Flawed Governance of the National Health Service

From strikes to shortfalls: what governance failures tell us about the NHS

Nearly ten years ago we wrote about the UK’s National Health Service, summarising its origins and history to date, and with a strike by junior doctors looming, we considered its governance in the light of the views of the main stakeholders.

Now, following another recent strike by the latest generation of junior doctors, we look again at the effectiveness of the governance following the changes made by subsequent governments and the current views of stakeholders expressed in opinion polls and personal experiences.

Recent developments

The NHS took a major hit with the impact of the Covid-19 epidemic, resulting in a huge increase in demand, but with resources constrained by Treasury financial restrictions. This followed the years of ‘austerity’ after the financial crash, and compared with the more generous years of the earlier Blair administration.

The general drift of governmental policy has been to work towards integrating community care with hospital care and to increase the focus on prevention to reduce the demands on hospitals. So an important development was the introduction of Integrated Care Systems (ICS) in 2022, dividing England into 42 area-based communities, ranging from some 500.000 to 3 million population. These ICS are responsible for planning local services to improve health and reduce inequalities between the various regions of England and improve productivity and value for money. Each ICS is made up of two bodies: an Integrated Care Board (ICB), responsible for controlling NHS resources and planning health care services in their area, and an Integrated Care Partnership (ICP) responsible for collaboration between the NHS and local government and other local agencies to develop an integrated care strategy to guide local decisions.

Most recently, the current government has announced plans to abolish NHS England (NHSE), the body set up in 2013 by the government of the day to enable the NHS to operate more independently of government. The justification for this new decision is that NHSE has grown to be a huge quango, with a staff of over 15,000 people, compared with the Department of Health and Social Care (DHSC) which employs just over 3,000. The argument is that amalgamating the two organisations will bring the NHS back more closely under democratic control and allow the elimination of some 9,000 jobs. The money saved will then be available for care services.

This all brings to mind the words attributed to Gaius Petronius, soldier and courtier in the reign of Nero:

‘We trained hard . . . but it seemed that every time we were beginning to form up into teams we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralization.’

Finally, prior to this year’s Labour Party Conference, the Health Ministry issued a 10-year plan whose broad objectives were to deliver three shifts: from hospital to community, from analogue to digital and from sickness to prevention.

Recent reports

A recent report from Nesta produced in conjunction with the Health Foundation in November 2023, and titled Nine Major Challenges Facing Health and Care in England, defined the issues it saw the country facing as it approached the forthcoming election, and described nine trends representing some of the major challenges that the new government would face on health and care in England.

It’s worth listing these, as these are what holistic governance in the NHS has to address in the years to come:

1.  Life expectancy is stalling and health inequalities are widening

2.  Key risk factors are driving a significant and unequal burden of preventable ill health and premature death

3.  People are living for longer but with major health conditions

4.  Unmet need for NHS and social care services is substantial and increasing

5.  Long-run trends in health and care spending show a decade of underinvestment

6.  The health system lacks capacity compared with many other countries

7.  Staff shortages are persistent, with stress and burnout high

8.  Public satisfaction with the NHS is at a record low, but support for its core principles remains rock solid

9.  The NHS is repeatedly reorganised, while social care is overlooked

   
   

 A second useful source of information is an article by Camilla Cavendish published by the Financial Times in February 2023 in which she draws on her experience as a journalist, an author of two independent government reviews, a board member of the regulator, head of the No 10 Policy Unit and temporary adviser to the Dept of Health in the pandemic. She describes a ‘crazy series of fiefdoms’, a ‘story… of good people being thwarted, in a disconnected landscape’, and the staff of the health secretary ‘trying to find out what the chief executive of the NHS was actually doing’ during a television interview of the health secretary.

She points out that junior nursing and care staff are the people that patients see most, and hence can make the difference between patients feeling scared and feeling safe, but are the worst paid and least valued. While on the board of the Care Quality Commission she discovered that the CQC didn’t have the data to tell whether doctors were diagnosing properly – a key measure of performance. She quotes a successful CEO of a major hospital who says: ‘the NHS invents its own financial measures and incentive systems … NHS finances are difficult to explain to clinicians, so it is hard to engage clinicians in improving the performance of their hospital’.

