaneously telling them to become semi-independent organisations with more autonomy. The two things just don't stack up.
So, in practice, not only has this irritated local NHS staff (both clinical and non-clinical) who have not felt sufficiently consulted in the decision making processes, it has also provided local NHS leaders with a stick to beat ministers and DH with by allowing them to use non-cooperation and foot dragging on national schemes as a potent weapon.
So what changes are required in order to avoid repeating the mistakes of the past? Well the prescription is broadly the same as it was ten years ago. Any central IT function should be seen for what it is: a producer service; an entity that largely exists to satisfy the needs of NHS organisations as its customers. It's primary purpose is to provide products and services that help those organisations to do their job. If it can't do that, then it has no business being in business.
More problematic, is the other dimension: the central IT function must also be able to satisfy the legitimate needs of the centre for change that benefits the system as a whole and for functionality that it needs to do its job in terms of management and oversight.
Perhaps the most important challenge for the new information strategy being developed through this Autumn will be resolving these two potentially conflicting needs – and that does it in a way that resolves opposing pressure whilst delivering a coherent programme of evolutionary development for NHS IT.
Quite a tall order, but the key decision is abandoning this concept of the primacy of the patient.
My point at the time was that the IA had in effect determined that 'the patient' was the ultimate customer and the needs of the patient ought to drive all decisions – although I'm not sure how explicit the process was that lead to this conclusion.
There is obviously some logic to this – the patient after all is the ultimate user of NHS services and since all tax payers are entitled to use NHS services free of charge, there is a very strong overlap between tax payers and patients. It's a fairly easy step from this proposition to saying that the ministers in the Department of Health, and DH officials more widely in effect have a popular mandate to articulate what 'the patient' and 'the tax payer' want.
Both the IA and the philosophy underpinning the National Programme for IT / NHS Connecting for Health were largely based on this fundamental principle. The problem is that in both cases, this does non seem to have worked terribly well in practice, and the reasons for this need some consideration.
The key problem as I see it is that the concept of 'primacy of the patient' is used by the centre as a pretext for foisting things on NHS organisations that they don't want or feel they don't need. Effectively, it's just a mechanism that ministers and DH use to give legitimacy to any kind of heavy handed, top-down scheme that they think the NHS ought to have.
More charitably and more importantly,it has also been used to try to impose change that makes sense at a larger geographical scale than the individual NHS organisation, but that has little benefit within those organisations. In effect, you're asking NHS organisations to implement some new system that does not actually benefit them, because it works better for the overall system, whilst simultaneously telling them to become semi-independent organisations with more autonomy. The two things just don't stack up.
So, in practice, not only has this irritated local NHS staff (both clinical and non-clinical) who have not felt sufficiently consulted in the decision making processes, it has also provided local NHS leaders with a stick to beat ministers and DH with by allowing them to use non-cooperation and foot dragging on national schemes as a potent weapon.
So what changes are required in order to avoid repeating the mistakes of the past? Well the prescription is broadly the same as it was ten years ago. Any central IT function should be seen for what it is: a producer service; an entity that largely exists to satisfy the needs of NHS organisations as its customers. It's primary purpose is to provide products and services that help those organisations to do their job. If it can't do that, then it has no business being in business.
More problematic, is the other dimension: the central IT function must also be able to satisfy the legitimate needs of the centre for change that benefits the system as a whole and for functionality that it needs to do its job in terms of management and oversight.
Perhaps the most important challenge for the new information strategy being developed through this Autumn will be resolving these two potentially conflicting needs – and that does it in a way that resolves opposing pressure whilst delivering a coherent programme of evolutionary development for NHS IT.
Quite a tall order, but the key decision is abandoning this concept of the primacy of the patient.
Friday 9 September 2011
The smartest man in the room is not always right
There has been a minor debate on the internal NHS CFH bulleting board about the role of choice and competition in the NHS. Specifically, the discussion has centred on what the evidence is to support the government's oft-repeated notion that it will drive up quality.
The reality is that such evidence is pretty thin on the ground. The theoretical underpinnings to the potential role of choice and competition in the NHS come largely from the work of Julian Le Grand, professor of social policy at LSE and one-time senior adivsor to Tony Blair. In spite of the lack of hard evidence, competition and choice have become articles of faith for the current administration. In particular, they are drawn to nudge theory as a means of manipulationg choice to bring about better outcomes.
