Top-down NHS management culture could undermine local reform initiatives, experts warn

Confusing accountability structures and a return to a ‘command-and-control’ style of managing the NHS risks undermining local initiatives to better join up health care services, a new report from the Nuffield Trust claims today.

The study examines the accountability and performance management arrangements for clinical commissioning groups (CCGs), drawing on accounts from senior CCG leaders, interviews with policy-makers in NHS England and expert analysis of the current system [1]. The report then looks at the implications of these arrangements for the sustainability and transformation partnerships (STPs) and accountable care systems (ACSs) currently being developed across the country.

There is an opportunity to rectify this pattern of behaviour with the move to STPs, but this will require a significant change in approach at all levels in the health service.

Helen Buckingham, report author

The report describes the network of relationships between national and local organisations in the NHS as “extraordinarily complex”, with the policy agenda for CCGs often set not by clinicians responding to local need, but by NHS England. This creates poorly coordinated policy, leading some CCGs to be asked to adopt plans they consider “unrealistic” or “counter-productive”.

Despite the intention that NHS England should work collaboratively with CCGs to improve patient care, the authors suggest that pressures across the whole of the NHS are leading to a more punitive, top-down approach. One interviewee suggested that politicians were “losing patience” with the NHS, noting that high levels of anxiety in the NHS and the Treasury cause “absolutely ridiculous” amounts of data collection.

The authors suggest this translates into the return of a “command-and-control” style of management, with one NHS England leader noting that while they used to “coach’” CCGs to achieve, they are now “requiring them to make changes”.  This approach also causes stress and anxiety among leaders themselves, with nearly all CCG interviewees feeling that there is little support available to them.

In the words of one leader: “It seems that the natural behaviour at senior echelons of the NHS is to think it’s motivating to threaten you with your job. It doesn’t motivate me.”

Looking ahead to the development of STPs and ACSs, the authors note that, with the majority of STPs still developing their governance arrangements, high levels of trust will be needed between them and the national NHS bodies if they are to avoid some of the pitfalls experienced by CCGs. The authors say that success will depend heavily on these working relationships and that NHS leaders will need to move away from a ‘heroic’ model of leadership to one where responsibility and decision-making capabilities are shared.

Commenting on the research, Nuffield Trust Senior Fellow Helen Buckingham said:

“The move to STPs makes sense: integrating NHS commissioning and service provision should in theory lead to better patient outcomes. But to succeed, local and national organisations will need to develop trusting and supportive working relationships - something that eludes the NHS all too often, as this study suggests.

“Despite the laudable aspirations of fostering collaboration and local leadership underpinning them, the experience of CCGs is that when pressures start to grow, the NHS reverts to type, with national bodies making ever more directive demands of local organisations, and local leaders feeling isolated and demoralised. There is an opportunity to rectify this pattern of behaviour with the move to STPs, but this will require a significant change in approach at all levels in the health service.”