Whatever happened to the British traits of 'stiff upper lip' and dignified
understatement? It used to be a (no doubt inaccurate) piece of received
wisdom that Americans overdosed on optimism whereas the Brits were
hard-wired with restraint. No longer, were it ever true....or maybe it is
England(I speak as a Scotsman) which has yielded to hyperbole, with
'metaphysical doubt' only remaining on the Celtic fringes!
I opened my copy of The (London) Times this morning, to find an article
entitled, 'How the NHS could make money for Britain', sub-titled 'We have
a world-class service that we could sell to China, the Middle East and
Africa.' It was written by Mark Britnell, who is now 'chairman of global
health practice' at a well-known major consultancy but who was until a
couple of years ago Director General for 'Commissioning' at the (London)
Department of Health. He was a career NHS manager before that, becoming (a
successful) CEO of a major Birmingham hospital trust and then CE of one of
England's 'Strategic Health Authorities.'
Mark seems to be fond of the moniker, 'world-class.' He is credited with
devising the phrase 'World Class Commissioning' (WCC)in the mid-2000s,
while at the Department of Health - which solidified into a major
initiative, indeed industry, in the English NHS. All Primary Care Trusts
(PCTs) - the NHS's 'commissioners' (ie bodies responsible for assessing
their populations' need for medical and health care, and procuring
services in the 'market to meet that need) - were regularly assessed
through a complex, multi-dimensional 'tick-box' or check list, covering
what were supposed to be all the elements of successful commissioning.
'Commissioning' is in effect strategic planning of services, but conducted
in a market environment rather than a publicly-planned system. It was
sometimes observed at the time that WCC became all about process, and this
may be fair, in that a central aim was to ensure that PCT 'commissioners'
were subjected to the sort of benchmarking which acute hospital and mental
health Trusts had to undergo in order to become 'Foundation Trusts' (the
initial linchpin of New Labour's 'new market' in the English NHS.)
The Coalition government which came to power in 2010 has 'abolished'
'world-class commissioning' as a system, if not as an aspiration, in that
the PCTs are to be abolished, with 'commissioning' in the future to be
done by GP-dominated clinical groups. This assumes that the Health Bill
2011 is passed in the House of Lords - but elements of the reforms
contained in the Bill are already happening 'de facto' on the ground. This
continues the trend begun with the Thatcher reforms (what became the Act
of 1990) of being impatient with old-fashioned inconveniences such as the
legislative process.
Cynics have of course pointed out that the major consultancy groups scent
a major opportunity, at a time when a steely eye is being cast over (some
of) their contracts with the public services and government, for work in
and around the English NHS. With institutional memory departing the
English NHS in a rush for the exits of many senior managers, the new
'commissioners' will need help, and lots of it. Mark Britnell's own work
is global - there is no suggestion that he has moved from the public
sector to the private through a revolving-door inappropriately. The point
of this 'blog' is not, in other words, to 'pick on' Mark, who had a good
NHS record by accounts, but to take his approach as an example of how
consultants might be interpreted as viewing what is, in essence,
comparative health care.
What are the opportunities scented? One is that, in countries which need
new hospitals, "we can use our extensive experience of public-private
projects...." (he mentions China, Asia more widely, Africa and the Middle
East.) The Private Finance Initiative (PFI) was the centrepiece of
'public-private projects' in the NHS, although Mark could point out that
there is more to the concept than the PFI. In the NHS, the PFI has been an
extraordinarily bad deal, and was lambasted as to its effect by the
Conservatives before they took power last year (although it was their
policy, dating from the early 1990s). What do we have to learn about the
PFI, and wider 'public-private' deals, before we export...? Or is it just
about hard cash?
Another opportunity is that "many governments in the developing world
admire our primary care system of GPs and local surgeries....". Now is
this the traditional UK model of primary care, or the English one after it
had been re-re-re-organised out of its wits by ever-increasing waves of
'market reform.' I think we should be told, Mark!
Another is "a wealth of expertise in health data services and management
knowledge..." and the "National Institute for Health and Clinical
Excellence." Call me a pie-eyed altruist, but should we not be helping
countries with advice on the latter - if they so wish - as good world
citizens. And regrading the former, let's clarify that we are not talking
about the multi-billion 'white elephant' formerly known as the National
Programme for Information Technology, another 'public-private partnership'
which has had the English NHS over a barrel since it crashed and burned by
reference to its original aspirations.
I'll leave it at that. In the 1990s, during the NHS 'internal market',
what from memory was called NHS Overseas Enterprises set about exporting
elements of these reforms before they had been evaluated - or even fully
implemented. Poor African nations are tiny Caribbean islands were
astonished to hear about the 'purchaser/provider split' as the answer to
their problems! I hope lessons have been learnt....
Contrast the ethos of the above with the approach of the US Veterans
Health Administration, which was willing, I have been told on US visits,
to share its Electronic Patient Record approach - 'for love not money'
(indeed I believe that, as a federal department, it is not allowed to blur
its mission).....a pity the English NHS had not listened to alternatives
to its 'IT' approach at the time (see above.)
Even were some of Mark's breathless list to be validated, what
consideration is given to how, and under what circumstances, it is
possible, just possible, to transplant policies and management
initiatives?
I do not want to come over all old-fashioned, but come off it, Mark. Some
modesty, please.......!
Calum Paton
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