As we are nearing the time of publication for the Government’s 10 Year Plan for the NHS, it is clear that the real difficulty tends to not lie in pointing to a place on a map and naming it your destination, but in explaining how you actually get to where you want to go to. And I am reminded of the old joke where someone is asked for directions, and responds: ‘Well, sir, if I were you, I wouldn’t start from here.’
Because ‘here’ is not a good place: Humongous waiting lists for specialist care, rock bottom public satisfaction with access to general practice, growing burdens of preventable illness, and inexcusable levels of inequality when it comes to how long you can expect to live in good health. And equally importantly, we are low on assets that could help us solve these pressing issues: very little if any fiscal wriggle room, loss of goodwill from the increasingly demoralised workforce, and a muddled and ineffective set of leadership teams and organisations that don’t between them create clarity of mission.
Since taking office last year, the government has been clear on the ‘where’: The need for a more preventive, digitally enabled, community-based health service is undisputed and widely supported by all system partners. It is the ‘how’ we are yet to gain clarity on.
One of the core questions you have to answer when thinking through change is where you locate decision-making power. We have heard conflicting signals from government about whether we are entering an era of centralisation or devolution, with either the centre or places and providers empowered to drive change.
This is indicative of a wider clash of perspectives on how you change and improve public services. Broadly speaking, people either insist on a strong central steer, backed up by rewards and penalties (characterised by critics as ‘targets and terror’ during the early 2000s health policy landscape), or argue for local leadership, coproduction and experimentation that takes into account local variation and circumstance.
A recent IPPR report demonstrates that while targets and league tables can be helpful in driving up activity levels for transactional outcomes (for example knee replacements), they cannot be solely relied upon to perform the shifts we now need to see: towards prevention, equality, and greater, digitally enabled agency for staff and service users. After all, most knee replacements, particularly in working age people, are obesity-related – rather than focusing solely on replacements, we should incentivise obesity prevention, which requires a whole system response.
Where in my view we then often go wrong is that we throw our lot behind local leadership and experimentation and let places figure out how to: combat obesity, build neighbourhood teams and reduce inequality. What this approach tends to ignore is what local leaders will conclude after years of creative and ambitious experimentation: that the many structures, rules and obstacles embedded in our systems of service design and delivery make progress very hard to achieve and even harder to sustain.
Examples from the NHS include:
- Rules around data sharing and information governance that make shared records very difficult
- Short-term and over-specified funding flows that incentivise services to go it alone rather than work in partnership
- Upwards accountability for service delivery can prevent the sharing of risks and responsibility across different providers and sectors.
Local leaders cannot solve these system-wide problems; that is where there is clear need for intervention from the centre. It was therefore extremely heartening to see the Cabinet Office Public Services Reform Programme, which is committed to locally led ‘Test, Learn and Grow’ methodologies, prioritise the need for change at the centre. Its Director Nick Kimber recently published the draft principles guiding their work, which state as their first commitment: ‘We’re here to change the centre, because that is where the rules of the game are set’.
Saying we need to combat over-centralisation is not a naïve assertion that local is good and the centre is bad. To do so would require every Metro Mayor, every hospital CEO and every Voluntary Community Social Enterprise leader to develop bespoke workarounds to overcome data sharing obstacles, regulatory misalignments and short-termism of funding programmes. These are centrally created problems that require change from the centre. It is therefore good to see that the Department for Health and Social Care, Cabinet Office and people working on neighbourhood health are coming together for a workshop in Leeds this week to commence the realignment of relationships through working differently in places and in the centre.
To leave the short-termism, fragmentation, lack of compassion and disempowered staff and users behind its time to build a new relationship between policy and practice, strategy and delivery, and centre and place.
At FGF we plan to focus in the coming months on new models for public service reform, with a particular focus on ‘Test, Learn and Grow’ methodologies – please reach out if you would like to contribute and sign up to our newsletter to be the first to hear of updates.
