Does the NHS need 'disruptors, heretics, radicals and mavericks'?

Banksy-style graphics can't disguise that the 'change leaders' in the NHS are set on ever more marketisation, not genuine radicalism.

John Hully
26 September 2014

Front page of NHS IQ White Paper - Keep Your Coins, I want Change.

The blogger Sue Marsh, who has severe and Crohn’s disease, has been a user of the NHS for decades. Last weekend she published an account of her most recent hospital experience.

“If I listed the catalogue of disasters I’ve experienced … this post would be 10 pages long. Possibly 20..”

Several days into this hospital stay she decided that she would be safer at home and left, to return only after negotiation.

Around the same time, the leaders of NHS Improving Quality, responsible (since April 1st 2013) for 'driving innovation across the NHS' published a new White Paper. They believe the NHS is fundamentally failing, too.

 So what's their solution?

Their manifesto, or 'Call to Action', turns out to be a call to “disruptors, heretics, radicals, and mavericks” - replete with management jargon and wrapped in consciously anarchist pseudo-Banksy style graphics.

NHS IQ state that improvement drops out of change, and change is equivalent to disruption of equilibrium. It wants heretics and radicals to take control. It wants to summon mavericks – the fourth horsemen of this apocalypse – to replace those who resist the revolution. 

NHS Improving Quality is a creature of the Coalition’s Health and Social Care Act. It turns out to be completely without self-awareness, as a body set up by and reporting directly to NHS England demands innovation to be led “from the edge”. 

The NHS IQ report’s barely legible fonts call to “curate rather than create knowledge”, complete with impenetrable definition.

But its ethos is entirely consistent with Lansley’s vision of that Act, it seems.

Before becoming the Health Secretary Lansley set out just this kind of thinking very clearly (to the NHS Confederation, at least).  Change would be led from the edge, he suggested:

“…for staff across the NHS, especially managers, to stop worrying about, and waiting for, the next initiative from the Department of Health, and instead start creating potentially successful providers in a competitive environment.” 

Lansley was determined that target-led command-and-control from the centre should be swept away. Tragically, he was totally persuaded that the only alternative was competition. He thought previous privatisations had failed by merely replacing public with private monopolies.

Once in office, Lansley legislated to move the NHS in England into a new condition of permanent change, no longer the responsibility of the Secretary of State. Like Monitor and the Care Quality Commission, NHS Improving Quality orbits in Lansley’s system of quasi-independent bureaucracies: designed and implemented to pull the NHS from its previous position as a public provider and prevent it from returning.  For ‘heretics and radicals’, read ‘advocates of competition and private provision’.

The ‘new thinking’ of NHS IQ is that quality cannot be improved incrementally, from the bottom up, by identifying improvements and implementing them. A new narrative – its new story – is in fact the very old one of ‘creative destruction’. Competition – to be the most heretical, the most disruptive, the most radical, the biggest maverick – replaces collaboration. Few would want to work – or could work - in such insecure cultures. They are wholly inappropriate for health systems.

The NHS is a complex system. What emerges from the interactions and feedback loops within the NHS and between the NHS and the rest of society cannot be predicted. The political consensus of the last four decades is that whatever might emerge could not be desirable: public employees could not be trusted. New Labour tried to constrain what could emerge from the NHS with targets and soviet-style control: Conservatives and Liberal Democrats combined to create a new NHS, with its participants distracted not by fear of targets, but by fear for their jobs.    

Like Lansley, NHS IQ advocates experimentation on non-volunteers. Meanwhile, problems in front-line care multiply, unaddressed.

Sue Marsh’s experience is a much better indicator of what is required to improve quality and safety. A simple explanation of an actual problem that needs fixing, no:

“I have barely had a single nurse who wasn’t competent and kind. There simply aren’t enough of them. In the 20 years I’ve spent an average of a month of every year in hospital, I haven’t experienced staffing levels as bad as this since 1995. They simply don’t have the time to do all the jobs they need to. To be more accurate, they don’t even have time to get through the very basic tasks of ensuring patients have nutrition, fluids, cannula care and a referral to a doctor.”

If the NHS Improving Quality team were to direct time, budget, and resources at understanding and improving the experiences of patients rather than producing showy leaflets, videos and grand plans to impress their bosses, calling for disruption, or indulging maverick behavior, the NHS might well be a safer, improving, organization.

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