Bureaucrats cannot aid the Health Act

As the evening progressed, an increasingly impressive coterie of British Rail top brass assembled to look at solutions, while thousands of commuters stranded on trains waited.

It was, however, a local engineer who recalled previous problems in one of the complex signal circuits, identified the fault, rectified the problem and restored thousands of broken journeys.

I remembered this story while watching Jeremy Hunt, the new Secretary of State for Health, at the recent Conservative Party conference, and wondered idly about the size of his in-tray. The phrase “poisoned chalice” does not seem to come anywhere near it. First, he has the implementation of the Health and Social Care Act to contend with.

If he fully understands and unstintingly supports it, he will be in a minority of less
than two. He has on his desk the findings of the children and young people’s health outcomes forum, which was a response to the criticisms that the act failed to address children’s health needs.

He has soon to deal with the aftermath of the Francis Report into the Mid Staffordshire NHS Foundation Trust and its severe failings in emergency care. The government is committed to clinical commissioning groups, although all the signs indicate that they are struggling to become established. 

Hunt is seeing the private sector questioned over the health care it increasingly provides with, ironically, Virgin Care challenged recently by parents in the West Country over its recent contract to deliver children’s services.  And, as a backdrop to all of this, he has the almost insurmountable problems of an ageing population and the way future care will be delivered.

If this wasn’t enough to guarantee sleepless nights, it is accompanied by a commitment to find £20bn of savings, with mutterings from the Treasury that, even if achieved, may not be enough.

The response to all of this has so far been not dissimilar to how British Rail responded to the southern rail breakdown, bringing in greater numbers of health top brass.
So, when a foundation trust fails, it is the PricewaterhouseCoopers’s of this world that are conscripted – not to run the services, but to oversee commissioning processes with private or independent providers.

Similarly, trusts aspiring to foundation status are almost all obliged to draft in a range of consultants who speak the language both of strategic health authorities and of the regulator Monitor, and who can assist with the achievement of performance targets, governance issues, audits of clinical and financial matters, and large numbers of risk registers. 

The real irony here is that this new level of bureaucracy allows one set of consultants to communicate in the same way as others. It is not a dialogue of organisations that know how to run effective services at the coalface.

So just as it was the engineer on the ground who had a detailed knowledge of how the signalling wiring really worked, the question has to be asked as to what these extra layers of bureaucracy really add. Will they really solve the problems facing the NHS? In paediatric clinics across the UK, children still have to be seen and, as a doctor recently said to me: “There is a level at which my job just goes on in the same way.”

None of this is an argument for opposing improvement or resisting the measurement of success. With budgets increasingly stretched as more people demand more sophisticated treatments, savings have to be found. But it is an argument for ensuring that change and evaluation takes place as close to the ground as possible – just like the inside of the signal junction box.

Let’s just hope Jeremy Hunt’s relative silence since taking office is due to him contemplating how he can listen to the NHS “engineers” as well as the management consultants.

Chris Hanvey is chief executive of the Royal College of Paediatrics and Child Health