Results tagged “nhs”

Following the Health White Paper in July, Paul Corrigan wrote a fantastic series of posts analysing Andrew Lansley's proposals. It wouldn't be an exaggeration to say that it was the best thing out there on the White Paper - so good that I collected them into a handy series of posts.

Well, he's at it again.

This time, Paul has looked beyond the current and apparent position of strength Lansley finds himself in (as a man with a plan) and identified four potential issues that can make current strengths into weaknesses.

Each of these four themes is linked to below, with a choice quote taken from each. Even if you have a passing interest in health, social care or the political process for major reform, I urge you to read them all.

1. Are the NHS reforms owned by the Government as a whole and how strong is Andrew Lansley’s position as the main exponent of that reform?:

So the political strength behind the NHS reforms is that the Cabinet and the Prime Minister support Andrew Lansley. The political weakness is that no one apart from him, including the Prime Minister, 'gets it'.

2. Where will the politics of NHS reform in October 2010 stir up some enthusiasm?:

I may be wrong but I get the impression that the current Secretary of State doesn’t think this is his job. I think he genuinely believes that since he is removing ‘NHS bosses’ from the NHS, then enthusiasm will simply "spring forth" of its own accord. This may also be how they think of the Big Society - that all this energy has just been suppressed and therefore it is somehow wrong for members of the Cabinet to go around stirring it up.       Waiting for others to do this will not work.

3. The politics of NHS reform in October 2010 - Will the Change Process Work?:

The current Secretary of State did not come down from his revolutionary pre-election base in the mountains with thousands of Conservatistas who could run the NHS in the new revolutionary way. He has no-one. He may believe that there are groups of bandoliered GPs ready to take on PCTs and fight for GP Consortia (All power to the GP commissioning consortia!) But the few there are, are not enough. The people who will make change happen are the people who are going to be sacked and have always rather liked the old system.

4. NHS resources between now and the proposed abolition of PCTs in April 2013 - Will the sums add up or will there be deficits?:

This means that for the next three years there will be two conflicting systems for the distribution of finance at work in the NHS. One that believes the finance should be controlled by a hierarchy which goes from the DH down to the SHA to the PCT, the other that believes it is the job of the PCT to look out for its local population and buy the best health and health care they can find.

(*Long post title in honour of Paul's own length blogpost titles!)

DH statement, 29 August 2010:

NHS 111 telephone number will eventually replace NHS Direct when it is rolled out nationally

(copy of letter available here):

I have not announced plans to scrap NHS Direct

This is sophistry born of arrogance, ignorance and power. Lansley is taking us all for mugs, and we should be absolutely plain that we won't stand for it.

It's an unusual thing, and is normally the result of dodgy motivations, but the Daily Mail is occasionally right in being outraged by something.

In this case, it's the dual role held by one of the government's obesity advisers:

A senior adviser in the Government’s battle against obesity has been criticised for receiving thousands of pounds from the slimming industry.

Of course, the funny thing about this is that it's a perfectly natural extension and intellectual bedfellow of Andrew Lansley's policy for

Beer companies, confectionary firms and crisp-makers [to] fund the government's advertising campaign to persuade people to switch to a healthier lifestyle.

I suppose the only unusual thing about this particular adviser is that she also works for someone who is broadly trying to support the government's agenda, i.e. supporting the public to become healthier, rather than not.

Following a whole series of post on the #healathwhitepaper (see "other posts" below), it's interesting to note that the powerful BMA is doing its best to ignore the proposals contained in the White Paper and focused instead on GP contracts:

We hope there will be few changes to the GP contract as this is a UK contract and commissioning is an England policy. We know that the government wishes to make a few, very significant, changes, but we will be trying to minimise these.

Doesn't fill me with confidence if the representative body of professionals in whom virtually everything is being entrusted don't seem that keen.

Following up my post on patient voice in the Health White Paper, here's one capturing my confusion over how health relates to social care.