However, the reality is that re-engineering the entire NHS in order to promote choice and competition between 'any qualified provider' is a massive experiment, based on a largely untested theory and driven forward by an ideologic faith in market mechanisms as the best way of distributing all goods and services.
The problem as I see it, is that even where the introduction of competition and choice are thought to have delivered benefits for 'consumers' the results are pretty equivocal. Also, the introduction of market mechanisms into complex sectors and natural monopolies tends to lead to both a plethora of unintended consequences and a consequent creation of a large and complex regulatory mechanism to try to manage those consequences.
To take some examples. The privatisation of public utilities in the UK was undertaken in the 1980s on the basis that it would lead to more efficient services and keep prices down for consumers. The reality is that, although it can be argued that prices have been kept down, the net result is also included the rise of 'confusion marketing' and complex tariff structures to inhibit the workings of the market. And that's in spite of the significant amount of interia in the system(s) which have seen only a small proportion of consumers switching suppliers.
On top of this, there have been significant strategic problems. Firstly, the privatisation of energy supply helped to create the 'dash for gas' and has made the UK dependent on Russia for its energy. Secondly, the privatised power companies have prioritised profits over investment with the net result that the energy infrastructure of the UK has been run down and is now likely to require government intervention and public investment to ensure it is fit for purpose for the future.
It might be argued that in the case of the railways, the problem was that privatisation was the goal, rather than the creation of mechanisms to promote choice and competition to drive benefits for the paying customer. But there is a real lesson in there about seeking to introduce market based reform into something that is a complex, multi-facetted organisation where quality and safety depend on collaboration rather than competition.
So in sum, the omens for further market based reforms to the NHS are not good. Like many people, I believe that the market based reorganisation of the NHS will at the very least lead to a host of unintended consequences that will probably have a detrimental effect on the quality of patient care and the integration of different parts of the service.
In spite of the academic credentials of Professor Le Grand and the authors of Nudge, I remain to be convinced by hard evidence. To quote US politician Richard Holbrooke: 'The smartest man in the room is not always right.'
The reality is that such evidence is pretty thin on the ground. The theoretical underpinnings to the potential role of choice and competition in the NHS come largely from the work of Julian Le Grand, professor of social policy at LSE and one-time senior adivsor to Tony Blair. In spite of the lack of hard evidence, competition and choice have become articles of faith for the current administration. In particular, they are drawn to nudge theory as a means of manipulationg choice to bring about better outcomes.
However, the reality is that re-engineering the entire NHS in order to promote choice and competition between 'any qualified provider' is a massive experiment, based on a largely untested theory and driven forward by an ideologic faith in market mechanisms as the best way of distributing all goods and services.
The problem as I see it, is that even where the introduction of competition and choice are thought to have delivered benefits for 'consumers' the results are pretty equivocal. Also, the introduction of market mechanisms into complex sectors and natural monopolies tends to lead to both a plethora of unintended consequences and a consequent creation of a large and complex regulatory mechanism to try to manage those consequences.
To take some examples. The privatisation of public utilities in the UK was undertaken in the 1980s on the basis that it would lead to more efficient services and keep prices down for consumers. The reality is that, although it can be argued that prices have been kept down, the net result is also included the rise of 'confusion marketing' and complex tariff structures to inhibit the workings of the market. And that's in spite of the significant amount of interia in the system(s) which have seen only a small proportion of consumers switching suppliers.
On top of this, there have been significant strategic problems. Firstly, the privatisation of energy supply helped to create the 'dash for gas' and has made the UK dependent on Russia for its energy. Secondly, the privatised power companies have prioritised profits over investment with the net result that the energy infrastructure of the UK has been run down and is now likely to require government intervention and public investment to ensure it is fit for purpose for the future.
It might be argued that in the case of the railways, the problem was that privatisation was the goal, rather than the creation of mechanisms to promote choice and competition to drive benefits for the paying customer. But there is a real lesson in there about seeking to introduce market based reform into something that is a complex, multi-facetted organisation where quality and safety depend on collaboration rather than competition.
So in sum, the omens for further market based reforms to the NHS are not good. Like many people, I believe that the market based reorganisation of the NHS will at the very least lead to a host of unintended consequences that will probably have a detrimental effect on the quality of patient care and the integration of different parts of the service.
In spite of the academic credentials of Professor Le Grand and the authors of Nudge, I remain to be convinced by hard evidence. To quote US politician Richard Holbrooke: 'The smartest man in the room is not always right.'
