Power and Influence in the NHS

Oceans Without Continents

Ian Banks

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315348629
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Explains the NHS as a political environment, and concentrates on understanding the relationships of power rather than on the role of apparent authority. The book presents a range of management frameworks and personal examples to illustrate what a primary-care-led NHS means.

1

Introduction:

manifesto

‘Hereby it is manifest, that during the time men live without a common power to keep them all in awe, they are in that condition which is called Warre.’*

People are confused about the NHS. They know that its organization has changed, is changing, and they are not clear about where in the future these changes are leading. This lack of clarity breeds uncertainty which in turn too readily gives way to a pervasive sense of insecurity. Given the scale of the NHS as a national institution this affects the community at large and at all levels. It is a special relationship. The NHS is a microcosm of society in the United Kingdom; they create and re-create each other in their own images.

People are conscious of discontent among those working in the NHS. This fuels further the feelings of uncertainty. Clinicians especially voice their concerns at the impact of continuous change and the managers managing the changes change too often and too quickly themselves to command credibility. In such a context even genuine reports of reductions in waiting lists are tainted with suspicion, and Ministerial statements about improving Patient’s Charter standards are alleged to ring hollow.

The purpose of this book is to help bring clarity where there has been confusion. In 1990 Professor Chris Ham at the University of Birmingham’s Health Services Management Centre (HSMC) wrote an excellent account of the NHS reforms designed at the time for an essentially student readership.¹ As it turned out, however, such was the lack of internal clarity in the NHS, even then many managers, clinicians and their professional colleagues kept it on their desks as a vital source of reference and understanding. This book is a similarly short publication and in that it seeks to explain the NHS, a natural successor to The New National Health Service: organization and management. Its difference lies, however, in its approach.

From planning to political processes of development

In 1990 it still seemed appropriate to describe the NHS in terms of its structures and strategies. By 1994 ‘functions’ had replaced ‘structures’ and the Department of Health’s organizational chart of the functions in the reformed NHS, reproduced by Professor Ham in his follow-up book very soon became a standard induction and training aid (see Figure 1).²

By 1994, however, Ham had replaced ‘organization’ with ‘competition’ in his book title and now, three years later, we all have our very different diagrams of today’s NHS. As Peter Key and his colleagues’ account of The Unsupported Middle illustrates so vividly, all maps of the contemporary health care system have become essentially experiential.³ (Figure 2 provides one graphic example from a Community Health Council perspective.) The task now is to make sense of these; to re-draw the lines of what has become a world which, in Key’s memorable phrase, presently has ‘oceans without continents’.

This book seeks to explain today’s NHS as a political environment. Its central premise, moreover, is that, with the demise of strategic planning and organizational coherence, the contemporary NHS in terms of its continuing national identity can only be recognized, and its behaviour truly understood, as a political development. The aim is to be authentic; objectivity for the purpose of this particular publication comes second.

Figure 2 Into the unknown – the 1997 NHS galaxy. As drawn by user and carer representatives at a regional learning event in November 1995.³

The book therefore concentrates on understanding the new relationships of power rather than on the roles of apparent authority. Drawing on a range of experience, both personal and general, it sets out how decision making in the UK health care system now takes place. Its aim is to recognize the realities, to reveal the risks and above all to clarify the opportunities for influence now available to a much wider spectrum of participants in the NHS power-play than was hitherto ever the case.

Translation of contemporary NHS into wider UK health care environment

The exercising of this influence – becoming real contributors to the shaping of health care – is the life blood of the NHS annual cycle. As a matter of basic principle individuals, groups, whole communities always need to be more involved, alongside the established professional bodies and representatives factions. It is upon this involvement and expanded participation that the claims to survival and legitimate primacy of a National Health Service in the UK health care system may well, in the future, substantially depend.

Notes

1 Ham C (1991) The New National Health Service: organization and management. Radcliffe Medical Press, Oxford.

2 Ham C (1994) Management and Competition in the New NHS. Radcliffe Medical Press, Oxford. (Second edition is now available)

3 Meads G, Huntington J, Key P et al. (1997) The Unsupported Middle: future developments in a primary care-led NHS. Radcliffe Medical Press, Oxford.

