Guest Post by David Lock QC
[NB: This is a slightly longer version of a post that appeared on the BMJ blog earlier today.]
Politicians, delusional managers and the future of the NHS: have NHS leaders failed to “speak truth unto power”?
This blog is not a rant – well not too much of a rant. It is an expression of serious frustration about the way the NHS is run and about the willingness of senior NHS managers to become complicit in dishonesty. It also needs to acknowledge the brave role of some in the NHS – particularly in NHS Providers – who keep telling it as it is and being decried for doing so.
Everyone at the frontline knows the NHS is running on empty. The more perceptive know that more money for the NHS alone will not improve services for patients. But – and this is perhaps the unpopular “but” – NHS senior managers ought to accept their share of the responsibility for the present crisis. The problem is the failure of NHS managers to “speak truth unto power” to those above them and to our political masters for too many years. Long before Sir Ivan Rogers used the phrase, a 2015 FCO blog explained the centrality of this concept as part of public service as follows:
The UK Civil Service doesn’t have an official motto – but if it did, it would almost certainly be: “speak truth unto power”. It’s a maxim that’s in the blood of good civil servants, even if they know that it won’t make their lives any easier. The best politicians learn to cherish civil service advice which points out the flaws in their arguments. The worst surround themselves with sycophants who create a micro-climate which wraps a warm embrace around their worst tendencies.
But, this principle appears respected in the breach in the NHS. The £22bn efficiency challenge came out of nowhere and yet became an article of faith. Of course, it has not been delivered and was never going to be delivered, but the planning process has continued in a parallel universe where no one has the courage to say “Actually this is nonsense – a public service has never delivered these efficiency savings and the NHS will not do so”. So the fiction is maintained that this is what the NHS has to do by 2020. But, of course, we are now in 2017 and so there is precious little time to deliver the undeliverable.
Secondly, the fiction is that the present government is putting an extra £10bn into the NHS, as well as promising an extra £350m per week as a Brexit dividend. The £10bn claim was never accurate. No set of “true and fair” NHS accounts could ever include the £10bn claim. The £350m a week claim was made for votes, not for spending. And yet who in the NHS has held the government to account for either promise?
But it does not stop at the £22bn challenge or the fictional extra £10bn. The Sustainability and Transformation Plan process – called STPs – is the latest set of “plans” where NHS managers have been asked to promise to deliver the impossible and are signing up to plans which are more fiction than reality. Privately, the vast majority of NHS senior managers I have worked with in recent months know that STPs are totally undeliverable and certainly not within the timetables set out in the plans. They shrug their shoulders and say the plans are impossible for a series of interlocking reasons.
First, they know that the NHS does not have effective change management procedures. Every small change has to be negotiated and agreed in detail with every stakeholder before NHS England will allow changes to be implemented. Thus, in practice if not in theory, every CCG, every truculent local authority and every NHS Trust holds a veto to stop change happening. That will stop any controversial plans happening for year after year.
Secondly, even if all the institutional stakeholders can be lined up, politicians can cause so much fuss to prevent changes happening to a timetable (if at all). Time after time, local managers been, in effect, overruled by senior NHS staff to avoid political embarrassment.
Thirdly, even if changes could be agreed locally within the ambitious timetables proposed by an STP process, the capital needed to deliver effective changes is not available. Managing change is expensive, new buildings cost money and must be built before old ones are sold and a measure of double running is inevitable. Where is the capital money to fund the STP change programme? It is being spent plugging existing deficits. The iron rule of public service – you can only spend the same money once – seems to have been lost.
So why have local NHS officials signed up to undeliverable plans that they know the NHS does not have the capacity to deliver? The answer is that they have been told they have to do so and have failed to speak truth unto power by refusing to sign up to fictional plans.
In recent years we have seen this pattern again and again. Every NHS Trust and NHS Foundation Trust has to have a plan to cure the deficit and deliver against government targets including the 95% A & E target. Plan after plan is signed off and, if they all had worked as predicted, the NHS would now be in financial balance and Trusts would deliver 95%. But, in the real world the deficit gets worse month by month and hardly any Trusts are delivering 95%.
So why does the NHS repeat a failed planning process? The main problem is that, scratch the surface, and many will reluctantly admit that the management culture of the NHS is close to dishonest. NHS England or NHS Improvement tell commissioners and providers what the plans are required to deliver. Once the targets are set, it is just not acceptable to say to NHS England or NHS Improvement that a plan to create financial balance or deliver 95% A & E performance “cannot be done”. It is equally unacceptable to say “It cannot be done without substantial capital investment, money for double running and political will to deliver a series of unpopular changes”. So what do NHS officials do? They come under intense pressure to produce plans that confidently predict the undeliverable and bow to that pressure.
Then NHSE or NHSI officials go through a ridiculous process of “testing” the plans. The Trusts and the CCGs know the plans will not be delivered, and NHSE or NHSI officials know that too. But no one can admit the emperor has no clothes. The plans get signed off and the “system” confidently tells ministers that Julian of Norwich was right in that “all will be well, all will be well and all manner of thing will be well”.
But, of course, now we know that all will not be well. We know this for at least three reasons. First, the STPs will fail just like the last set of plans and the set before that. The NHS cannot manage change and there are too many patients, too few trained doctors and nurses, too few community services to keep people out of hospital and an ever growing number of elderly people with multiple co-morbidities needing care. But, when will NHS senior managers have the courage to tell NHSE and NHSI that “it cannot be done”?
Secondly, even if the NHS now gets extra money, that is highly unlikely to produce significant numbers of new staff. Competition to recruit doctors, nurses and physios is already intense. So pledging more money at this point will not lead to more staff in A & E, even if it means the staff in A & E are (slightly) better paid.
Thirdly, virtually nothing can be done to assist NHS with the “flow” of patients through NHS hospitals without tackling the crisis in social care. Delayed discharges are on an inexorable rise. Many of the affected patients are elderly people who need social or NHS community care packages to effect a safe discharge, and the money is just not there to fund the care they need. So social care service users remain stuck in an NHS hospital, with the NHS funding their care.
Paradoxically, unlike additional investment in the NHS, paying sensible sums to social care providers may lead to additional social care capacity and so could genuinely improve this problem. But save the NHS by more funding for local authorities is a complex message. There is only a muted cry from NHS leaders that more money – and it will now take much more money – is desperately needed in social care because this is essential to making the NHS function properly.
The NHS in England in the mess it is today because of systemic overpromising and underfunding. That is primarily the fault of politicians. But the NHS itself must bear its part of the blame. NHS managers, with some honourable exceptions, have colluded with politicians to tell them what they wanted to hear, and then demanded those under them produce plans to make good on those promises. And the real cost of pulling the NHS out of the present mess will, of course, be far higher and far more difficult than it would have been if the NHS had not colluded with politicians by promising the NHS would deliver the undeliverable.
So where do we go from here? A first start might be for NHS managers at all levels to start standing up to the demands of those above them and to refuse to sign up to plans that they know cannot be delivered. That, and only that, would bring a dose of reality up the chain to the Secretary of State who would then be properly held accountable for the NHS before Parliament (see section 1 of the NHS Act 2006).
Here endeth the rant.
David Lock is a QC with a particular interest in healthcare law. He chairs Innovation Birmingham Limited and is a former Labour MP and Parliamentary Under-Secretary of State in the Lord Chancellor’s Department. He is a member of the BMA Medical Ethics Committee.