It is baffling to me that a White Paper entitled "Liberating the NHS" makes so many references to social care. Indeed, the White Paper may be liberating the NHS, but it feels like it's making a landgrab for social care.

The direction of travel all seems to be from social care to the NHS. Take paragraph 4.19, for example:

Local authorities [will have] influence over NHS commissioning and [there is] corresponding influence for NHS commissioners in relation to public health and social care. NHS commissioning will be the sole preserve of the NHS Commissioning Board and GP consortia.

At the end of the White Paper (para 6.7), it's casually dropped in that the role of NICE will be extended to social care. Why? David Brindle notes the concerns wonderfully here, and what it might mean for social care more generally:

[T]he decision to extend Nice's writ raises questions about the continued separate identity of social care. The sector has long pressed for the joining-up of health and social care - and the white paper seeks to promote this, particularly through the proposed new role for local government in respect of public health - but the ambition has been on the basis of equal partnership.

Nice's planned move into social care, coming after the collapse last year of the Commission for Social Care Inspection into the Care Quality Commission, suggests that health is being seen very much as the senior partner in this relationship.

Is this the right way round? Figures out this week indicate that the social care sector employed 1.6 million workers in England alone in 2009, an increase of almost 250,000 on a previous estimate for 2007-08. Some of the rise is ascribed to better data collection, but mostly to soaring demand for care services.

The total is significantly higher than that for the NHS workforce, often described as one of the largest in the world, and whereas recruitment in health has been funded by public spending, it is the market that is driving the growth of social care. Of the 1.6 million workers enumerated by Skills for Care, the social care skills agency, 1.2 million are in the private and voluntary sectors.

In business, the acquisition of a big company by a smaller one is sometimes called a reverse merger. Or a reverse takeover.

For those of you so inclined, this makes for fascinating reading:

Personal health budget pilot sites have faced early challenges in funding personalised care packages for patients, a national evaluation has found. Pilot leads in primary care trusts said they were struggling both to calculate the value of budgets and to find money to resource them.

The key issues in introducing Personal Budgets in health seem to be:

• PCTs can't calculate the value of budgets - some try to calculate a unit cost from existing contracts, others take an outcomes-based approach, and others just guess
• PCTs can't find the (additional) resources to fund such budgets, since they can't extract this money from block contracts
• Choice and control for patients doesn't seem to have followed where the Personal Health Budget leads.

Now, these are early findings, but they are very interesting indeed. The main reason is that they show just how difficult it is to move from block contract provision to something more flexible and personalised, and to ensure the money follows this move.

It confirms that the main relationship in health commissioning remains between supplier and commissioner, rather than supplier and customer, and is not something I would envisage the Health White Paper (on which more here and here) will overcome.

This is a guest post by Christine Burns MBE, an Equality and Diversity consultant currently embedded in the NHS war zone.

Since Andrew Lansley’s NHS White Paper was published last week, most of the public commentary has inevitably centred on the alleged savings to be achieved and the open door which the plans will create for privatisation.

The White Paper, “Equity and Excellence: Liberating the NHS”, proposes to remove two tiers of regional and local governance from the structure of the health service and to pay the lion's share of the NHS budget direct to GPs, organised into consortia to commission services from a wider market of providers.

Do the changes make sense?

Already there is a hot debate about whether GPs are willing or able to handle such a massive managerial responsibility. GPs themselves seem divided. It’s widely expected that the new consortia will contract functions like commissioning and purchasing out to private sector companies, for whom a bonanza is predicted.

I’ll not try and add much to that side of the debate, as it is being covered so well by others. It’s important to establish two points though.

Firstly, although many don’t realise it, the NHS is already part-privatised.

Every one of 34,000 GPs in the land is a private contractor. They’re the people whom the coalition propose to hand £70bn a year of our taxes to spend. Foundation Trusts (who run most of our hospitals and specialist services) are presently allowed to do a small percentage of private work; the new Government proposes to open that up and allow a flood of new private sector providers into the market.

