The Secretary of State for Health and Social Care, Steve Barclay, recently took to the Mail on Sunday to launch a new review promising to be “ruthless in axing NHS red tape”. Predictably enough, this was framed by headline writers as a “cull of jobsworths and futile targets”, even if in this case they were only taking their cue from the DHSC’s own press statement, which said that the review would “explore how best to cut through red tape”.
The official intent of the review into integrated care systems (ICSs), led by Patricia Hewitt, is to make recommendations on how ICSs should best be held to account for reducing inequalities, improving outcomes and driving innovation and efficiency at a local level.
This is by no means the first time that the relationship between national organisations and local NHS trusts and commissioners has been reviewed, and there are some common themes that bear re-reading.
A familiar story
As NHS England and NHS Improvement came together in 2020, Nigel Edwards and I undertook a piece of work looking at the lessons to be learned from how strategic health authorities (SHAs) worked to oversee providers and commissioners at a local level. It’s a report that feels highly relevant now.
One of the issues we discussed was the relationship between SHAs and central government. SHAs occupied a somewhat delicate space as both locally run and accountable organisations with their own boards, and to all intents and purposes also acting as outposts of the Department of Health. We discussed the challenges associated with that, including the tensions between local priorities and national programmes, the role of the SHA as the buffer and the sense-maker – in both directions – and the role of the SHA in managing and reporting on performance. A quote we used, which still resonates now, was:
“One week you might have absolutely no contact with the Department of Health, the next week you’d get 500 phone calls from different parts of the Department, all clearly on their tick list of ‘have we checked up on this?’ It was unfiltered everything.”
Looking further back, in 2017 we published a report on the accountability relationships between clinical commissioning groups (CCGs) and NHS England, with some pointers for relationships in then-emerging sustainability and transformation partnerships (STPs), the forerunners of ICSs. We described the implications of a dysfunctional performance management system and noted that, “at a time of extreme pressure on the NHS as a whole, these issues, coupled with an apparent lack of structured support for CCG leaders, have led to significant stress for those individuals.”
And further back still, in 2014, we undertook an early review of the implementation of the recommendations of the Francis report, which noted that “it is hard for boards and senior managers to engender a culture of compassion, support and mutual learning inside trusts when they experience a form of external management that is seen as punitive at times”.
Almost 10 years on from Francis, it seems not much has changed.
Upwards but not onwards
Our reports all described a culture that, despite all the exhortations to ‘look out, not up’, continued to look up. The recent Messenger Review repeated this, warning that “the sense of constant demands from above, including from politicians, creates an institutional instinct, particularly in the health care sector, to look upwards to furnish the needs of the hierarchy rather than downwards to the needs of the service-user”.
So it seems to us there is some root cause analysis that may profitably be undertaken by the Hewitt review, with questions including:
- What is it about the NHS, its governance and our political systems that lead to this culture of looking upwards?
- How does the relationship and the power dynamic between No. 10, the Treasury and DHSC affect this?
And if we are serious about changing this culture, we need to understand the theory of change and the practical steps that will get us from where we are now to where we want to be.
There have been plenty of statements of good intent from national bodies, including the recently published Operating Framework for NHS England. I doubt anyone would argue with the ambition that “integrated care boards and NHS England will ensure oversight and performance management arrangements within their ICS area are proportionate and streamlined, and do not create duplication or unnecessary bureaucracy and reporting requirements for providers”.
But we have seen statements like this before. What is actually going to be different about how NHS England teams work with each other, with Whitehall colleagues (including political leaders) and with ICS teams to make this a reality? What are we going to do this time that we failed to do before?
Finding the right balance
NHS England is not the only player on the pitch. ICSs and their constituent providers are also regulated by the Care Quality Commission, and many other bodies have a legitimate interest in understanding what is going on within organisations and systems, including local authority overview and scrutiny committees, professional regulators, deaneries, the Health and Safety Executive and more. This complexity is a fact of life, but it makes it all the more important that central bodies understand the totality of the reporting burden placed on local organisations, and the part they can play in ensuring that burden is proportionate to the accountabilities placed on local leaders.
Paradoxically, the risk may be that while reducing the weight of external oversight and empowering ICSs to focus on their local communities feels more important than ever, the state of NHS performance across the country makes it harder than ever for politicians to loosen their grip. At a time when people are literally dying as a result of the pressures in the urgent care system, how can NHS England and ministers ‘back off’?
In our CCG report, we noted that “to those working in leadership roles in the NHS, accountability can be described as something that is felt”. Local leaders are profoundly conscious of their accountability to the people they serve, as are politicians leading at a national level. The challenge the Hewitt review now faces is to find a way to balance the needs of both. The NHS’s tendency towards hierarchy and central interference is deeply rooted in many institutions, and changing it will mean different behaviour from the very top.