Wednesday 31 August 2011
NHS IT
Today I posted a comment in response to an article about NHS IT by the Guardian's Michael White that appeared in the HSJ. As always, Michael's analysis is perceptive and relevant whilst also managing to be clear and entertaining. His two key point on NHS IT were:
- The public sector does not have the monopoly on failure, but the private sector manages to hush it up.
- Some parts of the National Programme have been a succuess - he cites Choose and Book, although this, and any other possible candidates is/are debatable in my opinion.
My comments were intended to augment these points with some specific issues relating to the strategic failure of NPfIT in spite of any tactical successes. I'm not sure this was wholly successful, but it does help to clarify some long-standing thoughts about the problems with the programme.
The points that you 'gently' make are correct, but I think there are other significant issues that have acted to stymie the National Programme:
Firstly, the arrogance and hubris of key decision makers who want to inflate the scope and complexity of such projects so they can take short-term credit for their visionary leadership (ie the largest civil IT project in the world etc) even if it then fails in the long-term (the NHS failed to deliver).
Secondly, the blind faith of those decision makers in private sector ethos - NPfIT was largely conceived, lead and managed by management consultants or former management consultants. Even today, key parts of NHS Connecting for Health are staffed by these people, some of whom have been retained at public expense for a decade. Whilst creating the impression of intense activity, many of the decisions made by these people have been ill judged and self serving.
Thirdly, the complex organisational dynamics between the DH, its quangos and the many quasi-independent NHS organisations. This results in a constant tension as each organisation seeks to exert control, but has also generated a culture of 'constructive disobedience' in local organisations. It is this that has enabled the leaders of those organisations to resist taking nationally procured systems that benefit the NHS as a whole but may not represent a significant improvement locally.
I'm sure there are many many more points that could be made, but these are three areas where i can't see any prospect of change occuring any time soon.
Friday 26 August 2011
HealthSpace - stuck in policy purgatory
It comes as little surprise that the NHS HealthSpace system si to be reviewed yet again. Anyone familiar with this online 'personal health organiser' (and there are precious few of them) will be aware that it provides very little functionality that is not better provided elsewhere.
Having been thrown together hastily by a government / Department of Health keen to be seen as at the cutting edge of Web 2.0, it has had next to no development or investment, whilst the decision to tie it in to Summary Care Record (SCR) rollout has added and unwelcome political dimention. The unfortunate truth is that the SCR in its current form will not pull ih the crowds for HealthSpace.
So what are we to make of the decision to continue with the service pending another review? Trisha Greenhalgh, the lead reviewer for the UCL team looking into the SCR and HealthSpace is scathing of NHS Connecting for Health for not recognising the system's failings and taking the bull by the horns:
“It shows a bit of a lack of courage from NHS Connecting for Health that it can’t actually look squarely at something that hasn’t taken off and
say ‘well that didn’t work did it? Let’s stop pouring money into it’ – they kind of just left it hanging.”
Whilst the sentiment is quite correct - someone in authority ought to make this decision - the problem is that it's not CFH's call to do so. Saddled with a government policy to deliver the thing, CFH cannot just turn it off without the policy owner in the Department of Health taking responsibility for the decision. As is so often the case, nobody in the DH is actually willing to take that decision.
So we have an impasse: people in CFH know that HealthSpace is a crock, but lack the authority to do anything about it. The people responsible for the policy in DH can't or won't make a decision. So CFH must continue to provide the bare minimum life support for a service it thinks is pointless and rubbish, but DH continue to keep it on the policy roster and occasionally big it up for a soundbite.
Ah, the machinations of government.
Having been thrown together hastily by a government / Department of Health keen to be seen as at the cutting edge of Web 2.0, it has had next to no development or investment, whilst the decision to tie it in to Summary Care Record (SCR) rollout has added and unwelcome political dimention. The unfortunate truth is that the SCR in its current form will not pull ih the crowds for HealthSpace.
So what are we to make of the decision to continue with the service pending another review? Trisha Greenhalgh, the lead reviewer for the UCL team looking into the SCR and HealthSpace is scathing of NHS Connecting for Health for not recognising the system's failings and taking the bull by the horns:
“It shows a bit of a lack of courage from NHS Connecting for Health that it can’t actually look squarely at something that hasn’t taken off and
say ‘well that didn’t work did it? Let’s stop pouring money into it’ – they kind of just left it hanging.”
Whilst the sentiment is quite correct - someone in authority ought to make this decision - the problem is that it's not CFH's call to do so. Saddled with a government policy to deliver the thing, CFH cannot just turn it off without the policy owner in the Department of Health taking responsibility for the decision. As is so often the case, nobody in the DH is actually willing to take that decision.