Second, the argument that the NHS has too much managerial overhead just doesn’t stack up.

The NHS is the world’s second largest employer. It employs 1.4 million staff. It spends almost all of the annual £110bn health budget on the treatments we receive, with a relatively tiny chunk on public health promotion and disease prevention. Less than 2% of the total actually goes into management.

The best estimate for savings from shedding 45% of NHS management is £1bn. This to produce a system which is, by definition, less managed.

In reality the saving from all those redundancies is likely to be closer to £250m. Yet the NHS Chief Executive, Sir David Nicholson, is reported to be setting aside £1.5bn to cover the cost of dismantling the existing system of 10 SHAs and 152 PCTs (where all that management currently occurs) and to replace it with an estimated 500 GP consortia.

All those consortia will require significant numbers of managers - whether directly employed, or on the staff of private companies contracted to manage a massively complex system for them.

That’s madness.

Diversity is not a minority affair

Lots of people are commenting on those aspects of the biggest revolution in the NHS’s 62 year history. What nobody is talking about is whether the new system will produce better outcomes for all those groups in society who presently get a less than fair deal from the NHS.

Before you switch off and think I’m talking about minorities that don’t concern you, however, think again. Let’s do the numbers.

An average of 7% of the population in England has a Black or Minority Ethnic (BME) background (over 30% in some cities). 20% have some form of disability that would be covered by the Disability Discrimination Act. At least 6% of the population is Lesbian, Gay, Bisexual or Trans. Within the decade almost half of the population will be over 50 years of age.

In fact, the North West Development Agency calculated a while ago that only 20% of people now match the old-fashioned stereotype of the working age population: white, male, non-disabled, straight and aged between 18 and 45.

Count the equivalent 20% of women and it’s immediately apparent that around 60% of the population don’t fall into that white, middle class vision of the population which the NHS was designed for in 1948.

Does that matter? Well, yes it does, because the evidence is that the NHS is serving many of that 60% of the population very poorly. And, if a better understanding of what goes wrong were applied in the existing system we could save a heap of money.

Understanding diversity produces better outcomes, saves money

Take prevention. The evidence is overwhelming. Here are a few examples.

A disproportionate number of BME men find themselves sectioned into mental health services. Why? Well, it’s not because they’re more susceptible to mental illness. In fact, if you don’t know why then I advise finding out.

What’s the point of having Mental Health services that don’t know how to prevent admissions for a massive chunk of the population?

Most GPs don’t know enough about sexual orientation to understand that lesbian women are susceptible to cervical cancer like their heterosexual counterparts. They don’t understand that, among the 20% of older women who don’t undertake breast screening, lesbians are significantly over-represented. The result in both cases is cancers being detected far later than they could be.

Massive expenditure on trying to treat less treatable tumours. Lower success rates. All avoidable.

What about something that may be closer to home for some: what’s the point in screening women for chlamydia if you don’t screen the men who have an equal part in spreading it? Yet many public health professionals will bleat that they don’t know how to reach those men, because they seldom go to see their GPs.

Failure to understand the different ways in which women and men relate to health services is endemic. That alone suggests that 50% of public health ineffectively is ineffectively spent.

I could go on listing such examples, but it would get boring. Besides, any competent Equality and Diversity practitioner should be able to reel them off, point to the documentary evidence and tell you about the innovative solutions that will work.

Directors of public health, commissioners and finance managers are too busy to ask though.

Issues that transcend the ways the NHS is organised

You’re going to point out that this is all going on in the present NHS. And you’re right. The existing system often performs quite badly in terms of identifying the need for smart interventions and delivering successful (cost and life saving) outcomes.

But before I discuss whether the new NHS structure would be any better, it’s important to understand why the NHS (and practically every other public service) fails in this way.

The problem is not to do with any lack of policies, processes or inputs. In fact there are lots of those.

