What the NHS really needs

A report in today’s FT suggests that the savings from the government’s latest NHS reorganisation will be quite a lot lower than promised.  That does not come as a great surprise.  Every NHS restructure is costly and time-consuming.  As they happen every few years it means, as one senior manager told me, that as soon as the new organisations it creates are mature and actually achieving something they are abolished in favour of a different configuration.  And back to square one we go.

It is not that the current changes and the many previous ones do not make some sense or have not contributed to some improvements.  My experience is that NHS Trusts are far more focused on efficiency, for example, than they once were and the separation of commissioning (Primary Care Trusts at the moment) and provider functions (hospitals, community health staff and so forth) may have helped to achieve that.

But restructuring never delivers what is promised because it cannot.  It may be part of the solution to organisational challenges, but only in support of something else, as a way of institutionalising something that already exists, not as a way of creating that change.  For governments wanting to make a difference it is a tempting route to go down.  It is something they can actually do.  It is a grand solution and one within the scope of the government.

But the key to improving the effectiveness and efficiency of the NHS, especially of the hospitals, is changing the way those who work in it think and behave.  I do not mean that people in the NHS – doctors, managers, nurses, support staff – are not dedicated and highly capable.  I do think that the management skills of the NHS could be improved but it is not the main issue.  It is more that each of those groups has a different take on what is important and has different priorities.  The relationships between managers and doctors in particular are fraught.  The managers are trying to improve the performance of the whole system.  Doctors tend (I know it is not universally true) to be more focused on their work with their patient.  And the reality is that doctors have a status in the system that makes them pretty well untouchable.  And yet I also know they frequently feel marginalised from decision-making.

What would really make the difference is getting all these parties on the same page.  And that can only be managed locally.  The key to it is re-connecting everyone with what brought them into the NHS in the first place – an often passionate sense of purpose, a commitment to a set of values.  It is this – and only this – that would create the basis for renewed relationships, changes in thought and practice and concerted action.  It is only this that can shift the bureaucratic mind-set that bedevils the NHS whatever structure it finds itself in today.  And it is this that gets lost in all the restructuring and the change fatigue. It is a precious resource that keeps being squandered.

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