Hard truths or home truths?

It has been a very busy November for the NHS. Hospitals, general practice, community and other services have been battling to deal with the apparently incessant demand for emergency advice and care – a warning sign of how difficult it will be for the service to make it through the winter unscathed.

How far this pressure is due to constrained funding, the effects of the recession on people’s health and access to social care, growing numbers of frail elderly people, or a lack of available routine appointments in primary care, it is almost impossible to tell.

On top of this pressure at the local level, there has been feverish activity in Whitehall, with what has felt like an ‘emergency pressure’ of policy announcements intended to give direction and coherence to a somewhat beleaguered NHS.

The importance of quality and safety running through the year has been emphasised by the publication of the Clwyd/Hart review of NHS complaints, amendments to the Care Bill to introduce a duty of candour for providers, the Department of Health’s formal response to the Francis Inquiry, and then the Care Quality Commission’s State of Care report.

In the wake of the many policy initiatives and directives in November, however, I was led to wonder if the most difficult truth has yet to be addressed by the policy and political centre

The publication of a refreshed NHS Mandate might well have heightened a sense amongst local boards and commissioners that they are increasingly being steered from the centre. The refreshed Mandate has a strong focus on assuring proper co-ordination of care for vulnerable older people and gives more detail about how NHS and social care providers can access the new Integration Transformation Fund, in time for its implementation in 2015.

The challenge of crafting services that enable well-co-ordinated care for frail and vulnerable people at a time of financial constraint is huge, and will require careful design and evaluation if the consequences for patients and their families are to be properly tracked and assured.

Indeed, there will be a need to look far and wide for inspiration, and the experience of Japan and its development of new forms of care for its older people – explored in a new Nuffield Trust report – should prove helpful here.

Such was the volume of policy announcements this month that we published a briefing for Parliamentarians, highlighting the questions that are raised by this welter of guidance and direction.

We also raised the question of ‘who is in charge of the NHS?’, given that there are now at least six national bodies seeking to steer the NHS and hold it to account, when a decade ago there was one (the Department of Health).

This question is one we will be returning to in a Nuffield Trust publication in 2014. Meanwhile, the impact of multiple organisations struggling to capture the attention of busy managers, boards, commissioners and clinicians, deserves further consideration.

I was fascinated by the title ‘Hard Truths’ used by the Department of Health for its response to the Francis Inquiry. The title was obviously intended to reflect a belief that the Inquiry Report had delivered a tough message to the NHS (which it did) and that the Department of Health is taking this seriously in leading the NHS response – which indeed it is.

In the wake of the many policy initiatives and directives in November, however, I was led to wonder if the most difficult truth has yet to be addressed by the policy and political centre.

While Robert Francis QC was clear that the primary responsibility for what happened at Stafford Hospital lay with the foundation trust board, a message for the health service’s central bodies also runs through every chapter of his report.

A centrally-driven culture that focused unduly on targets and what Robert Francis called ‘the system’s business’ led to an overall management and organisational culture that could in some cases be unhealthy, uncaring and ultimately damaging to patients.

The reforms embodied in the Health and Social Care Act were intended to ‘liberate the NHS’ at a local level, and enable clinically-led innovation and service development. The experience of this last month, with its avalanche of initiatives and instructions, together with reports of daily checking from Whitehall with trust chief executives about A&E targets, paints a picture of business as usual in the NHS.

It also carries unfortunate echoes of the ‘targets and terror’ culture of the last decade which, whilst leading to major reductions in waiting times and other improvements, also created an environment which contributed to the events at Stafford.

The NHS is working hard to respond to the Francis Inquiry. It would seem that trusts and commissioners are giving a much greater emphasis to the quality and safety of care. Nevertheless, one has to question whether the hardest truth of all has been addressed.

Has the wider leadership of the NHS (and its political masters) really embraced a more supportive, transparent and enabling approach when working with trusts, foundation trusts and clinical commissioning groups?

Or to put it another way, as winter pressures collide with austerity and the need to maintain quality, the old top down ways offer those in charge a modicum of safety and security.