The constipation of the NHS

There is an awful lot of old nonsense written about the Health and Social Care Act.

It is said that it was a mistake to put decision-making in the hands of GPs. Well, it did at least provide the foundations for shifting power away from the hospitals – though, of course, GPs are not really in control (they are providers and the CCGs are purchasers, so they can’t co-ordinate properly, as they need to).

It is said that it has opened up the NHS to privatisation. On the contrary, most of the marketisation measures were removed by the Lib Dems, and most of what we have now are the basic outsourcing structures set out by the Blair-Brown governments (yes, there is an issue around the scale of what is happening now).

But what on earth possessed the Department of Health to split regulation between three competing bodies – NHS England, the CQC and Monitor – and to leave the boundaries between the three of them obscure enough to get in the way of innovation?

I encountered all three of them in a brief official capacity, and found them all obsessed with each other’s remits, nervous about each other and very, very careful.

It does explain something of the bitterness behind the NHS blogger Roy Lilley’s attack yesterday morning on the way the NHS is led – a dearth of leadership on the ground, and a pointless stream of negativity from the regulators to anyone who thinks differently or experiments or takes risks with the targets.

It is as if the coalition took the disastrously concrete and wasteful design of public services from the Brown years, and then set up three super-quangos to entrench those mistakes further.

When I met CQC in 2012, they were still using fax machines – enough to make any of us nervous.

Now, you can criticise Roy for trying to let NHS providers off the hook. The CQC, which is – as he says – far too big for its own effectiveness, is the illegitimate child of the Mid-Staffs scandal. But this paragraph is absolutely right about NHS leadership:

“As the boss, you have no control over the business model, compulsory frameworks that might be completely inappropriate for where you work, fixed prices, targets and tariffs that create perversity, arbitrary regulatory rules, and required to do plenty more with plenty less.”

There is the NHS in a nutshell. What can you do about it? Well, I think you have to accept that the NHS can’t be run as a vast great centralised edifice any more.

The danger is that anyone who says this tends to get accused of wanting to sell it off – but it badly needs to be decentralised to local units, and to accept that these might look very different.

You also urgently need to decentralise inspection. There is no way that mega-CQC can do more than a paint by numbers approach, and they need to be stripped down to concentrate on training local authorities to inspect instead.

I’m not sure that Monitor has a role at all, though clearly somebody has to watch over the business practices of the foundation trusts and to speak for patients and their right to be treated flexibly.

Somehow this devolution has to be done without a major new re-organisation, which is politically unacceptable. Nor can you use rhetoric like ‘setting the NHS free’, because again it sounds like weasel words for privatisation.

But you do have to rescue the NHS from its undergrowth of constipation. In short, we need a major dose of laxative.

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