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.

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:

1. We are not convinced that the reorganisation of the service will deliver the promised benefits
2. We believe the reorganisation will waste time, money, goodwill and undermine patient care
3. We believe the reorganisation of the service will have significant negative unintended consequence
4. These unintended consequences are likely to include increased (if better hidden) management costs and bureacracy and an undermining of integration and cooperation
5. 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
6. that this will have a detrimental effect on service delivery in the longer term.
7. We are not convinced that the reorganisation will allow ministers to distance themselves from their responsibilities for the NHS
8. 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

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.

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.