Foretelling the future: 2011 predictions and speculations

With Christmas and New Year at the way it’s time to read the retrospectives on 2010 and the crystal ball gazing for 2011.

I have not yet listened to Radio Four’s Correspondents Look Ahead programme but Paul Mason of Newsnight makes an interesting prediction on the BBC website. He suggests that in 2011 the Coalition will fall “because everytime it tries to do something serious a bit falls off the machine”. (Interestingly Tony Benn and Dennis Healey made a similar preduction yesterday on Radio Four's Broadcasting House.) Paul Mason foresees a Liberal Democrat pull out leading to “a Second Coalition to be formed between the Conservatives, an inner core of Orange Book Libdem leaders and various Unionists, with a slim majority.” We will see if that happens and what it means for the public and third sections.

The London School of Economics blog on British Politics and Policy has a look ahead at some of the big issues that could dominate 2011. The list is far-ranging although it is a list of questions rather than predictions. While it features the Coalition and austerity, it does not mention the impact of the changes in schools and the NHS which are potentially profound and, the case of the slow painful death of Primary Care Trusts, possibly toxic.

One area which I will be watching and trying to understand is open source government, armchair auditors and some of the technology which may make this something significant. I am sure that there will be some headlines as more public bodies have to publish the detail of their financial transactions. There may even be some good to come out of these exercises.

Informed analysis on public policy: the NHS reforms and other changes

With so much change swirling around public services it’s useful to have a place to go for informed analysis. Today I stumbled on the LSE's British Politics and Policy blog which features a wide range of academics. Some of the bloggers, such as Tony Travers, are found in publications like CIPFA's Public Finance; others are more elusive (I cannot remember reading anything by Nicholas Barr since studying public sector economics at university sometime ago.)

This morning I read with interest Julian Le Grand’s thoughts on the Coalition’s plans to overhaul the NHS. Le Grand is a former advisor to Tony Blair on public service reform. He describes Andrew Lansley’s proposals as “impressive” with “their origin in policy reforms initiated by John Major’s Conservative government in the 1990s and subsequently developed by Tony Blair’s Labour government”. Similar sentiments were expressed last month by another advisor to Tony Blair – Simon Stevens wrote in the Financial Times that the Coalition’s plans take forward earlier reforms blocked by “internal opposition”.

Can’t get no satisfaction (statistics): reporting performance

One of the most promising developments in public services in recent years has been the increasing attention to customer satisfaction - whether those customers are students, patients, residents, or whoever. Often regulators require the publication of satisfaction statistics. When the results show improvement, public sector organisations do no need much encouragement.

I was therefore interested in the latest newsletter from my local NHS hospital trust. The headline was "Survey reveals patient satisfaction is on the up":

Significant improvements since 2007 included:

- The hospital room or ward was very clean - up 12%
- Always offered a choice of food - up 12%
- Doctors always washed or cleaned their hands between touching patients - up 10%...

But where did that take the Trust? What were the new percentages? (How many doctors had dirty hands?) How do the new percentages compare with last year's? What were the old percentages? What about the average rates for other comparable hospitals?

There were no charts illustrating any of this. Just words.

Perhaps the article was not intended to report performance - only tell of how the Trust was on "on the up". But accountability is about reporting performance.

Effective boards: 12 principles

The excellent Healthcare Governance Review blog notes that the recent publication by the Department of Health of a review of healthcare regulators includes an endorsement of the Carver policy governance model for boards.

As an appendix to the DH report, the Council for Healthcare Regulatory Excellence working group sets out the 12 principles for an effective board:

1. The board should determine the purpose and values of the organisation, and review these regularly
2. The board should be forward and outward looking, focussing on the future, assessing the environment, engaging with the outside world, and setting strategy
3. The board should determine the desired outcomes and outputs of the organisation in support of its purpose and values
4. For each of its desired outcomes and outputs, the board should decide the level of detail to which it wishes to set the organisation’s policy
5. Any greater level of detail of policy formulation should then be a matter for the determination of the chief executive and staff
6. The means by which the outcomes and outputs of the organisation are achieved should be a matter for the chief executive and staff; the board should not distract itself with the operational matters
7. The chief executive should be accountable to the board for the achievement of the organisation’s outcomes and outputs
8. In assessing the extent to which the outcomes and outputs have been achieved, the board must have pre-determined criteria which are known to the chief executive and staff
9. The board should engage with its ownership regularly and be confident that it understands its ownership’s views and priorities
10. The membership of the board should be capable and skilled to represent the interests of the ownership; this should not be done in a tokenistic way
11. Information received and considered by the board should support one of two goals - to enable decision making, or to fulfil control and monitoring processes
12. The board must govern itself well, with clear role descriptions for itself, its chair, and its members, with agreed methods of working and self-discipline to ensure that time is used efficiently

