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Stop criticising the NHS and learn from it

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A guest briefing by Health Service Journal editor Alastair McLellan on recent controversy over the NHS long-term plan

First let me state that I am a fan of local government. I became editor of Health Service Journal in 2002. Up until January 2017, HSJ and LGC were owned by the same business and operated from the same division. Between 2009 and HSJ’s sale eight years later I was LGC’s editor-in-chief. My wife is a former deputy and acting editor of LGC.

This gave me plenty of opportunity to appreciate what local government does well and to compare it to the NHS.

I would suggest, for example, that the average local authority chief executive is likely to be a more rounded and effective leader than their NHS equivalent. This is particularly manifested in the ability to work with partners – a skill NHS executives are struggling to pick up as the service exits the era of competition and embraces system working.

I have also argued the need to fund local government better is more urgent than finding extra funds for the NHS.

But.

I have noticed over recent years that local government has developed a chip on its shoulder about the NHS. This chip has two characteristics. First, there is anger that the NHS dominates public and political debate and, as a result, sucks up all the available cash. Second, that this happens despite the many and manifest deficiencies of the NHS and the clear superiority of local government.

As you will see from the editorial above, I have some sympathy with the first point of view. However, the hubris portrayed in the second characteristic feels like a coping strategy in the face of a harsh financial climate (‘we know we’re the best, even if others don’t recognise it’) and a way of avoiding the hard questions about local government’s standing and future.

This anti-NHS feeling came to head with a kite flown in January’s Long-Term NHS Plan suggesting that the service might take back some responsibility for some elements of public health commissioning.

Naturally this produced some push back from local government – some of it measured, some of it not. But it also gave some commentators the opportunity to roll out a series of hackneyed clichés about the NHS’s shortcomings.

Well, it is time for some home truths.

Let us start with the Long-Term Plan and public health.

Under a section entitled: ‘Action by the NHS is a complement to, but cannot be a substitute for, the important role for local government’, the idea was floated that there could be “a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses.”

If that is a “land grab”, it’s a very cautious one.

The briefings given to HSJ made it clear this was a Plan B if the Treasury did not invest enough money in public health via local government.

In other words, it was an attempt to get more money for local government or relieve it of a burden if that was not forthcoming.

The NHS has quite enough to do (thank you very much). It does not search for extra responsibility – especially a responsibility that comes with relatively little money and dollops of risk - on a whim. It especially does not want any more structural change than the benighted Lansley reforms are already forcing it to undertake.

Above I commented on the quality of local leaders in local government. However, when it comes to national leadership, the NHS is streets ahead. They have consistently managed to negotiate significant funding rises since 2010 – and believe me there were plenty in government who fought tooth and nail to stop that happening – while local government has noticeably failed to do so.

The increases in social care funding that have been produced recently and may be forthcoming in March’s spending review are largely the product of lobbying by the NHS’s leadership. If you have chance to talk to NHS England chief executive Simon Stevens, take it – he can teach you a lot about managing ministers – including prime ministers.

I will leave others to debate whether the NHS or local government are (on average) better commissioners of services – may guess would be that it is the latter. BUT any service within the remit of the NHS is likely to be better funded.

The NHS is trusted with public money by government (and indeed the public), local government often is not. You might want that to change, but it is not likely to soon (under any possible administration) and therefore it might be wise to recognise that and consider moving public health commissioning skills back to the NHS.

As for the suggestion that public health would be a Cinderella within the NHS. Well maybe so, although demand pressures are such the NHS now has no option to take it seriously. Anyway, better to be a Cinderella in a palace than a princess in a poorhouse.

Let us now turn to that chip on the shoulder.

A couple days after the publication of the Long-Term Plan, Adam Lent, director of the New Local Government Network wrote a piece for LGC.

In it he suggested the NHS was: “an organisation lacking a coherent grip on its own failings and able only to generate a mind-bogglingly complex list of unconnected solutions.”

He suggested there was a “vast conceptual chasm” between the “inclusive” innovation practised by local government and the “transactional methods” employed by the NHS.

Rightly praising local government for its involvement of local populations in service design and change, he goes on to allege: “There is no self-analysis of the way the NHS’s hierarchical, status-obsessed culture militates against relationships with patients based on empowerment and collaboration rather than ‘doctor-knows-best.”

Of the Plan itself he suggests “Maybe they should have asked a friend to take a quick look first. They could have done worse than ask local government.”

Strange then that this same organisation is perhaps the world’s best known and most respected national public service; that it is the country’s best loved institution (by a mile); and that the people who work within it command the greatest public admiration and regard.

It is also the case that in almost every part of the country, despite the valuable work many local authorities undertake with their populations, it is whether the local hospital is threatened or thriving that most view as the strongest signifier of the relative strength of their community.

Could it be the NHS is doing something right? You could do worse than ask them.

Alastair McLellan, Health Service Journal editor

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Readers' comments (2)

  • Simon Stevens' Cheerleader in Chief responds then! Not sure this actually answers any of Jim McManus' points. Of course the NHS does some things well. It does an awful lot of things wrong. This response feels like the critics have hit a nerve. Good.

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  • The NHS does do something right. The NHS is exceptionally good at speaking with one voice, and where there are areas of relative deficit eg mental health, getting external agencies such as charities to make the point so that it doesn't become "mental health trusts versus hospitals" but "mental health needs more money". As a result NHS is good at growing its cake. For a variety of deep structural reasons LG tends to fight fairly publicly over distribution of cake (despite best efforts of some exceptionally able people to hold the sector together). "Game theory" theories study organisations where cooperation is mutually advantageous but cannot be enforced, and where there are short-term benefits from deviating from the common interest. Game theory says that NHS-style collaboration will work under two conditions: when it is very easy to see what other players are doing, and when all of the players have a very long-term focus. NHS has a ten year plan, lots of well networked "lifer" senior folk, and lots of consistent information sharing. Austerity pain and the playing out of politics makes it harder for LG as a sector to ignore signals that one bit of the sector appears to have made a short-term benefit over others (even if the sector cake just grew a little as a result). It will be interesting to see if a greater focus on ICSs and places potentially scrapping over resources will lead to the NHS catching the LG disease!

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