The Public Sector Equality Duties have encouraged lots of consultation and planning on equality over the last eight years. Organisations have been able to satisfy those public duties by producing nicely printed Equality Schemes, ticking the “compliance” box and putting them on the shelf.

What hardly anyone has done has been to measure the actual outcome performance of NHS organisations. Scratch the surface to look for evidence of reducing inequalities and the results are plain as day.

Whilst E&D practitioners undoubtedly work very hard, they are often unable to present evidence of their organisations actually achieving anything in terms of identifying and reducing adverse effects of a ‘one size fits all’ approach.

It’s not the structure that matters

Yet at least the existing NHS system has all the tools and levers to tackle the problem. The present NHS is built for accountability and governance.

In the present NHS, the Department of Health oversees Strategic Health Authorities as regional outposts to determine policy and manage performance. It’s just that nobody has used that line of accountability (from the centre to the regions) to performance measure and manage equality outcomes, and to make sure they achieve them.

The ten Strategic Health Authorities can likewise set performance measures for Primary Care Trusts and hold them to account on the results. It’s just that they’ve not been doing this till now.

The Primary Care Trusts, which were split into commissioning and provider bodies, manage their own local health economies, but have not been effectively managing E&D outcomes in outcome terms.

A methodology called World Class Commissioning was launched a couple of years ago to improve the effectiveness of commissioning managers in other respects. This included language about using evidence of needs and understanding one’s local population.

The Department of Health mysteriously failed to make the connection between these words and the idea of diversity competence.

This means that commissioning has not been used as effectively as it could to mould the design of services around a sophisticated understanding of needs and circumstances. Likewise contracts with providers have not been used all that effectively to drive up equality outcomes.

What’s not measured doesn’t get done

In the absence of equality performance management, few PCTs have thought to manage provider services in this way. The current picture is therefore not very good. But that isn’t the fault of the NHS structure. The fault lies in the failure to have utilised the lines of accountability in that structure effectively. E&D professionals undoubtedly work very hard in our PCTs and providers. Without performance management, however, there’s not been the strategic focus.

So will the new NHS structure fix all that? Well, sadly no it won’t. In fact it could make it worse.

The new structure, whilst it does have some forms of scrutiny around the edges, provides precious little where it matters: holding GPs to account. After all, Andrew Lansley listened to the GPs. The GPs (understandably) told him they didn’t like being managed. So the Government is not only removing the management but giving GPs the ultimate power of holding the purse strings.

Ask anyone from any equality target group and they will regale you with examples illustrating that Britain’s 34,000 GPs have a very poor record in terms of their attitude towards diversity. Most GPs live a life of privilege, with large salaries and a place in the community which sets them apart clearly as “Us” rather than “Them”.

Andrew Lansley claims that his new proposals will empower communities to scrutinise their local NHS. But when he talks about communities he really means people who also have privilege. The people who typically turn out to consultation meetings and can have their voice heard.

And the scrutiny on offer appears to be at second hand. The existing SHAs and PCTs all have statutory responsibilities to consult with the public they serve before they make changes. The Public Sector Equality Duties ensure that includes people from all the equality target groups. Yet, when questioned recently, a policy manager from the Equality and Human Rights Commission was uncertain whether GP Consortia would come under the ambit of the Public Sector Duties.

Lansley has not defined yet whether and how GP Consortia will be expected to consult and involve, aside from the broad sweeping statements contained in the White Paper.

Members of the equality target groups, many of whom don’t have the resources to take part in consultation with 152 PCTs and hundreds more providers, are hardly likely to have the capacity to hold 500+ GP consortia to account. And, whereas NHS Provider Trusts currently fall under the Public Sector Equality Duties, the expected rush of private sector providers won’t do.

This means that, even where accountability to equality groups is theoretically there on paper, many communities will simply lack the capacity to advocate for themselves.

A bleak future

The future is therefore bleak. I can forsee an NHS branded health system which will increasingly focus on what’s easy and what GPs visualise as “deserving”.