Perhaps the report might be read by the boards at Newcastle United and West Ham where there have been some issues around the involvement of boards in operational decision-making.

Governance: what is it?

On the Health Service Journal website there is an article on the role of NHS boards and their duty to the public. Paul Stanton argues:

There is significant confusion and muddle in the DH and the NHS about the nature of governance. It is not uncommon to hear senior figures talking about boards managing or leading their organisations. This implies a fundamental lack of clarity about the explicit separation that should exist between the task of a board, which is primarily legislative (making policy, setting strategic goals and holding the executive, and through them the organisation, to account) and the task of the executive (albeit some executives are also corporate directors within the legislative board), which is to lead and manage the organisation so that policies are implemented, strategic goals are achieved and the local community is served.

He credits the American non-profit governance guru John Carver whose model distinguishes governance and management. The board's role is primarily to set policies - essentially, the ends.

While Carver was influential in thinking about the governance of FE colleges soon after they were incorporated as autonomous bodies, his thinking does not get enough attention in the public and third sectors where many bodies drift and range far and wide rather than focusing on their core tasks.

An alternative take on governance was the recent comment that "[Good] governance is a little bit like porn" from Robert Daines, the co-director of Stanford University's Rock Center for Corporate Governance. (This was apparently referring to a Supreme Court judge's comment about recognizing obscenity. "I can spot it when I see it, but it is hard to say what it is.") Who ever said governance was boring.

Good governance improves performance even if effective board members don't save lives

It is always reassuring to see evidence of how effective boards result in better performance. Board trainers like myself like something to prove the need for good governance with more than horror stories of where governance went off the rails. Therefore, I was pleased to read about Stuart Emslie's study Exploring the Association Between Board and Organisational Performance in NHS Foundation Trusts (pdf available on the Healthcare Governance Review blog).

Stuart Emslie found "strong and highly significant correlations" between board performance, as measured using a self-assessment tool with "measures of financial performance, and measures of staff satisfaction derived from the annual national staff survey". However, he did not find any correlation with better patient mortality. Perhaps that will change as better financial management generates surpluses for re-investment and as improved staff morale benefits service quality.

The NHS, Polyclincs and progress

As the NHS awaits the July report from Lord Darzi with its likely promotion of polyclinics (where several GPs’ surgeries are brought together linked to other services), I thought this quote was worth pondering:

We tend to meet any new situation by reorganising [to create] the illusion of progress, while producing confusion, inefficiency and demoralisation.

Usually attributed to Roman Consul Petronius but possibly dating from a British Army officer after the second world war.

Better integration of primary services makes sense. The fact that the medical profession does not like polyclinics could be seen as positive as the BMA has always opposed change including the foundation of the NHS.

On the other hand there is a risk that polyclinics will make primary care more distant from the individual – at least geographically. Nevertheless, we should all be conscious of the investment of time and resources (including the reserves now being accumulated in parts of the NHS) - will it be value-for-money?

What’s the point of complaining: learning from mistakes

This month the Heathcare Commission has published its second report on NHS complaints systems. It suggested that the NHS should use complaints to learn from mistakes and promote improvement.

It’s not a new or radical idea. As Bill Gates commented: “Your most unhappy customers are your greatest source of learning."

Yet reporting on complaints is often seen as chore of governance rather than an opportunity for learning. Reports labour over who complains, what about and what happened (in terms of whether complaints “upheld” and remedial action) – with hardly a mention (probably no mention) of what lessons were drawn from upheld complaints (and, of course, even rejected complaints might indicate scope for improvement).

