Take me to your leaderBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2092 (Published 03 April 2013) Cite this as: BMJ 2013;346:f2092
- Nigel Hawkes, freelance journalist, London
For an organisation that sets a lot of store by evidence, the NHS is easily swayed by fashion. An idea takes hold, gains purchase, and becomes the accepted wisdom so swiftly that you have to be on the alert to keep up. Perhaps that’s why there are so many breakfast meetings, seminars, and one day conferences in which the same cast of people exchange views on whatever idea has temporarily captured the zeitgeist.
Currently, it hardly needs saying, integrated care is it. The parliamentary select committee on health strongly endorses it, the think tank the King’s Fund proselytises about it, and the Labour Party—in the person of Andy Burnham, shadow health secretary—has proposed yet another reorganisation of the NHS in England in an attempt to achieve it.1 I may just have a suspicious nature, but when everybody is in such warm agreement my instinct is to take to the hills.
A US psychologist, Carl Rabstejnek, has identified at least 100 management fads and fashions since the second world war, from “acceptable risk” at one end of the alphabet to “zero defects” at the other, taking in “just in time,” “management by walking around,” “dress-down Friday,” and “transformational leadership,” to pick a few at random. Rabstejnek argues that fads reflect managers’ need to appear to be “in the know” and to talk the language of change even when actual change is imperceptible. The largest financial support for fads comes, he argues, from large companies that are actually slow to change: no parallel to the NHS, clearly.
The NHS has not embraced all these fads, though it does have a weakness for those that include the word leadership. I’m sure you will be as pleased as I was to learn that the NHS is to train 25 000 new leaders, starting in September. This is the largest ever leadership programme to transform NHS culture, the NHS Leadership Academy declared. A huge cast has been assembled to carry out the task, including the consultancy firms KPMG and the Hay Group, six universities (four of them outside the United Kingdom), and various other facilitators and assorted hangers on. If the target is reached the NHS will have nearly as many leaders as the Duke of Wellington had followers at Waterloo.
In the wake of the Francis report into the failings at Mid Staffordshire, the NHS portrays this programme as a means of achieving a culture of “dignity, compassion, and respect” through better leadership. It’s a worthy aim that perhaps doesn’t merit my scorn, but if you have to teach people who already work in healthcare these values, we’re in a bad place. At the same time, we have the respected US guru Don Berwick providing guidance to the NHS on “zero harm,” a management tool so newly minted that it doesn’t even make it on to Rabstejnek’s list.2
As for integrated care, it would be a start if everybody agreed on what it means. Maximalists argue that it involves the integration of health and social care, minimalists that it is about providing a seamless programme of healthcare without any awkward transitions across primary, secondary, and community care. Burnham has recently adopted the maximalist position, calling for local authorities to swallow the new clinical commissioning groups to become the commissioners of both health and social care.
This is an idea that would have delighted Herbert Morrison, Labour’s postwar champion of local government, who argued unavailingly that councils should be given control of the hospitals in the new NHS. The minister of health, Nye Bevan, disagreed—and won the argument, setting up regional boards that were appointed rather than elected and had no political accountability. He was swayed by the country’s consultants, who didn’t want to work for local authorities, but it’s arguable that the outcome produced a system so opaque and detached from local politics that people had little idea of the costs and realities of delivering their local healthcare. Over the years this opacity has made any change in existing provision, such as integrating care, more difficult to achieve.
So Burnham’s proposal has virtues, if we overlook the reorganisation involved and the fact that it is incompatible with his opposition to “any qualified provider” providing care. Local authorities have contracted out services through competitive tender for the past 20 years, to the point where roughly a third of their services are provided externally by private sector, third sector, or mutual based organisations. Healthcare under the council banner would be no different, with Conservative councils likely to contract out more services than those led by Labour or the Liberal Democrats. An interesting experiment—but I’m not sure that, on reflection, Labour would think it a very attractive one.
More modest “care only” integration is assumed to improve care and cut costs, but a characteristic of management fashions is that everybody accepts them as true without arguing. Research findings present a more nuanced picture. The evaluation of 16 integrated care pilots launched in 2008 showed that staff were happier in their jobs and believed that the care they were providing had improved, but patients were not so sure.3 There were suggestions that care became professionalised and that focus on the individual patient was lost. Emergency admissions of patients in the pilot areas were higher than in the control group, and it was hard to draw any clear conclusions about overall costs.
Other findings cited by the King’s Fund in its publications are more encouraging, though some of the examples it chooses are not really integrated care—the success of the London stroke programme, for example, is surely the result of reconfigured acute care. To my eye the existing evidence falls some way short of justifying integrated care as a panacea for the NHS’s ills, attractive as it may seem. To call it a fad would be unfair; at the moment it’s a fashionable policy in search of persuasive evidence that it really works. Given the obstacles to change in the NHS, its time may pass before it has even been tried.
Cite this as: BMJ 2013;346:f2092
Competing interests: None declared.