Have NHS leaders failed to “speak truth unto power”?

NHS Management

This is blog is not a rant—well not too much of a rant. It is an expression of serious frustration about the way the NHS is run and about the willingness of some senior NHS managers to become complicit in something near to dishonesty.

Everyone at the frontline knows the NHS is running on empty. The more perceptive know that more money for the NHS alone will not improve services for patients. But—and this is perhaps the unpopular “but”—NHS senior managers ought to accept their share of the responsibility for the present crisis because they have colluded in pretending the NHS can deliver the impossible. Does anyone believe that NHS managers have “spoken truth unto power” about limits of NHS productivity?

The importance of public servants confronting ministers with uncomfortable truths has a long tradition. Long before Sir Ivan Rogers used the phrase, a 2015 FCO blog said:

“The UK Civil Service doesn’t have an official motto—but if it did, it would almost certainly be: “speak truth unto power.” It’s a maxim that’s in the blood of good civil servants, even if they know that it won’t make their lives any easier. The best politicians learn to cherish civil service advice which points out the flaws in their arguments. The worst surround themselves with sycophants who create a micro-climate which wraps a warm embrace around their worst tendencies.”

But, who speaks truth unto power in the NHS? When do NHS managers draw lines in the sand about what is realistically achievable in response to NHS England or NHS Improvement? Rarely, and often only at the (premature) end of a career.

The STPs are the latest set of “plans” where NHS mangers have been asked to promise to deliver the impossible. In response the NHS is signing up plans which are more fiction than reality. Privately, NHS senior managers know that STPs are totally undeliverable for a series of interlocking reasons.

First, they know that the NHS does not have effective change management procedures. Every small change has to be negotiated and agreed in detail with all stakeholders before it can get the green light. Thus every CCG, every truculent local authority, and every NHS Trust holds a veto to stop change happening. That stops controversial plans happening for years.

Secondly, politicians can block change. Time after time, local managers are overruled by senior NHS staff to avoid political embarrassment.

Thirdly, even if changes could be agreed locally, the capital needed to deliver effective changes is not available. Managing change is expensive, new buildings cost money and must be built before old ones are sold, and a measure of double running is inevitable. Capital money to fund STPs is spent plugging existing deficits. The iron rule of public service—you can only spend the same money once—seems to have been lost.

So why is the NHS repeating a failed planning process? Because it is told to. Scratch the surface, and many will reluctantly admit that the management culture of the NHS is close to dishonest. NHS England or NHS Improvement tell commissioners and providers what the plans are required to deliver. Once the targets are set, it is not acceptable to say that a plan to create financial balance or deliver 95% A & E performance “cannot be done.” It is equally unacceptable to say “It cannot be done without substantial capital investment, money for double running, and political will to deliver a series of unpopular changes.” NHS officials come under intense pressure to produce plans that confidently predict the undeliverable and most bow to that pressure.

The plans get signed off and the “system” confidently tells ministers that all will be well, all will be well, and all manner of things will be well. But, of course, now we know that all will not be well without substantial new investment in health and social care or if standards are substantially lowered. But, no one in the NHS is allowed to say that.

The NHS in England is in the mess it is today because of systemic overpromising and underfunding. That is primarily the fault of politicians. But, NHS management culture must bear its part of the blame. NHS managers, with some honourable exceptions, have colluded with politicians to tell them what they wanted to hear, and then demanded those under them produce plans to make good on those promises. Is it time to change the NHS culture by having courage to say what can and cannot be achieved with current resources?

This was first published by the British Medical Journal