The decision by the British Red Cross to suggest that the NHS was experiencing a ‘humanitarian crisis’ predictably instigated a public debate as to exactly what the terms of reference were for an event to be considered a humanitarian crisis in a Western liberal democracy. Deaths of patients in Worcestershire were reported to have occurred following long waits on trolleys in corridors and long waits for care, chronic bed shortages and staff shortages were taken as evidence of extreme crisis, the proportions of which are more usually associated with areas experiencing conflict or disaster. Through NHS managers, GPs, Politicians and GP who are politicians, a rapid mobilisation of the forces of political centrism ensured that the tone of the debate settled on the conclusion that, while the NHS was under unprecedented pressures, the use of the term ‘Humanitarian crisis’ was an excitable lurch into incongruous shock rhetoric. If for no other reason than to ease the burden on Sarah Wollaston’s answering machine, this blog post is going to focus on an arguably more damaging crisis engulfing the administration of the NHS.
The most recent of the many mass infrastructure changes visited upon the NHS will see the development of 44 ‘Sustainability and Transformation Footprints’. Advocates of the machinery of Simon Steven’s 5-year forward view herald this as a victory for a more integrated and coherent relationship between health and social care services. Those less convinced see Sustainability and Transformation Plans (STPs) as a convenient way to devolve £22bn of cuts into already financially besieged localities by 2020.
Prior to STP, the capacity of the public to be engaged in the management of their services was questionable. For all of the bureaucratic machinery thrown into patient engagement, the actual extent to which people could hold local and national decision makers to account for the decisions made about their health services was limited. Health systems, such as the NHS, are framed by an increasingly prescriptive and centrally driven set of performance metrics, such as waiting times. This creates a bureaucratic double whammy of rampant audit regimes and central command structures. This may account for the relatively few examples where citizen participation leads to tangible improvements in services or changes in policy. Indeed the most recent round of accountability tools and procedures have been described as a form of ‘organisational hypocrisy’ which in practice enact restrictions on meaningful stakeholder voice. The possibilities and benefits of participation are now seriously limited by social and technological complexity which, when refracted through the hierarchical, authoritarian relationships found in public administration, facilitate people to participate as consumers rather than citizens. In such circumstances, it has been suggested that an idealistic and utopian theory of deliberative democracy has taken centre stage with many in positions of power unwilling or unable to discuss matters that might adversely impact their own interests.
With the development of STPs, there has also been a transformation from questionable public accountability to no public accountability at all. Arguably the single thing that advocates and detractors of STPs agree on is the complete lack of even the idealistic utopian democracy resonant of the previous practices. Despite requests from various organisations, the STPs have largely remained secret. Recently, both Birmingham & Solihull and Camden released their plans against the instructions of NHS England and little or no public consultation has taken place on the plans. Even GP leaders, who will be directly affected by the plans, have reported that they are being excluded from discussions.
Kieran Walshe, in an article in the HSJ, noted that we have entered “a shadowy era of extra-legislative reform where it is getting difficult to work out where accountability lies, who’s in charge, and whether organisations are doing their job properly….For NHS boards, there is a potential conflict between their statutory duties as a board and an organisation, and some of these changes which require them to cede autonomy and authority to new organisational forms (like STPs) which have no formal existence.”
Medical director Sir Bruce Keogh says that “those who are proposing the change have a duty to explain to local communities why those changes offer an improvement” while the King’s Fund suggests that ‘Honesty will be needed in communicating these messages to politicians and the public’. Regarding accountability, the STP model is not deliberative or participatory but explanatory. i.e., the changes have been made so let’s tell people what they are. What impulse underlies this altogether more paternalistic version of public engagement currently being pulled centre stage and does it matter?
The breakneck speed of STP implementation has ensured that these paternalistic engagement tropes resemble what Leonardo Avritzer calls democratic elitism- that is, policy premised on a concern for protecting democracy from too much participation by ill-equipped masses. This rationality suggests that the only way to make democratic participation effective is to limit it to bureaucratic elites. The problem is that such democratic elitism is premised almost entirely on instrumental rationalism. Here, health service planning is a technical exercise where health services have only an instrumental value.
However, people do not only have a rational relationship to health services. Health services and hospitals, in particular, are important to peoples’ ideas about local identity and sense of place. In the UK, hospitals play an important symbolic role; they are more than just buildings where healthcare is delivered. They are the physical incarnation of the NHS and its values within a particular locality. Indeed the narrow instrumental rationality that underlies much health policy can be seen as deeply irrational because it denies the basic humanity of the people who work within and are served by them. Hospitals are places of suffering, death, life, hopes, fears, anxieties, emotions, relationships and values. Whether by collective imagination or individual experience, hospitals exist at the juncture of life and death and are bound up with our notions of ontological security. And such security is central in mobilising people to protect local health services at risk when such instrumental rationalism is driven to excess by central government ideology.
The moral division of labour between reason and sentiment is embodied by currently dominant models of citizen engagement that are purified of affective dimensions. Here, public opposition becomes conflated with an opposition between reason and sentiment. When genuine engagement is completely removed, the wheels of democratic elitism become easier to turn but health services outcomes are almost invariably damaged.
In a time of little support for governments’ policy package among health professionals and where local health care professionals are in opposition to local and national changes in health policy and commissioning, local communities are important to balance the rational pragmatics of cost control with lived experiences of health outcomes. In this context, paternalistic explanatory modes of engagement can be understood as self-defeating.
Draft plans have now been published in 43 of the 44 areas. In some areas the plans have included proposals to cut hospital wards and downgrade local services. Previous incarnations of health accountability, for all their flaws, opened up spaces for public voice to be heard on what will inevitably be experienced as profound changes to communities, towns and cities. The Kings Fund recently suggested that the STP process must continue, and the current plans need to be ‘stress tested’ to ensure that the assumptions underpinning them are credible and the service changes they propose can be delivered. One might add that meaningful public engagement be the central component of this stress testing. Otherwise rationalised central planning dictat of £22bn worth of NHS cuts will engender a crisis that will have even Teresa May calling for Red Cross intervention.