At the risk of over-extending a metaphor, is it possible to change the mood music in health policy without a touch of discord? Judging from the debate about market reform, it would appear not. Health Secretary Andy Burnham’s assertion that the NHS is the government’s ‘preferred provider’ of health services undermines competition and constrains commissioners’ flexibility, his critics claim.
However, the government’s shift of tone on the use of markets in healthcare should not be read as a change of direction. Rather than protesting about the political slogans, commentators and leaders should focus on the practical implementation of smart reforms that engage staff in the challenge ahead.
We are heading into the most challenging period in the history of the NHS. All quarters recognise that an acceleration of change is needed to prepare for lean times ahead, and that this is going to impact on frontline staff as well as back offices. Almost all efficiency improvements – from productive wards to lean pathway redesign – will need the co-operation and leadership of everyone in the NHS team. It is in this context that Burnham has felt now was the time to change the mood music of system reform, from ‘Live and let die’ to ‘All together now’.
The debate that this has sparked risks generating a lot of heat but little light for those making decisions locally. Ironically, protestations against a perceived backsliding on reform risk exaggerating the impression of a change in direction. Opinion leaders would do better by interpreting the lyrics than attacking the style.
Mood music matters. In such a complex system, practitioners’ (and investors’) interpretation of what they think they should be doing comes as much from the high-level signals as it does from the detailed guidance.
Mood music also affects frontline staff. At the peak of Blairite rhetoric, NHS staff hearing the signals from government would be forgiven for feeling that politicians saw them as part of the problem – that reform was a threat, something done to them, not with them. Public service reform strategy at the end of the Blair era – in part responding to Burnham’s insights from spending time on the front line – was beginning to recognise the need for staff engagement to deliver transformation on the ground. Contestability and choice (less so, competition) were part of a range of levers for change, including leadership, public voice, workforce reform, planning, regulation and performance management.
Burnham and his ‘pro-reform’ critics may have more in common than implied. The message that both sides would like primary care trusts to hear is that the market should be used, cleverly and carefully. Structural change, health policy’s shock and awe, is no alternative for winning hearts and minds to transform services on the front line. The fact is that the vast majority of the 1.5m healthcare workers are employed in the NHS. In the timescale, only they will be able to meet the challenge of improving quality whilst meeting rising needs and costs in the financial squeeze ahead.
If the system is so susceptible to mood music as we all seem to think it is, then it might be better for commentators to explain how the shift of political emphasis should not significantly change what wise commissioners are doing anyway. The illustrative scenarios published by the Department of Health suggest that this is not, in practice, the policy u-turn that has been claimed by some commentators and interest groups.
The main focus of Burnham’s announcement has been about addressing poor performance. The NHS performance regime already sets out the process for identifying underperformance, ensuring improvement plans are in place where necessary, and providing a backstop of a failure regime that could include franchising and tendering as part of a range of options. The preferred outcome is to improve the performance of existing providers through good leadership, detailed clinical benchmarking, and economy-wide reorganisation if necessary. If it works well, leaders and their teams will have the support and space to turn around their organisations before their contracts are terminated and transferred to alternative providers. This approach would be preferable to instability and turnover of leaders in difficult organisations. Focusing on standards not structures has more chance of succeeding – according to experience and evidence – than kneejerk sackings, mergers and tenders.
‘Preferred provider’, Burnham’s ill-chosen slogan smacks of policy making by alliteration and shares some responsibility for the current confusion. ‘Preferred provider’ is a poor descriptor of the scenarios he has set out and could raise (or lower) expectations about the use or otherwise of contestability. The preference for improving an incumbent provider over sacking them and re-tendering should apply to private or third sector providers as well. But is as alarmist to suggest that Burnham has reversed reform as it is to claim that the Independent Sector Treatment Centre programme is the wholesale privatisation of the NHS. It would be more useful to interpret for commissioners how to use the new guidance to ensure that third and private sector entrants can vie for patients through choice in the market, and can bring forward innovative proposals that can add value.
Disruptive innovation, including bringing in new providers, is just one tune in the commissioner’s repertoire. We should also encourage commissioners and service leaders to use the full range of system management methods to improve services. There was a risk with the mood music of competition that it would be seen as the default. The real challenge for the NHS’s leadership is to unleash excellence and innovation within organisations by engaging with staff as agents of change, not by condemning them as the problem.
Joe Farrington-Douglas is a senior policy officer at the NHS Confederation