If public and third sector want to improve their complaints processes, there is help out there. The Housing Ombudsman published a guide some year ago which sets out key principles and best practice (pdf available).

Commitment to reduce public sector bureaucracy

Sadly the aim “to reduce the enormous quantity of meetings, co-ordinations, permissions, conciliations, dispositions, regulations, circulars, etc, etc.” is in Cuba rather than in the UK public sector.

It will be interesting to see if Raul Castro can deliver on his commitment and breathe new life into Cuba’s centrally planned economy. Closer to home the jury is still out on Gordon Brown’s own commitment to regulatory reform. There does appear to be continuing threat to the independence of foundation hospitals.

The Healthcare Commission learning from investigations – mergers, targets, governance and other common themes in public services

The Healthcare Commission watchdog has published an interesting analysis of lessons from 14 investigations into patient safety failures. Such analyses of failing organisations are always to be welcomed. In social housing there are the Learning from Problem Cases series of reviews into "supervision" cases (see the Housing Corporation website here and here). Sadly in other sectors, such as further education colleges, there are ad hoc reactions to failures rather than systematic reviews and efforts to promote learning.

The Learning from investigations report (pdf available) found common themes:

1) Leadership and management: Poor leadership was a problem in nearly all of the investigations carried out by the Commission.

2) Some boards had been focused on mergers or targets at the expense of their broader activities.

3) Lack of continuity in leadership was a problem in some trusts, where frequent changes in management were a factor in poor care. Bullying and harassment by managers was a factor in two cases investigated. The Commission found there was a fine line between promoting change vigorously and bullying.

4) Investigations often uncovered a breakdown in leadership and management, with a lack of clarity on responsibilities from board to ward. Poor teamwork, either between management and clinicians or between clinicians themselves was another common factor in failings.

5) Use of information: The Commission found that most of the trusts investigated did not have adequate systems in place to routinely inform the board of trends or potential problems.

6) Mergers and restructures: Seven of the trusts investigated had recently undergone mergers or significant organisational change.

7) Safeguarding vulnerable adults: Poor understanding of adult protection procedures and responsibilities was a serious problem in the two investigations into learning disability services and also a number of interventions in trusts.

8) Poor care on general wards: When its investigations looked at acute hospital care, the Commission noted that care on general wards fell well below the care provided on specialist wards. Older patients were most at risk as they were often most dependent on good nursing care.

It is note-worthy that the first five of these themes are found widely across public services.

Foundation Trust governance: Network Rail and NHS Direct

There has been some debate about the effectiveness of the governance of NHS Foundation Trusts – in particular, the poor levels of participation seen in some Trusts. However, it is interesting to see that there is an emerging campaign to reform the governance of Network Rail along the lines of Foundation Trusts. In the aftermath of the new year “Network Fail” engineering works, some stakeholders of Network Rails are frustrated by the lack of accountability seen in the organisation.

On the issue of Foundation Trust governance, there is a big opportunity for everyone to have a say in a widely used NHS service. NHS Direct receives 120,000 calls every week. Now it is seeking Foundation Trust status and, hence, asking members of the public to join as Trust members. Its Foundation Trust zone is here.

NHS financial turnaround - superficial or sustainable?

In the Public Finance website’s archive there is an interesting article (yes, really) on the state of the NHS’s finances. In “Surplus to requirements” Sally Gainsbury explores how the NHS has managed to turn a deficit of £547m into a surplus of £510m in one year.

The article looks at some of the most spectacular turnarounds in the performance of Primary Care Trusts.

These paragraphs give a good taste of the explanations:

In annual turnover terms, the biggest recovery was in Western Cheshire PCT. There, the provisional NHS accounts show a move from a £16.3m deficit in 2005/06 to a £4m surplus in 2006/07 – a turnaround of £20.3m, representing 6% of its annual turnover.

But monthly finance reports presented to the PCT’s board between April 2006 and May 2007 show that it received more than £33m in non-recurrent funds in the financial year 2006/07, all of which have been absorbed into its final income and expenditure account.

Other case studies are worryingly similar with one-off windfalls and the like.

Too often “efficiencies” and turnarounds throughout the public sector are a little too superficial.

NHS at 60 – faltering progress on reform

The Economist has made content from its crystal ball gazing The World in 2008 available on the internet. It’s worth a look.

