The NHS--from stalled bureaucracy to 'Era 3'.

AuthorIliffe, Steve

The NHS's existence so far can be divided into two broad periods. Era 1 was characterised by noble, beneficent, self-regulating professionalism. In negotiating the compromises needed to launch the new health service in 1948, the political class conceded to the professions the authority to judge the quality of their own work. The NHS grew rapidly, taking up new technologies (like X-Rays) and new medications (like Penicillin) to transform clinical care, and allowing access to health services for the whole population.

Era 2 began when the variations in the quality of care, the injustices and indignities inflicted on people because of class, gender and race, as well as the profiteering and sheer waste of Era 1, became inescapable. New modes of accountability, scrutiny and measurement were introduced, along with incentives and market mechanisms like rewards, punishments and pay for performance. Labour contributed to the consolidation of Era 2 during the Blair/Brown governments, but it had really begun in the late 1980s under a Conservative government--with the introduction of the 'purchaser-provider split', the promotion of contracting-out services, the encouragement of evidence-based medicine and, overall, the industrialisation of the NHS.

In this second era, the language of the NHS changed as much as its architecture. It began to speak of 'commissioning' rather than planning services, 'trusts' rather than hospitals, and 'providers' rather than organisations providing a service, as well as the 'regulators' who scrutinised clinical and managerial activity. New institutions were created to replace the hierarchic order of Era 1 NHS management, with a flurry of structures (like 'Monitor' and the NHS Trust Development Authority), which themselves were subsequently merged and shrunk (in this case to make NHS Improvement). Some old institutions metamorphosed--Primary Care Groups became Primary Care Trusts which became Clinical Commissioning Groups, which are now being merged.

In 2010, at the end of the New Labour period of government, the NHS Institute for Innovation and Improvement focused managerial attention on the cost and quality of services across the NHS, expressed in the Quality, Innovation, Productivity and Prevention (QIPP) goals. (1) It used insights from social movement theory to connect QIPP messages to the core values of staff and create a 'contagious commitment' to rapidly improving quality whilst driving down costs. It came to the conclusion that face-to-face communication with trusted individuals--credible clinical leaders and peers--was the most powerful means of mobilising staff. This reasoning led to the growth of leadership training, which we have described elsewhere. (2)

What happened at local level was, however, different from the mobilisation envisaged in 2010. Clinicians, managers and national bodies all agreed that reporting requirements (to NHS England regulators) were increasing. National bodies overlapped in their responsibilities for judging providers' performance, resulting in duplication of reporting efforts. These additional tasks were further complicated by the lack of a clear definition of 'quality' and of a core dataset to measure it. The NHS Confederation noted that there had been progress to reduce the volume and increase the efficiency of requests from national bodies for performance data, but more still needed to be done. (3) Far from liberating clinicians to meet patients' needs, the quasi-market of Era 2 created a bureaucracy that competed with patients for practitioners' time. Just as Era 1 stalled after its initial transformational phase, so too did Era 2.

The stalling of Era 2 was apparent even during the period of NHS funding growth under New Labour. One problem was the sometimes inadequate monitoring of results following increased funding, as happened, for example, when spending on long-term neurological conditions--such as Parkinson's disease, multiple sclerosis and motor neurone disease--was increased by 40 per cent. While access to health services and waiting times were both improved by the 2005 National Service Framework for Long-term Conditions, the National Audit Office found that quality standards were not being monitored. So the NHS did not know whether the services themselves were improving. (4) There were signs that they were not. Emergency admission rates...

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