Robert Ede is Head of Health and Social Care at Policy Exchange
An independent report into leadership across health and social care, led by Sir Gordon Messenger, has been published. The Review was first announced by Sajid Javid, the Health Secretary, on the eve of last year’s Conservative Party Conference as the Government identified that leadership was a crucial part of “make every penny of taxpayer’s money count” in public services delivery.
Reviews of NHS management are nothing new; Javid’s political hero Margaret Thatcher commissioned supermarket executive Roy Griffiths in 1983 to undertake a Review which led to significant power shifts, including the introduction of general management into the NHS. Many others have been tasked with following Griffith’s footsteps. In the past seven years alone, we have had four similar investigations into leadership conducted by Lord Rose, Sir Ron Kerr, Tom Kark QC and Sir Robert Francis.
This matters because NHS management is in the spotlight. Planned spending for the Department of Health and Social Care in England reached £190.3bn in the past financial year. There has been an ongoing debate in the media about both the level of spending as A&E performance tumbles, people struggle to access GP appointments, and waiting times lengthen.
The public believes that how spending is controlled could be improved: ‘money is wasted in the NHS’ was the fourth most popular reason for the historic low levels of satisfaction with the NHS in the latest British Social Attitudes Survey. In offering suggestions, a blizzard of different commentators suggest that the NHS is either over managed or under-managed, over centralised, or too disparate, too politicised, or not politicised enough.
The document is a good read. Independent reviews on NHS leadership are often voluminous; this is just 10,000 words and can be digested in an afternoon. The brevity is matched by the modest number of recommendations – just seven – all of which have been accepted in full by the Government.
Targeted interventions at entry and mid-level management. Positive action rather than tokenism on equality, diversity, and inclusion. Consistent, accredited training. A standard appraisal system. A new talent management function in the regions. More effective recruitment of non-executive directors. Incentivising talented managers to take the most difficult roles.All sensible. Little to fundamentally disagree with. Does that mean a solid output, or an opportunity missed?
When first appointed alongside Dame Linda Pollard, Chair of Leeds Teaching Hospital in October 2021, Sir Gordon was tasked with assessing the state of leadership across not just the NHS but also social care, and in particular understanding mechanisms to address variation in quality across the country. A seven week wait ensued before the terms of reference were published. Re-reviewing the ten domains and comparing them to the final product is instructive.
The final report make few explicit observations about leadership in primary and social care. The terms of reference suggested that the Review would explore the ‘systems for intervention’ in providers and Integrated Care Systems. Yet the role of inspection and national oversight only receives a short paragraph, and no specific recommendations. Proposals to drive up efficiency were also trailed in the launch, but whilst efforts to standardise training may lead to improvement, as solutions they feel modest when you are setting punchy 5% efficiency savings targets for Trusts to deliver.
Bigger questions are left hanging. The Review says that constant demands from above, including from Ministers, created an instinct to look upwards to “furnish the needs of the hierarchy”. An interesting finding – but with the centre’s role not formally included within the scope of the Review we are left with no solutions.
This feels odd. The Health and Care Act signals a major change in how the NHS is run. Dependent on who you speak to in healthcare policy you’ll get a mix of optimism and pessimism about integrated care systems – the new sub-regional structures with have replaced the Clinical Commissioning Groups under the Lansley reforms of 2012.
Policy Exchange tend to be on a pessimistic side. But where there does appear to be consensus is on the need for an open and legitimate debate around the role of the centre. Questions that keep coming up include:
– Is the current size and respective roles of both NHS England and DHSC justified as we move to a new phase in the pandemic?
– What should be the role and function of the NHS England Regional Teams?
– Does the existing structure and operational independence model allow for a true health-creating agenda across Whitehall?
– Can Ministers find the right balance between achieving good oversight and accountability whilst creating an environment of innovation and professional autonomy?
Policy Exchange think we should lean into, not walk away from these awkward questions. Our recent research on specialised services ruffled feathers when we pointed to the significant growth in both NHS England and DHSC during the past two years.
When NHS Digital and NHSx are formally subsumed, NHS England will have a workforce greater than 20,000 – easily the most complex arm’s length body in the country. We wanted to highlight this, but our argument was never to call for a cull of management across the NHS. Indeed, managers make up a lower proportion of the workforce than most other sectors and in previous research we recommended that the Government expand skilled manager roles with data analytical expertise in trusts with the biggest backlogs.
Management is worth its weight in gold when managing a dynamic and growing planning care waiting list of 6.5 million. The bureaucracy is not too big, but it is in the wrong place.
When it comes to the Messenger Review, Sir Gordon and Dame Linda Pollard offer no assessment of the total numerical and skills mix required to manage the NHS and social care sectors. Indeed, there is almost a complete absence of any quantitative analysis or statistics to underpin the findings.
Ministers also receive no direct advice from Sir Gordon on how to tackle the tensions between accountability and management, apart from being encouraged to spread the limits on the freedom for local leaders to try things “without fear of failure”. Perhaps this is a failure of those commissioning the review rather than Sir Gordon. Policy Exchange has been one of the few organisations to defend the additional Ministerial powers set out in the Health and Care Act– which we believe are proportionate and justifiable.
The timing of the launch is significant given the media headwinds about bureaucracy and waste. This is not just an agenda of the Conservative-leaning press. Since his appointment as Shadow Health and Social Care Secretary, Wes Streeting has chosen to criticise spending on both management and consultants, and recently told the audience at an Institute for Government event that “producer interest has to take second fiddle.”
The Review was an opportunity to offer an assessment on these debates and set out a clear vision for NHS leadership and management as we move towards system working – in the same way that the Griffiths’ Review made the weather for the introduction of the internal market.
This chance has not been taken. Further work is likely – with both Skipton House and the Department working on a future operating model. But you are left feeling that if an independent review couldn’t create the space for something radical, then NHS England is unlikely to yield anything better.