NHS Reforms Part 1: too many new dawns, too many inefficiencies

Successive governments have implemented change upon change, in every area of the NHS, in an effort to make it more cost effective

As Minister of Health, Enoch Powell was heard to complain that his sole task seemed to be restricted to pay negotiations. Such were the restraints for introducing innovations into the NHS, which had remained static since 1948. Then it came to the attention of Margaret Thatcher. The shock to her was that there was no accounting for the flow of cash within the NHS and the Treasury was expected to pick up the bill. For a grocer’s daughter this was totally unacceptable.

Since then, successive governments have implemented change upon change, in every area of the NHS, in an effort to make it more cost effective. A cynical view arose within the NHS that no innovation ever reached the desired effectiveness before yet another swingeing change was introduced. The service, therefore, could always be criticised for being inefficient, which gave the excuse for the next round of innovations.

A widely accepted system of good management is founded on small changes to promote the smooth running of the organisation, to eliminate the glitches causing problems and to encourage the experienced members to make realistic suggestions for improvement. By allowing growth to be organic, innovations which work are retained and those which don’t are naturally abandoned. Most communication is done verbally and face to face. The more the organisation grows and becomes more complex, the more it requires written protocols.  Once the organisation grows beyond a certain size, it loses its natural efficiency and needs to split, enabling both parts to re-establish their own renewed level of efficiency based on personal communication. Many businesses go through this natural evolution repeatedly and with great success.

Regrettably, evolution within the NHS does not happen like this. Each successive Government has a mission to put its own stamp in the hope of creating a new dawn. In reality, it delivers new inefficiencies, and never allows time for the workforce to iron these out. The result is a body which feels exasperated, undervalued and demoralised. The only sustained area of satisfaction within the NHS is the clinical work. The rest is the cause of burn-out.

The Covid epidemic has revealed how quickly and effectively the NHS has adapted to the clinical needs; discovering several new successful methods of treatment and producing a vaccine in record time. Without any false hyperbole, this has been world beating. Compare that with the Trace and Track system handed to SERCO and based on idealistic plans but with no prior experience. It didn’t work and never would.

“Ultra-violet screening for potentially Ebola-carrying liquids” by DFID – UK Department for International Development

The public’s appreciation has been a much-needed restorative to NHS staff, but will not be enough to offset the previous feelings of dissatisfaction, particularly on top of post-traumatic stress, staff illness from Covid and overwork.

Yet another revolutionary NHS Reform is not what the doctor ordered. But this is precisely what the government is proposing and it is unrealistic to expect the NHS to be ready for it. The changes brought in by the Health and Social Care Act 2012 created a set of complex and fragmented organisational structures which made collaboration difficult. It encouraged Clinical Commissioning Groups (CCGs) to compete for services and removed experienced medically trained personnel away from the work they were trained to do and enjoyed.  So there is a resignation that some change is needed, but not right now.

Abolition of the 2012 Act and its replacement with a reform involving the recently created Primary Care Networks (PCNs) might be a step too far. General Practice was barely recovering from the new measures of data collection, target setting and tied payments when they were told in July 2019 to reform themselves into amalgamated groups or PCNs. GPs from different practices, who had never worked together, suddenly had to adjust to close collaboration with no previously established hierarchy. Inevitably and not surprisingly, many partners, nurses and administrative staff were unsettled. Some felt demoted and angry, whilst others felt pleased and smug. It was not an environment for a happy or efficient workplace. Many practices declined to merge, preferring instead to stay as they were.

For some time now, patients have had to adjust to being registered with a practice rather than their own doctor and they didn’t feel particularly happy about it. The creation of large PCNs made this depersonalisation worse. Time would be needed to adjust, but there was no time at all. Covid struck. General Practice had again to adapt immediately to a totally unfamiliar and dangerous situation. The response was telephone consultation and e-Communication. We all had to accept it, but we weren’t happy with it. I don’t imagine practices were either. I feel sure this difficulty in accessing General Practice has been one of the main reasons for many medical conditions going unattended or managed too late.

By the end of the pandemic, General Practice will be expected to adapt yet again to another new structure, which I shall deal with in greater detail in Part 2. Here it is in brief. The 135 CCGs will be replaced by 42 Integrated Care Systems. Each Integrated Care System, each covering a population of 1 to 3 million, will include as many as 60 PCNs. The PCN clinical directors, who have invested time and energy in developing working relationships with CCG officials, will now find their influence and contact diluted. Many may even find that they are not perceived as having equal standing with clinical or managerial leaders of larger NHS providers. It is a recipe for more dissatisfaction and further erosion of morale.

PCNs will be expected to deliver a set of nationally defined specifications, covering areas such as improving early cancer diagnosis, better health care in care homes and reducing health inequalities, in addition to their contractual requirements – even more work.

These might be lofty ideals but are unlikely to be received with warmth and enthusiasm by the people who have to implement them. In metaphorical terms you might expect all in the NHS to be told: “You’ve done a brilliant job, hugely appreciated. You need to take it easy and have a bit of a rest”. Instead they are told: “Here’s just another little job for you”.

You can almost hear the expletives.