There is a fairly depressing prognosis for the NHS as it reaches the age of 60. The article notes that Gordon Brown lacks the enthusiasm for introducing the market forces of competition among health care providers. The article concludes:

It is hard for the public to feel confident about how Labour is handling the NHS when its staff are so dissatisfied. And one of their biggest gripes has been the threat of private health-care groups moving in on their territory. But there will be a long-term price to pay. For it is exactly that threat which has the potential to unleash real change in the NHS, as Mr Blair belatedly realised. His vision of turning the NHS into a publicly funded health-care market may have run into difficulties, but that reflected the resistance of the vested interests of its staff as well as ministerial incompetence. Under Mr Brown and his health secretary, Alan Johnson, genuine progress in transforming the NHS looks set to falter in 2008.

Moore is less? NHS and Sicko

Although cinema is one of my enthusiasms, I don’t plan to turn this blog into me talking about my favourite films. However, I think I will comment on Michael Moore’s new film Sicko as it touches on public services here.

Sicko movie is Moore’s polemic against the lack of free universal healthcare in the USA. It makes a strong case against what many Europeans would see as indefensible. When Moore leaves American shores, the film is more ropey.

Moore shows the NHS as idyllic. No reference to MRSA, Clostridium Difficile, the neglect of mental health, the way the NHS has sucked in huge additional resources without a proportionate improvement, etc.

When Moore visits France, its not just the social insurance based healthcare that is wonderful – it is everything. I am no expert on French healthcare but I am aware that there is racism, social exclusion, youth unemployment, etc – and that is just the suburbs of Paris.

I did like Moore’s trip to Cuba. Viva Fidel!

NHS Foundation Trusts and accountability - some evidence

One of the legacies of Tony Blair will be foundation hospitals (FTs). They appear to be here to stay too.

A key characteristic of FTs is the governance structure which creates accountability to patients, staff and communities. The example of the co-operative movement served as a model. (Its worth adding that FTs remain not-for-profits and are not a form of privatisation - contrary to what their opponents say.)

Recent research suggests that these structures are working. (It’s a pity that my local FT appeared to lose my membership details for best part of a year. Hopefully I am isolated exception.)

The FT model (and the example of the co-operative movement) is worth applying elsewhere in public services.

Between a Northern Rock and the NHS

The new report from Derek Wanless rings warning bells on the productivity problem in the NHS. There is an executive summary and an interview on the King’s Fund website. The report repeats some of the critique from think tanks like Reform although it does not go so far.

It is unfortunate that Wanless is a board member of Northern Rock. The NHS isn’t the only organisation a bit short of cash at the moment.

The NHS: gifts and markets - the need for both economies

Life has been busy so I have only just got round to reading last week's Society section of the Guardian. It carried an interesting article, Gift rap, by Paul Hodgkin about the role of gift economies in the health service.

I agreed with the main thrust of the article that altruistic and collaborative enterprises (such as support groups) have a vital role in NHS. Hodgkin is chief executive of Patient Opinion which is itself a good example of such gift enterprises. “Co-production” is likely to be a growing part of NHS activity in the future too.

What I disagreed with Hodgkin about was his casual rejection of "markets" in the NHS. He commented:

there are a number of reasons why the search for fully functioning markets in healthcare has little likelihood of success.

He went on:

First, markets within the public sector are zero sum - more hip replacements here means less chiropody there. Or put another way, the foundation trust's surplus tends to mirror my PCT's deficit.

But there will always be a choice between hip replacements and chiropody - unless resources are unlimited. Love it or loathe it, but the National Institute for Clinical Excellence is a way of making those decisions by setting entitlements. The market (or call it choice for patients and competition among providers) is a tool for resolving whether those treatments are at hospital A or hospital B or polyclinic C.

Hodgkin continued:

Second, the "goods" the market is trying to allocate are usually not desirable - unlike a holiday in the Maldives. No one aspires to go to hospital for a mastectomy. As consumers, patients can call some shots in a market. But their fears and anxieties are easy to exploit by suppliers (read doctors) inducing demand for ever "better" care.

