It lives! The Health and Social Care Act 2012

Having just completed Nick Timmins analysis of the sorry saga of the Health and Social Care Bill 2010-12 Never Again, it’s worth reflecting for a few minutes on our ability to ignore lessons from the non-too-distant past.

According to Timmins’ account, Lansley refused to consider carrying through his proposals without using legislation (widely considered to be a viable, lower impact option) because he wanted to ‘lock in’ the changes in such a way that only further legislation could rescind them.

On one hand, this seems entirely reasonable, given the history of NHS reform and the constant chopping and changing of policy with each new secretary of state and government, not to mention the tendency to recidivism across the service when faced with any change.

Timmins confirms my view that the Act is intended to work like a formal constitution for the NHS.  Whereas the actual NHS Constitution is a sort of Bill of Rights for the public, the Act details the machinery of government including the separation of powers (i.e. Lansley’s desire to distance ministers from the day-to-day management of the service). It can only be changed by amendments and supplementary legislation or by repeal.  All of which will take parliamentary time and debate.

Again, there is some logic in approaching the governance of the NHS in this way, given the damaging effects of constant changes in management and direction.  After all this kind of mechanism works adequately for many national governments and the scale and complexity of the NHS, not to mention its budget, is comparable with any number of states.

The problem I have is that in order to follow this path, Lansley and co have had to re-imagine the system from the bottom up in quite extravagant detail, and in a way that is constrained by existing structures.  So the ‘new NHS’ that Lansley has played Dr Frankenstein to is an elaborate, finely balanced contrivance, but one cobbled together from new and existing components and shot through with a dose of parliamentary electricity to kick it into life.  These are not auspicious beginnings.

What impresses is the shear arrogance and hubris of someone who really believes that they can re-engineer a complex mechanism like the NHS to this degree and in a way that will result in a functioning system largely free of inefficiencies and perverse incentives.

It beggars belief, particularly when set against the abject failure of similar attempts to re-engineer complex systems such as the privatisation of the railways. It’s no small coincidence that that ill-starred venture was rushed through at the fag-end of the last Conservative administration for entirely ideological reasons.

Rather hilarious then that David Bennett, the new chair of Monitor should claim that our experience of privatisation and regulation over the past thirty years means that we’re ideally placed to construct such an edifice. He’s obviously not been paying much attention.  There is little evidence to suggest that this attempt to build a clockwork universe will be any less prone to error that those created for utilities or railways.

But given the railways for context – the sacrificing of safety for profit, the expansion of overhead costs to run a contrived ‘market’, the loss of accountability in a morass of contracts and penalty clauses, the fragmentation of a once coherent system, the opportunity cost of potential investment siphoned off for personal fortunes and shareholder dividends, etc, etc – Lansley represents the ideological hard core who believe that the only way to run public services is via some kind of market mechanism however artificial.  Or in the case of the NHS a ludicrously contrived parody of a market, beset by unfathomably complex inputs and outputs, where nobody will be able to judge success or failure for years if not decades. 

Setting aside the fact that it’s naive to the point of imbecility to believe anyone working largely alone could design such a system successfully, Lansley’s ‘clockwork universe’, the supposed self-perpetuating, self-improving, perfectly incentivised mechanism, is a neoliberal myth.  But it’s a myth every bit as ugly and disturbing as the one Mary Shelley created, and ultimately, it’s just as relevant a comment on the arrogance and hubris of some of those who rise to high public office.

So we need to spend billions on the F35 fighter because...?

The news from the BBC is that 'Defence' minister Phil Hammond has just jetted off to Texas to see one of the new F35 fighter planes we've ordered be taken for a test drive.  At 100M each, they're certainly not cheap, although as always, it's not clear what is included in this cost.  Does it, for example, just cover the initial purchase of the aircraft, or are there additional costs rolled in, like the training of test pilots and maintenance personnel and support for their introduction into operational use.

For a bit of context, the RAF's Tornado aircraft cost around 15-17M each when introduced almost exactly thirty years ago.

Most interesting though were Hammond's words paraphrased by the BBC's Jonathan Beale: 'He said it would give the RAF and Royal Navy "a world class fighting capability" with the ability to "project power" off the two new aircraft carriers now under construction, anywhere in the world.'

In doing this, Mr Hammond is articulating our de facto defence doctrine, which, like the US is based on a degree of global power projection.  Obviously, this isn't in the same league as the US with it's numerous carrier battle groups, thousands of combat aircraft and asprirations to 'full spectrum dominance', but it is effectively a US-lite policy, albeit very, very lite in comparison.

All this raised some questions in my mind because, to my knowledge, defence policy hardly ever gets any real discussion in the media and certainly very little public debate, apart from the pros and cons of being in the nuclear club.  Although that's important for all sorts of reason, it is but one specific issue in what should be a wider debate about how our defence needs are met.

Perhaps more importantly, there is a debate to be had about where our actual defence needs start and finish and where the needs of our political masters to enhance their own importance and give themselves international political leverage start and finish, and whether the costs of maintaining the latter can be justified.  And I mean justified at all in a modern, post colonial world, and not only justified in the current financial climate - although does exert additional pressure.