So we have an impasse: people in CFH know that HealthSpace is a crock, but lack the authority to do anything about it. The people responsible for the policy in DH can't or won't make a decision. So CFH must continue to provide the bare minimum life support for a service it thinks is pointless and rubbish, but DH continue to keep it on the policy roster and occasionally big it up for a soundbite.
Ah, the machinations of government.
Monday 25 July 2011
Cutting down on bureaucracy and waste - goverment style
The news has come down through CFH channels that there will be additional processes in place for 'major projects' instituted by the Cabinet Office. Essentially, projects worth over £35M or considered 'novel, contentious or repercussive' will have to go through an additional authorisation process and have even more reporting overheads than they do already. This is in addition to the bureacratic overheads imposed by OGC Gateway review and the whole process of developing complex business cases and gettiing them signed off by the Treasury.
So, from a government committed to cutting bureaucracy we have .... even more bureaucracy. No surprises there then, because the reality is that the needs of the centre to exercise control and provide accountability constantly trumps any desire to cut bureaucracy or allow any level of delegated authority. The frustrating thing for the humble project manager trying to negotiate this labrynthine morass of opaque process is that there is never any attempt to integrate the new bureaucratic hurdles into the existing ones.
So even though the OGC has been absorbed into Cabinet Office, and the Major Project Authority is a collaboration between the Cabinet Office and the Treasury, there will still be completely separate processes for OGC Gateways, MPA approval and Treasury sign off. And there will need to be more people in CFH to help negotiate all of this.
Plus ca change.
So, from a government committed to cutting bureaucracy we have .... even more bureaucracy. No surprises there then, because the reality is that the needs of the centre to exercise control and provide accountability constantly trumps any desire to cut bureaucracy or allow any level of delegated authority. The frustrating thing for the humble project manager trying to negotiate this labrynthine morass of opaque process is that there is never any attempt to integrate the new bureaucratic hurdles into the existing ones.
So even though the OGC has been absorbed into Cabinet Office, and the Major Project Authority is a collaboration between the Cabinet Office and the Treasury, there will still be completely separate processes for OGC Gateways, MPA approval and Treasury sign off. And there will need to be more people in CFH to help negotiate all of this.
Plus ca change.
Monday 27 June 2011
Au revoir Christine
The news that Christine Connelly has resigned as the DH Chief Information Officer was met with a similar kind of weeping and waling that greeted Richard Granger’s exit more than three years ago. At least CC had the decency to announce her departure in a more conventional way to Mr Granger’s ridiculous ‘transitioning off’ statement. Although the formal word is that she is resigning, both the speed of her departure and the word on the bush telegraph seem to indicate that her continued input was not required by the powers that be. For that you can read that Sir Dave did not want her on board in the Commissioning Board.
As for her legacy, it’s difficult to work out exactly what that will be. On EHI I suggested that the Interoperability Toolkit or ITK was about the only significant thing, given that we still have failing LSPs and not much else to show for her three years at the helm. I’d go further and suggest that there is even less of a sense of direction than there was when she took over. This I attribute to her private sector background and her expectation that IT strategy would be driven from the top down with the DH taking responsibility for dictating the needs of the business.
This ‘corporate’ view of how things ought to work with the DH acting as the head office of the NHS is still very prevalent within CFH, indeed the entire Delivery Framework is designed around this principle. Unfortunately, the relationship between the DH and the NHS is far from that simple and ownership of IT projects, authority and accountability are far messier. In my view this is key to both Richard Granger and Christine Connelly’s failure at the head of NHS IT, because without an appreciation of the complex relationships and power structures in the DH / NHS world, it’s impossible to come up with a strategy that has any chance of success.
In this, CC hardly got off the starting blocks as I expect she was waiting for a clear steer from the NHS board as to what the IT priorities should be in the context of the business priorities. Positioning yourself as subordinate to the business in this way may win you brownie points in industry, but in DH /NHS world it makes you look clueless and like you don’t have an agenda.
Like everything else this is pure speculation, but that’s my guess as to why she’s making such an abrupt exit.
Thursday 16 June 2011
On opposing the current NHS reorganisation
In this week's HSJ, former Labour advisor and all-round competition evangelist Paul Corrigan hits out at opponents of the government's market-based reforms to the NHS accusing them of defending their own vested interests. It might be just me, but I think I detect a hint of tetchiness about his comments and the potential for the modifications to the Health and Social Care Bill driven by the NHS Future Forum to undermine the holy grail of competition. To true believers in the 'Gospel according to St Julian (LeGrand)' like Paul, this is heresy.