I think that medical treatment is very desirable when you need it - even major surgery. The point about professionals over-treating is valid although incentive structures can be developed that address that risk. So doctors and/or hospitals are rewarded for healthy outcomes rather than simple throughput of treatments.

One of the biggest obstacles for markets is the imperfect information that patients have about alternative doctors, hospitals, etc. But Patient Opinion and similar initiatives are tackling that.

I believe that Hodgkin's article reflects are cultural weariness of "markets". We hear the word and imagine Del Boy selling three legged tights or City traders yelling "Sell, sell, sell" into their mobile phones. Perhaps there would be less prejudice against "markets" (and associated hostility to reform) if we spoke about decentralised decision making by patients (or parents or service users or whoever) rather centralised decision-making by planners and politicians.

NHS targets - waiting for change

Apparently an investigation has been launched into waiting list figures at a Lancashire foundation trust. The case at Royal Preston Hospital will be an interesting one to watch.

Managing the public services by target is hazardous as I’ve noted here before. Hopefully the new regime will continue the moves away from targets. However, some experts, such as Professor Colin Talbot in Public Finance, are rather doubtful that a cull of targets will actually occur.

Retreat from reform? Gordon Brown and public sector reform

The public sector reform think tank Reform have produced a challenging analysis of the initial policy decisions of Gordon Brown's government.

Retreat from reform (pdf available) concludes:

The new Government has presented itself as an agent of change. Its initial policy decisions do represent a real change from the previous Government. Alistair Darling’s brave statements on taxation are a positive change, since they give greater prominence to the idea of competitiveness. But for the spending departments, the change is negative and represents a reversal of reform.

It identifies the themes of the new Government’s public sector policies as:

an inputs-led approach. Ministers have praised increases in public sector spending and costs for their own sake. Their key attack on the Opposition has been over putative reductions in spending.

central intervention. Ministers have pledged to intervene in detail, from the maths curriculum in schools to the buildings of the London NHS to the numbers of houses in different regions. This is at odds with the Prime Minister’s rhetoric of a decentralised, “people first” policy approach.

the producer interest. The NHS review, for example, gives much greater prominence to the views of health service staff than to patients.

I was pleased to read that I am not alone in my scepticism about the huge efficiencies (claimed and forecast) underpinning much of policy in public services (both the public sector and the third sector eg housing associations). The report notes:

The Government has indicated that these extra costs will be funded by efficiency savings. But the recent record on efficiency savings is very weak. However, judging by the experience of previous efficiency drives, it is unwise for the Government to fund new spending commitments through the promise of efficiency savings.

The report is well worth a read.

The private sector and the NHS - some unreported good news

I can't recall any coverage in the media last week when the Commission for Healthcare Audit and Inspection published its report on the work of the Independent Sector Treatment Centres (pdf available). Given the controversy associated with a mixed economy in NHS funded care, it would have been useful if this Healthcare Commission had been given a wider airing.

This week there was a mention in the Guardian focusing on the data issues raised by the report:

Last week, a report by the Healthcare Commission, which monitors NHS and private health services, criticised the £5bn ISTC programme for failing to provide information that would allow the clinics' work to be compared with similar services in the NHS.

Interestingly the Guardian didn't highlight the fairly glowing feedback from patients.

The report found that of the 33 issues explored in the patient survey, patients assessed ISTCs consistently better than the NHS on 28 of them.

In some areas the ratings were substantially better.

• 98% of those surveyed said the toilets and bathrooms were “very clean” or “fairly clean” in ISTCs, compared to 92% in the NHS
• 65% of those surveyed said they were given a choice of admission date in ISTCs compared to 27% in the NHS
• 96% of those surveyed said they were told who to contact if they were worried about their treatment in ISTCs compared to 76% in the NHS
• 98% of those surveyed said that there were enough nurses on the wards in ISTCs compared to 92% in the NHS

This is not to say that ISTCs (or the private sector more generally) is better. ISTCs were to some extent set up as treatment factories without complications such as emergency cases disrupting operating theatre scheduling. But the feedback does indicate that ISTCs (and the public sector) can deliver in a mixed economy.

Hopefully the report may contribute to ending some of the prejudice surrounding reform of public services. If so, it may be too late as the government seems to be turning against private sector involvement in the NHS.