5 days Ago By Heather Saul
Is there nothing new under the sun when it comes to NHS reform? This week, the Government has been making announcements that feel eerily familiar. First we had Alan Milburn warning that the health service was “drinking in the last chance saloon”, which he first said back in 1999. Then we had Wes Streeting announcing a rigorous performance management plan for the NHS, using phrases like “no holds barred” and “no more rewards for failure”.
So far, so very familiar, almost as though Labour thinks that serving up the Blair years on a plate will solve the problems facing the service today. In fairness to Streeting and Milburn, those New Labour years did see a lot of radical thinking on healthcare reform and improvements that followed a lot of investment. The reform and money were, then as now, a response to a genuine fear that the NHS was struggling so much that public consent for a taxpayer-funded system might start to fall away.
Read Next Lots more money for the NHS – but no plans for meaningful change Milburn first warned about the “last chance saloon” during a dinner with the medical royal colleges, not long after he had become health secretary. His warning was then followed by his NHS Plan, signed by the presidents of those colleges alongside unions, think tanks and key charities. As with Streeting’s “National Conversation” on the NHS, this list of signatories was designed to show that the reform plan had wide buy-in from across the sector, and so everyone needed to get on and deliver it.
The plan included 300 targets and almost as many uses of the word “change”. In many ways it did lead to the health service improving as a result of political attention and more money. But there are also lessons that Streeting really must learn from that time, because some reheated Blairism isn’t worth serving up again.
In fact, it can be quite poisonous. Streeting’s big “no holds barred” announcement was that NHS trusts would be put into a league table showing their performance on waiting times and other metrics. The best performing trusts will be given more autonomy.
The worst ones will be named and shamed and their managers will either face the sack or won’t see their pay rise as much as those in high-performing hospitals. There will also be a new college training high quality leaders. On one level, greater accountability for NHS management is really valuable.
A culture of excellence (another Blairite phrase there) for leaders in the health service is also a great idea. It just depends what the leaders are being held accountable for, and whether naming and shaming them is going to lead to care improving, or to unintended consequences. We don’t need to speculate about unintended consequences of poorly designed performance management, because we have the example of the Blair and Brown years to refer back to.
Milburn was amused to learn that a regional briefing of some of his hospital reforms had garbled his original “last chance saloon” message so that the civil servant speaking told health leaders that “you’ve got to understand that what the Secretary of State is really after here is to really change the NHS because he keeps saying that the NHS is engaged in a gunfight at the O.K. Corral”.
Ironically, that is how some of the reforms ended up manifesting themselves: the delivery-focused approach meant trust chief executives were hauled in for shouty meetings where they were asked why they hadn’t met key targets. That gunfight culture then bled down all the way through the ranks in hospitals so that even junior nurses were being shouted at because a patient was about to breach the four-hour A&E target. That four-hour waiting target created its own perverse situation where in some emergency departments, a line was painted on the floor and the patient wheeled over it into a notional different department so that they had “left” A&E before the four-hour limit.
A focus on finances rather than governance meant trusts reduced staffing which then led in some cases to the neglect that we saw in the Mid Staffs scandal. Even though the targets and relentless delivery culture were designed with the best of intentions, they did not lead to better patient care. Picking up the NHS and shaking it without giving trusts the resources they need to improve will have consequences, but again, not necessarily the ones Streeting is looking for.
We are getting Labour’s NHS reform plan in a weird sequence. Perhaps the national conversation will yield the missing pieces that will enable a no-holds barred approach to be more like the kind of high performance management you see in a sports team where the coach is shouty but the team are well-fed, conditioned, rested and ready to win. It’s difficult to argue the NHS is in that position right now.
Isabel Hardman is assistant editor of ‘The Spectator’ magazine.