Unfortunately, looking at other examples of privatisation and market-based reforms over the last 30 years, there's ample evidence for scepticism about the supposed benefits, and some clear alarm bells about the potential negative consequences of these reforms. To get a full appreciation of the issues here, you need to consider the two parallel processes that have operated in many of the privatisations that the UK government has undertaken. On the one hand, you have the transfer of ownership of publically run companies, either through stock market floatation or contract letting processes. Secondly, there is the creation of complex artificial markets and regulatory frameworks within which these newly privatised firms operate.
The NHS reforms tick both of these boxes to a greater or lesser extent. Certainly there has been an increasing willingness to contract out more and more NHS services so they are 'delivered' by the private sector under NHS branding. The coalition government's interest in encouraging NHS organisations to become mutuals, is and arguably more palatable version of the same thing.
But even before this, the last Labour government were heading down the road of creating an artificial market in which individual NHS organisations competed for business, the idea being that this would tap the supposed benefits of competition and markets (driving down costs, stimulating innovation, driving difficult decisions by reduction to a financial bottom line), with regulation offering protection against the negative elements.
The problem for me is that government has a poor track record in devising these artificial markets, particularly in more complex industries where the twin pitfalls of perverse incentives and unintended consequences beckon. You only have to look at the debacle of rail privatisation in detail to see the
potential for disaster. On top of that, government's track record on managing the healthcare sector generally is pretty poor. Part of the attraction of marketisation is the frustration felt by governments in trying to exercise control over a large, complex and unweildy beast like the NHS. The discipline of the market is a seductive model with its promise to automate some of the messy business of managing the beast whilst also insulating politicians from the consequences of change.
However, in attempting to redesign the systems they need to be mindful of Marios Papadopoulos' analysis of surgical patients using chaos and complexity theory, which if nothing else helps to illustrate the difficulty in predicting the outcomes of specific inputs. Papadopoulos' characterisation of the NHS as a 'complex system on the edge of chaos' rings so true to many of us with a reasonable amount of NHS experience.
So my response to Paul is that far from being concerned with defending our cosy little fiefdoms, those of us speaking out against the reforms are doing so from the following viewpoint:
Unfortunately, looking at other examples of privatisation and market-based reforms over the last 30 years, there's ample evidence for scepticism about the supposed benefits, and some clear alarm bells about the potential negative consequences of these reforms. To get a full appreciation of the issues here, you need to consider the two parallel processes that have operated in many of the privatisations that the UK government has undertaken. On the one hand, you have the transfer of ownership of publically run companies, either through stock market floatation or contract letting processes. Secondly, there is the creation of complex artificial markets and regulatory frameworks within which these newly privatised firms operate.
The NHS reforms tick both of these boxes to a greater or lesser extent. Certainly there has been an increasing willingness to contract out more and more NHS services so they are 'delivered' by the private sector under NHS branding. The coalition government's interest in encouraging NHS organisations to become mutuals, is and arguably more palatable version of the same thing.
But even before this, the last Labour government were heading down the road of creating an artificial market in which individual NHS organisations competed for business, the idea being that this would tap the supposed benefits of competition and markets (driving down costs, stimulating innovation, driving difficult decisions by reduction to a financial bottom line), with regulation offering protection against the negative elements.
The problem for me is that government has a poor track record in devising these artificial markets, particularly in more complex industries where the twin pitfalls of perverse incentives and unintended consequences beckon. You only have to look at the debacle of rail privatisation in detail to see the
potential for disaster. On top of that, government's track record on managing the healthcare sector generally is pretty poor. Part of the attraction of marketisation is the frustration felt by governments in trying to exercise control over a large, complex and unweildy beast like the NHS. The discipline of the market is a seductive model with its promise to automate some of the messy business of managing the beast whilst also insulating politicians from the consequences of change.
However, in attempting to redesign the systems they need to be mindful of Marios Papadopoulos' analysis of surgical patients using chaos and complexity theory, which if nothing else helps to illustrate the difficulty in predicting the outcomes of specific inputs. Papadopoulos' characterisation of the NHS as a 'complex system on the edge of chaos' rings so true to many of us with a reasonable amount of NHS experience.