In this context, is a small example from my own experience some years ago, when conducting a management consultancy exercise into the effectiveness of the organisation at one of London’s leading teaching hospitals. A senior consultant was asked how he would approach prioritising expenditure of c£1million to purchase a lithotripter or to fund keeping four wards open for a year at approximately the same cost. His answer: ‘Don’t be silly, we need them both’.

Cavendish quotes the scandal at Stafford Hospital where hundreds of patients are thought to have died due to poor care, but which was only exposed by the relatives of the deceased patients.

And finally, she draws attention to a big problem, overall, which is the short-termism of politics when a long-term approach is essential.

At the domestic level, another example is the dysfunction in primary care evidenced by the GP practice (local medical centre) serving my neighbourhood, where appointments have to be booked by lunchtime and there is no booking between lunchtime on Friday and Monday morning 8.00 am. So don’t get sick over the weekend! Indeed, GP experience has diminished almost to zero in recent years, hence the deluge of people visiting A & E (Accident & Emergency).

And experience from my family in regard to hospital care echoes the silo fragmentation of the organisation, staff bending rules to help patients and a culture presenting both arrogant and caring senior consultants, including one rare individual outstandingly concerned with the totality of one’s health.

ACG analysis

Our mission at ACG is to promote the concept of holistic corporate governance, with a set of metrics which together reflect good governance by the board of an organisation in pursuit of its long-term wellbeing, and measured and monitored by regular external surveys of the key stakeholder groups.

Applying this approach to the NHS, we have:

• Key stakeholders

  • Customers/patients

  • Employees/staff

  • Owners/DHSC

  • Financiers/Treasury

  • Suppliers/pharmaceutical companies etc

• Pillars of metrics

  • Culture: including environment impact, social policies and ethical performance

  • Operational model: consisting of a goal satisfying the objectives of the key stakeholders, a realistic strategy to achieve the goal, and organisation structured to deliver, adequate resources of people and finance, effective systems and controls, and accountability and transparency

  • Compliance with the laws of the land, the NHS constitution, medical operating codes and regulations applying to the NHS operations.

So let’s look at Nesta’s findings and Camilla Cavendish’s experience and our own and map them on to our holistic governance structure and measures:

• Culture

  • Patients’ experience is of a system in which individual performance varies from caring to callous

  • Staff are in regular, intermittent dispute with management over terms of employment

• Operational model

  • Patients still believe strongly in the goal of a service free at the point of use, but the strategy to achieve the goal doesn’t work, the organisation is disastrously fragmented, the staffing is inadequate and the finance is always tight; the infrastructure is ageing and inadequate, hence patients in beds in corridors; accountability is confused leading to a lack of transparency; overall patient experience is widely criticised

  • For staff, the fragmented organisation leads to duplication of activities and confusion; understaffing and perceived poor pay creates dissatisfaction; outdated facilities and crumbling buildings make life difficult and IT systems are a notorious problem.

  • The government still believes the NHS model is superior to others but is constantly having to wrestle with the means of delivering the promised service, and the Treasury is faced with an ever-increasing demand for money

• Compliance

  • From time to time, whistle-blowing or external investigations expose failings in regard to good medical practice, and some hospitals are regularly rated good, while others are consistently marked down. Putting right failures seems to be very difficult.

Conclusion

Overall, there appears to be no overarching, consistent set of metrics to assess holistically the performance of the three elements of health care, as perceived by the public: primary care (GP surgeries) secondary care (hospitals) and tertiary care (care in the community), let alone the overall performance of the NHS per se.

Moreover, there is no regular overarching and consistent surveying of the key stakeholders in relation to these metrics to measure performance holistically and deliver critical feed to the boards responsible for governing the NHS. Without such a system the NHS will continue to lurch from crisis to crisis, generating commissions of enquiry, periodic scandals and regular major reorganisations with all the disruption that entails.

Suggested initiatives

With the advent of generative AI, the time is right for a model to be built based on holistic governance to create a stable and workable NHS which satisfies the key stakeholders.

Meantime, each GP practice is required to set up a Patient Participation Group, and these could usefully introduce on-going holistic surveys to feed back to the management of the GP practices to improve primary care.

Also, recent findings by the UCL Business School for Health indicate that there is a major shortage of training for key staff in NHS trusts which will gravely hinder the government’s reform agenda. Here is an area where an on-line training programme could be easily and cheaply introduced, and structured to support holistic good governance and operational performance in hospitals.