* From Thomas Hobbes (1651) Leviathan (1968 edition). Penguin Books, Harmondsworth, p 185. This classic text of political theory set out the case for public institutions in society as the basic antidote required to contain the excesses of human nature.

2

The Balance of Power*

Devolution and difference – impact of general practice fundholding

As I write these words entries for the seventh wave of general practice fundholding (GPFH) are about to close. It is the 31st day of July 1996 and the last date for those looking to assume control of the purchasing of health care for their practice populations in April 1997, when nationally the level of population coverage is expected to reach 60 per cent. The principle of primary care-led commissioning appears to be irrevocably established in practice, regardless of future changes in national administration, and its expression signifies not simply a new era of devolution for the NHS but the sanctioning of difference throughout the UK health care system.

As this book proceeds I would like to describe, through these developments, the shift from planning to political processes within the NHS during the 1990s, and the aetiological relationship between these processes and their emerging organizational and service outcomes. In particular, I want to explore the dynamic now created by the abolition of Regional Health Authorities (RHAs) as national policy frameworks and local pressures, personalities and initiatives enter into a new period of direct encounter with one another. The pages that follow describe the passing of the familiar NHS as a much loved national public service institution and yet still anticipate, in the closing chapter of the book, a decade ahead in which NHS strategic priorities can, in my view, be extended more effectively throughout the public and independent sectors than ever before.

This is an important prospect and positive challenge, particularly for those still in direct NHS employment, most of whom are still a long way from being on terms with the continuous changes of the past few years and their significance. Their individual insecurities and collective uncertainty has not equipped them to be ambassadors for the contemporary NHS. The wider public has been left confused; often pleasantly surprised by improved quality and even speed of response, yet at the same time suspicious about motives and in particular that something they owned as precious is now being insidiously privatised.

Which brings us back to general practice fundholding as the exemplary source of this ambivalence. On the one hand, in the face of mounting workload pressures, the popular appreciation of individual general practitioners (GPs) continues to be virtually unrivalled; on the other, the scale and pace of resource transfer to their private businesses is almost unprecedented. In 1997/98 fundholders’ income and expenditure for the services they provide and purchase will be over £4 billion, i.e. HCHS/GMS expenditure.

Ten years ago, maybe even five, such a prospect was totally inconceivable. The nature of such change per se means that it cannot have been planned, let alone predicted. Development derived from political processes can generate pace but unexpected consequences are part of the deal too. Many of what are now in national terms mainstream service arrangements have been rapidly translated into practice through the successful exercise of informal power. Out-of-hours co-operatives, consortia, and health commissions themselves, are each examples of local developments initially frowned upon as being at the limits of legal discretion which, in a remarkably short space of time, have won such constituencies of support that significant statutory adjustments have been required. In each case the political imperative for change has come from within the informal organization of the NHS, its networks, learning sets and new pressure groups. By comparison the political mandate of parliamentary representatives has appeared at times almost irrelevant.

In terms of the NHS this is a complete about-turn in less than a decade. Ten years ago the NHS could be identified everywhere by the consistency of its structures and its plans. The district general hospital and the general practice were standard models; both often used off-the-shelf kit designs for their buildings. Regional and district plans were of ten and five year durations. Detailed and lengthy, they were underpinned by professional norms, particularly for staffing levels, that applied across the country. Now in 1996/97, as even NHS core values are subtly revised to incorporate choice and the consequences of consumerism, what is up for grabs is the extent to which there is any common ground at all nationally. The NHS has become a local creature; the risk, of course, is that in some areas the political processes behind its development could create a local monster (see Figure 3). Politics in any form is a messy business.

Ten years ago I was, almost, still a social worker and the NHS was, almost, still the NHS. Obviously these are simplistically sentimental assertions but it is not just personal nostalgia that fondly recalls a time when the terms ‘trust’ and ‘competition’ would rarely have belonged in the same sentence. In 1986 I had only recently begun a career that continues today in the no-man’s land between Health...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• Abbreviations
• Dedication Page
• 1 Introduction
• 2 The Balance of Power
• 3 Revolution
• 4 The Dark Ages
• 5 Counter Revolution
• 6 Renaissance
• 7 Reformation and Enlightenment
• Index