So my response to Paul is that far from being concerned with defending our cosy little fiefdoms, those of us speaking out against the reforms are doing so from the following viewpoint:
- We are not convinced that the reorganisation of the service will deliver the promised benefits
- We believe the reorganisation will waste time, money, goodwill and undermine patient care
- We believe the reorganisation of the service will have significant negative unintended consequence
- These unintended consequences are likely to include increased (if better hidden) management costs and bureacracy and an undermining of integration and cooperation
- We believe that the reorganisation will lead to reduced terms and conditions for staff and the fragmentation of the NHS as an employing organisation and
- that this will have a detrimental effect on service delivery in the longer term.
- We are not convinced that the reorganisation will allow ministers to distance themselves from their responsibilities for the NHS
- We believe the reorganisation will lead to an increase in costs and an overall decline in value for money for the public as an more money is siphoned out of the system for private profit
Friday 10 June 2011
To everything there is a season.....
Well, I'm not sure that the PM will be choosing That Byrds Track for his next outing on Desert Island Discs, but the climb downs are coming thick and fast this week. Although the No10 spin machine will be working overtime to put some positive gloss on things, there's more than enough justification for many of the criticisms that have been levelled at the government - that the proposed reforms have not been thought through fully, that Landsley didn't consult widely enought before drafting the White Paper and that the subsequent legislation is poorly drafted and dangerously muddled.
In light of this, it was interesting to hear the Laurence Buckman on the Today Programme this morning pressing home the advantage and demanding further changes including the dropping of the requirement for competition. Not very likely considering the broad political consensus that competition is inherently good as well as it being a Conservative article of faith.
So, whilst this is a turn of sorts, it's not a U-turn - it's more like a poorly controlled swerve that may yet leave the coalition limousine embedded in the lamp post of history.
In light of this, it was interesting to hear the Laurence Buckman on the Today Programme this morning pressing home the advantage and demanding further changes including the dropping of the requirement for competition. Not very likely considering the broad political consensus that competition is inherently good as well as it being a Conservative article of faith.
So, whilst this is a turn of sorts, it's not a U-turn - it's more like a poorly controlled swerve that may yet leave the coalition limousine embedded in the lamp post of history.
Wednesday 8 June 2011
Track record
David Cameron has just announced that the government will revise their plans for shaking up the NHS: a little tweak here, and little tweak there. Unfortunately Mr Cameron's party has form in this area. JacquesO's livre du jour is Christian Wolmar's book on rail privatisation and although there are huge differences, there are things that chime with the current debate in healthcare (I know I'm not the first to make this comparison).
The first issue is the unquestioned assumption that competition of any sort is an unalloyed good and any opportunity to introduce it should be taken. This overrides any rational or systematic assessment of whether competition actually makes sense in the context in which it is introduced.
The second is the presumption on the part of ministers and civil servants that they can contrive a highly regulated, pseudo market in a complex domain of which they have little real knowledge that actually works, and delivers the stated benefits without too many disbenefits or perverse incentives. Certainly the rail comparison indicates that the challenges of such a task is beyond even civil service high flyers.
The third is the unseemly haste with which poorly thought through policy ideas have been developed and converted into similarly poorly drafted legislation, the controversial nature of which results in much chopping and changing for the sake of political expediency.
The fourth is the impression (correct in the case of railways) that the government is making things up as it goes along.
Given this context it's hard to have any confidence in Mr Cameron's statements on the NHS, however well intentioned. As for the actual results on the ground of Mr Lansley's botched reorganisation, it's anyone's guess.
The first issue is the unquestioned assumption that competition of any sort is an unalloyed good and any opportunity to introduce it should be taken. This overrides any rational or systematic assessment of whether competition actually makes sense in the context in which it is introduced.
The second is the presumption on the part of ministers and civil servants that they can contrive a highly regulated, pseudo market in a complex domain of which they have little real knowledge that actually works, and delivers the stated benefits without too many disbenefits or perverse incentives. Certainly the rail comparison indicates that the challenges of such a task is beyond even civil service high flyers.
The third is the unseemly haste with which poorly thought through policy ideas have been developed and converted into similarly poorly drafted legislation, the controversial nature of which results in much chopping and changing for the sake of political expediency.
The fourth is the impression (correct in the case of railways) that the government is making things up as it goes along.
Given this context it's hard to have any confidence in Mr Cameron's statements on the NHS, however well intentioned. As for the actual results on the ground of Mr Lansley's botched reorganisation, it's anyone's guess.
Subscribe to:
Posts (Atom)