Now I'm no defence expert, but my view as a citizen is that our defence needs should be based on a systematic assessment of the following:

1. Any known threats we face and any future threats we have evidence for;
2. The defence needs for mainland UK and overseas territorial posessions we have a duty to provide for the defence of
3. The economic benefits to UK Plc of defence spending in terms of supporting employment, hi-tec industry and maintaining strategic industrial capacity

Now I'd be very surprised if a genuine review of that came out in favour of buying into the next generation of US nuclear weapons systems, but it might just about support the purchase of F35s. Although it might equally support the development of less elaborate, indiginously produced military technology. 

But if nothing else, we ought to have some debate about whether, decades after the end of the British Empire, we really want or need to spend vast amounts of money on global power projection to prop up ministerial egos.

Ever decreasing circles

In its infinite wisdom, the DH has published what it calls an 'infographic' which purports to depict the new structure of the NHS. It's available at https://www.wp.dh.gov.uk/healthandcare/files/2012/06/system-graphic.pdf.

For some reason, policy people love this sort of thing because they think it encapsulates the important high-level concepts at work in the re-disorganisation of the NHS.  It's also loaded with some fairly obvious symbolism: patients are placed right in the middle of seven concentric circles (ie patients are 'at the heart' of the reforms), whilst the DH and Lansley form a crust on the outside, perhaps holding everything together (I migth be reading too much into that).

But what does it really show? In practice, it illustrates the vast array of disjointed organisations - and entire solar system of quangos and layers of management than now surround patients and the 'real NHS' (ie the bit that the public actually use) and form an enormous buffer between the public and the secretary of state.

And whe all know what that huge layer of flab is really there for don't we?  Yes, to insulate Mr Lansley's ears from the sound
of falling bedpans.

What's wrong with a relatiionships and accountabilities model

A document hit my inbox recently that has emerged from the informatics transition programme and has the rather wordy title of the Accountabilities and Relationships Model.  Essentially, it’s an attempt to codify the relationships between different elements of the healthcare system (Department of Health, NHS Commissioning Board, Clinical Commissioning Groups, public health etc) and their responsibilities and accountabilities for informatics activity.

I dread to think how long it took to create this, how many hours of meetings and conversations, how many hours of head scratching, writing, revising and reviewing that went into the creation of the final document, because in essence it’s bollocks.

I’m not saying that it’s completely without value, because it does contain some useful information about what some of the organisations are expected to be responsible for and how they should related to each other.  The problem is that any value is drowned in a vast tide of detail and complexity.  It’s not just unhelpful in that it obscures some of the higher level information that people need to understand, but because there is no way at this stage in the development of the organisations that the detail is likely to be accurate.

Unfortunately, this kind of problem is quite common in government where very intelligent people (sometimes but not always management consultants) are given a task to try to clarify and explain something that is quite complex and obscure.  The frequent response is for those leading the work to try to model the detail very accurately, attempting to capture everything that is known about the problem and build it into some kind of coherent whole. 

This can be disastrous for those needing to understand what’s going on and for those trying to communicate this, because what emerges is something frighteningly complicated and difficult to understand.  In this case, my will to live started to evaporate before I’d got through the definition of terms and the initial paragraphs claiming that this was a ‘plain English language’ explanation of the relationships and accountabilities.

Paa and phoey.  It’s nothing of the sort.  In many cases these pieces of work are carried out by very intelligent people, so people for whom complexity is no barrier to comprehension.  Indeed, it might even be something that is appreciated, because these are people that enjoy getting their head around complex problems and ideas.  They are also likely to be the sort of people that have succeeded both academically and in work by demonstrating just how much complexity they can handle.

So we’re left with something that purports to illuminate us to the relationships and accountabilities that underpin the informatics functions in the new NHS but which has all of the simplicity and elegance of the average PhD thesis.  So the problem is, who is actually going to read it?  Who is it going to help and why did anybody spend a whole lot of time and energy in putting together something so patently useless?

Answers on a postcard please.

Accepting criticism gracefully

I've recently come across the writings of the self-styled 'Patient From Hell', the journalist Richard Sarson, or Dick Vinegar as he prefers to call himself on Guardian Healthcare Network.  I'm certainly not going to slag him off here, because he does raise some very important issues with the NHS from the perspective of an older patient, even if I don't agree with many of his solutions to the problems he identifies.

Unfortunately, criticism is one of the issues most of us that work in the NHS struggle with.  I've always thought that the NHS is a bit like our dear old mum in this regard.  Those of us inside the service are allowed to criticise all we like because we do it from the point of view of knowledge, affection and respect.  People outside the service are not coming from that position, so our response is to be defensive instead.

The problem is that there is some legitimacy to insider views on this, after all, those of us working in the NHS day in, day out do know the system better than anyone else and quite often have a clearer idea of its shortcomings.  Generally, patients have a very limited perspective which it's difficult to generalise from, and as anyone familiar with evidence-based medicine will tell you, anecdotes do not constitute good 'evidence'.

But that still does not render the perspective of the individual patient irrelevant - far from it.  If nothing else, these views should be seen as the symptoms that they are - something that we must listen to and understand in order to diagnose the problems in the service that they spring from.

So online platforms like Patient Opinion or NHS choices would be very valuable if they could aggregate patient feedback into something greater than individual anecdotes, and these could be used by the service in a systematic way to address some of the problems with the service.