A Brief History of Folly: the NHS, Integrated Care, and How to Challenge the Changes

John Carlisle, Chair, YSHA

25 March 2020 (revised 13 May 2020)

The NHS was an Integrated Care institution, until the politicians began to meddle with it. Norman Fowler started the rot when he set aside the Area Health Authorities (AHAs) in 1982, after being Health Secretary for less than a year. The AHAs had been running for eight years and were on the verge of integrating with local government to balance regional demand and supply. The management system was key. Local management teams integrated the hospitals, family medical clinics and community health centres; and decisions were made by consensus.

Fowler’s intervention was a major disruptor, opening the way for the top down, ‘efficiency’-driven fragmented encumbrance that Hunt and Stevens have left us with today.

What was Norman Fowler’s qualification for this key role? Just like Michael Gove’s for education – journalism! How much did he know about how large service organisations work best? Did he visit the Marriott or Taj hotels, famous for their service, or John Lewis, or even another successful health service? No, his opinion was sufficient. He clearly had never heard of Continuous Improvement, a policy used by the finest companies in the world, e.g. Toyota. Toyota has never reorganised in fifty years; but it obliterated General Motors in less than 10 years, with a little help from Honda and Nissan – not on price, but customer satisfaction.

Here we have the nub of the problem: Ministers are put in charge of vital services like the NHS, Transport, Justice, and Probation (the last three all fell under the egregious Chris Grayling) with no understanding of them as systems. Instead they arm themselves with neoliberal ideology, and with command-and-control management style. The extent of their ignorance is only matched by the degree of cognitive dissonance, which means they refuse to acknowledge any evidence that shows their policies are not working.

This is where activists have gone wrong. In the case of the NHS they have presented moving examples of very sick patients in corridors, nurses at the end of their tether, grieving families etc. This approach is not effective in challenging a money-driven government. The empathy in the political world, especially of the Conservatives, seems negatively correlated with the seniority and significance of the post, e.g. Theresa May and Priti Patel at the Home Office, Chris Grayling at Justice and Probation, Jeremy Hunt in health. In summary, those with the thickest skins get the posts requiring the greatest humanity.

What we need to do is point out clearly their failures as ‘executives’ in their jobs and the subsequent waste and increased costs. We need to relate these consequences to their flawed organisational model, i.e. targets, cost-cutting, outsourcing, privatisation, and, most subtly malignant of all, excessive governance and compliance. The YSHA will be directing its efforts to replacing the Tory public sector disaster with a State economy based on Bevan’s In Place of Fear (1952). This will resurrect the model of excellent service the NHS provided before the destructive tampering. It will then be applicable in all public services as they are brought back into the public domain, working hand in hand with a new green economic strategy.

We must be prepared to change everything!

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