Some of the details of how any scrutiny will work have not been set out in detail yet. However, when those details are consulted upon (if this Government still understands that concept) it is vital for men and women, those from all races and ethnic backgrounds, disabled people, young and old, lesbians, gay, bisexual and trans people to all look very carefully at the small print.

Ask yourself how will my local GP consortium take account of my needs and experiences when commissioning services that will affect me? Will anyone expert from my community be able to advocate on my behalf?

Ask yourself how will GPs in those consortia be trained to go beyond thinking of equality and diversity principles as ‘Political Correctness’ and see such understanding as part of their job.

Ask yourself how well can Local Authorities advocate on my behalf when they scrutinise services. Are they equipped to understand the vital nature of diversity in designing and delivering services that work for everyone.

Ask yourself whether the Care Quality Commission, charged with overseeing provider services, will have the capacity and the means to see that adverse outcomes are identified and dealt with.

Ask yourself whether the Equality and Human Rights Commission, though outside of the new NHS system, will have the capacity and capability to investigate organisations where discrimination occurs.

Ask yourself whether the GP consortia will have the capacity and capability to manage the provider sector through their contracts, especially the private sector providers who will otherwise be outside of public sector duty responsibilities.

And, finally, ask yourself how any of those areas of scrutiny can be performed effectively by anyone if there is no consistent and objective means for measuring the outcomes that matter in each organisation.

Remember, the existing NHS has splendid lines of accountability and governance but has not performed well on equality because there was no performance management framework.

The new system will be much harder to hold accountable. Therefore the need for an objective performance management system measuring real outcomes is all the more vital.

This post also appeared on Stable and Principled

The launch of the coalition government's Health White Paper has made for interesting reading this week. Probably the best reaction to the proposals came from :

The document's flaws are in two main areas: those of Emmentalesque holes; and of biscuit contraception (the bits that are fucking crackers).

For reactions and criticisms that capture the key issues of the plan, I would certainly recommend Civitas's analysis and the series of posts that Paul Corrigan is writing.

In this post, I'll cover one element of the White Paper that I haven't seen much coverage of elsewhere: patient voice.

As there are gaping holes and tensions in the proposed reorganisation to enable GP consortia commissioning, so there are for patient voice within the new set up.

The key tension throughout the White Paper is who is in charge of decisions about care: the patient or the health professional? In their introduction, Cameron, Clegg and Lansley say that "patients will be in charge of making decisions about their care". But the talk throughout the rest of the paper is of "empowering" health professionals. In principle, the interests of health professionals and patients are aligned, in the same way the interests of social workers and service users are aligned in social care. But in practice, the interests of professionals (and social workers) often override - and indeed undermine - those of patients (and service users).

Such professional interest leads to patients fitting around services rather than vice versa (as noted in para 1.9). Which begs the question as to why the whole narrative the coalition is pushing in these reforms is one of giving GPs more power and responsibility for commissioning local health services? It's an odd paradox that the patient involvement proposals (see below) won't sufficiently overcome.

One phrase in the White Paper slightly sticks in the throat: "Nothing about me without me" (also appearing as "No decision about me without me"). Those of us familiar with the disability movement will recognise the appropriation of that movement's clarion call: "Nothing about us without us". For disabled people that phrase represents freedom, choice, independent living and the desire to have the same opportunities as non-disabled people. For NHS patients and doctors, it represents something altogether more managerial and process focused.

There are, though, some good things in the White Paper. These include appropriate recognition that some people will need extra support to enable them to have effective choice, and an understanding of the potential of Personal Health Budgets and a commitment to their contuining piloting and evaluation.

