For politicians, the concept of setting the NHS free from political control was superficially very attractive. NHS professionals and managers have long disliked political interference and the public – always confused by NHS structures and jargon – has been happy to take its lead from them.
For the best part of a decade all parties toyed with various ways of increasing the operational freedoms of the NHS, from the then Labour Government’s Shifting the Balance of Power to the then Conservative opposition’s draft NHS Autonomy and Accountability Bill. So the ‘independent’ NHS Commissioning Board and further measures to protect providers from attempts at political interference which were introduced by the Coalition Government should not have come as a surprise to anyone. Equally, politicians on all sides had plenty of time to think through the political as well as operational implications of such a move.
Yet the reality is that we are in uncharted waters. For the first time, we have an NHS leadership that can legitimately rebuff the well meaning attempts of politicians to interfere, but we also have a political class whose instincts on the political importance of health remain as strong as ever. The Prime Minister’s intervention on nursing quality earlier this
year, including instructions that nurses should check on their patients at least once an hour, was hardly consistent with the liberation ethos. The instinct to interfere remains strong for a reason. Although the public, with a consistent distrust of politicians, may oppose attempts to interfere with the running of the NHS, they also desire swift action on issues of concern to them (think dirty hospitals or waiting times). More than anything, they want to see a sense of momentum, of a service that is seeking to improve rather than stand still.
This is a major challenge for the NHS Commissioning Board. Designed and staffed by managers who are by and large unused to making the case for change to the public and stakeholders and faced with a strong desire from clinical commissioning groups to run their own show, the temptation may be for the Board to assume a low profile, particularly as it gets to grips with setting itself up and overseeing a transition at a time of significant financial challenge. Yet adopting this approach would be a mistake.
Communications, as with nature, abhors a vacuum. Unless a strong narrative is developed by the Board explaining how the reforms will be applied to improving particular services, then someone else the politicians) will be forced to do so. Given the political importance of the NHS, no amount of legal safeguards for operational freedom will prevent politicians stepping in on communications if they feel the message is not getting through. Waiting for the new powers to be turned on and for the new system to bed down will not be seen as a valid excuse.
This is not simply about media-friendly announcements. There are a range of stakeholders in health – from the professions to charities or campaigning groups or even commercial suppliers – who can all be powerful intermediaries in getting a message across. However, to do this, they need to be engaged and enthused, often in private and in some detail. The best secretaries of state have been extremely effective at doing this (think Alan Johnson on ‘top ups’), whereas some of the less effective incumbents of Richmond House in communications terms struggled (think Patricia Hewitt on hospital
This is difficult territory for ministers. The new reality is that their answer to almost all stakeholder concerns should be to explain that it is a matter for the NHS Commissioning Board. Yet such a response is hardly tenable if the Board is not actively engaging with the same stakeholders, nor does it convey the sense of commitment to, or interest in, the NHS which ministers feel and which the outside world wants to see.reconfigurations). The danger is that the new liberated system creates a communications vacuum, whereby neither the political wing of Richmond House nor the NHS Commissioning Board fulfils this role effectively.
Although on an issue level, stakeholder engagement by the NHS Commissioning Board is happening (the development of the cardiovascular disease outcomes strategy is one example), on a more overarching level there is not yet a sense that the Board’s leadership is reaching out to stakeholders, explaining how it will all work. This may be because the details are yet to be developed but if this is the case a little bit of thinking aloud would not go amiss.
Charitably, it is possible to conclude that the NHS Commissioning Board is only just getting its key communications personnel into place and that now this has happened, the plan will become clear, with effective engagement beginning soon. However, it is also possible to speculate that, in all the legal debates about which body held which power, and in all the planning for the transition, the responsibility for developing and communicating the vision got overlooked. If liberation is to be real, then alongside the transfer of power there must be a shift in responsibility for communications.
If there is a plan, it should be enacted quickly. If there isn’t one, then someone should develop it. Otherwise, there is a danger that old habits will reassert themselves.