Visibility and invisibility in a leaderless NHS

Alex Stevenson wrote a piece on the politics.co.uk blog last week where he talked about leadership in the post-reform NHS.  He reviewed the findings of a recent Public Administration Select Committee, detailing a lack of accountability across UK healthcare provision, particularly between the Secretary of State for Health (Jeremy Hunt) and NHS England, (the body tasked with holding the 211 Clinical Commissioning Groups to account). Stevenson claimed that the only sensible conclusion to be garnered from this report was the rather shocking assertion that no one actually knows who is in charge of the NHS. It’s as if those who should be accountable are invisible in the complexity of the new processes. The question this raises is not one of how did this happen, but rather what might be gained by allowing this to happen. It raises questions around the role and function of leadership in the post reform NHS, about what issues might government be seeking to avoid addressing through a lack of (visible) leadership and how this allows them to be wilfully blind to the worst consequences of their reforms.

The term ‘wilful blindness’ describes a situation where someone purposefully remains ignorant of the facts and events that might lead to something gong disastrously wrong. Then, if and when it does, they can claim not to have seen what was going on and thus dodge liability, responsibility or blame. The confusion over who is accountable and who is not, creates a situation of wilful blindness where no one has to admit oversight in terms of what is going on; in this case, no one can be held to account for the dissolution of the NHS. I use the term wilful blindness with caution, it is not intended pejoratively. Linsey McGoey has talked about similar situations under an umbrella term of ‘strategic ignorance’; this is a useful phrase, but there is something about the highly visible way in which these actors need to be seen as unaccountable; there is an explicit tactic in being seen to be visibly unaccountable.

The most obvious example in the legislation is the statutory shift from a duty to provide a health service, to the duty to promote a health service. The lack of a duty to provide a service presents an opportunity for accountability and responsibility to be passed down to the level of local Clinical Commissioning Groups (CCGs). If it goes well, then it’s a triumph for red-tape cutting, bureaucracy busting modern government. If it goes badly, then the political powers that be cannot be held to account, as they were not aware of what was happening down at CCG level. After all now they are only concerned with promoting the opportunity for healthcare, not with providing the actual service.

But it goes even further; consider the idea of ‘provider blind provision’. Put simply, this is the idea of a franchised NHS. Members of the public roll up to their local NHS facility, still signified by the trademark blue sign with white writing, and assume that the health professional they are dealing with are NHS nurses or doctors. They are blissfully unaware of TUPEing, of the role of any qualified provider in the provision of care or any other of the myriad changes that have affected staff at the public face of health care provision.  Obviously, this is politically expedient for the policy makers, allowing them to maintain a semblance of an untainted NHS, with the presence of the privateers in large part unannounced behind the NHS franchise livery. And all the while justified behind an appeal to fairness and equity across providers behind appeals that

“our decision to choose a service provider should be governed by the organisation’s capacity to provide a good service, not the type of organisation offering that service”. Commissioners are “required to treat all contenders as formally equal in the competitive bidding process: commissioners are supposed to be ‘blind’ as to contenders’ size or internal organisational structure, caring only about the quality of services they promise to provide.” (p.18).

This is clearly a fop to processes of privatisation, where competition mechanisms are smuggled in via rhetorics of equity and fairness.

Fast forward a week from Stevenson’s blog and the front-page news is of a ‘cause celebre’ hospital. Colchester General is in trouble again, this time for what’s described as a ‘major incident’ in the A&E unit. Here we see a highly visible Care Quality Commission, holding the hospital and frontline staff to account. Here we see the hand of the regulators, visible and decisive. There can be no doubt in this instance of who is accountable, and that the state (indirectly) are taking firm and direct action to sort out a bad situation. However as Clifford Mann, (president of the College of Emergency Medicine) argues, this major incident is not simply an isolated case of bad practice within the hospital. No, rather it is indicative of pressure on funding and resource issues at every link in the chain, from people unable to get GP appointments for 3 weeks, so resorting to a visit to A&E, to the chronic underfunding of emergency care. However, all we can see is the regulator holding the hospital to account, whilst media reports further vilify the hospital, rather than the broader constrained financial context in which the hospital is struggling to operate.

With winter only beginning and an overloaded A&E sector already struggling to cope nationally, there is clearly a need for government to establish who the villains are, and to wilfully ignore their own role in the crime.