On the surface of it the introduction of HealthWatch - a "powerful new consumer champion" - also seems like a good thing. At the national level, HealthWatch England will advise the national bodies associated with the White Paper reforms (the NHS Commissioning Board, Monitor, and the CQC) on a variety of topics. It will also provide support to local HealthWatch organisations who themselves will ensure the views and feedback of patients and carers are part of the commissioning of health and social care. Through HealthWatch both nationally and locally, advocacy services will be provided to support patients in exercising choice in the healthcare system.

But there are a series of questions relating to HealthWatch England that need answering before we'll know whether it will be effective or not, as follows:

• HealthWatch will be "independent". If this is so, why does it need to be based in the Care Quality Commission? Why can't it be a separate entity in its own right?
• It's odd to suggest that the NHS Commissioning Board "will champion patient and carer involvement" in healthcare (para 2.4), will "promote patient and care involvement" (para 4.11) and "involve patients as a matter of course in its business" (para 4.11). Isn't this the role of HealthWatch?
• What are HW's governance arrangements? Will it be a separately constituted organisation (e.g. a charity)? Will it be an NDPB? Will it just be a separate entity with some form of Memorandum of Understanding between it and CQC?
• Related to the questions on governance are questions on who will provide HealthWatch's leadership? Will it have a Board that oversees the senior management team? If so, will that Board be patient/user-led? If not, why not?
• If HealthWatch is "new" what happens to existing national service user engagement organisations across health and social care? Will they be allowed to bid to become HealthWatch? Or will HealthWatch sit alongside them? If HealthWatch replaces them, what happens to those organisations?
• Why does HealthWatch England only provide "advice" to NHS Commissioning Board, Monitor, the CQC and the Secretary of State? Why is it not empowered to take part in joint decision making?
• Given the above entities are going to be or already are statutory bodies, will HealthWatch England be the mechanism through which they meet their Public Sector Duty and Duty to Involve obligations?

At the local level, the White Paper outlines that the current mechanisms for service user engagement - Local Involvement Networks (LINks) - will become local HealthWatches. This makes sense, but with some cautionary notes:

• The contracts for LINks are in the process of being renewed in time for April 2011. The White Paper's timeline says HealthWatch will be set up by April 2012 and LINks will work towards becoming local HealthWatches during 2011. What happens in terms of service user representation during that year? It is, after all, the year in which the Shadow NHS Commissioning Board is established, the NHS Outcomes Framework is published, GP Consortia are established in shadow form, and Patient Reported Outcome Measures are identified and embedded
• The level of funding available for LINks from April 2011 has yet to be determined. When will this be done? Given the importance of patient involvement in the NHS, will it benefit from the real-terms increase associated with these reforms? If not, why not?
• In the proposed partnership arrangements at a local level, will local HealthWatch representatives be formally involved in decisions or merely consulted?
• LINks are expected to both represent user views to local commissioners and also provide advocacy-based services. My experience of organisations operating on both the demand- and supply-side of the health/social care market is that it can happen, but very rarely does so effectively. Does the White Paper expect too much of LINks, given their current infrastructure and capacity to deliver? What will it do to support the building of effective HWs to undertake the role expected of them?
• The desire for advocacy services is welcome, but I'm concerned by the focus (highlighted in the Analytical Strategy paper associated with the White Paper) of these on particularly supporting people who lack capacity to make choices. Advocacy services actually benefit everyone and shouldn't just be thought of as being available to people subject to the Mental Capacity Act.
• Advocacy is quite a crowded market (especially in social care). The LINks contracts and the role of HealthWatches in future will create a massive bunfight between existing provides at the local and national level, which local politicians may not have the courage to address or let take its course when it inevitably happens.

As they stand, the reforms in the Health White Paper represent the culmination of six years of thinking in Opposition by the now Secretary of State for Health, Andrew Lansley. If the proposals had been laid out in a Green Paper for the intention of deliberation and consideration, I'd have more reason to be positive.

But as with nearly every other part of the Health White Paper, the ill-thought through tensions between patient-led and GP-led reforms and questions around HealthWatch at both a national and a local level mean that it's very difficult to have any confidence the reforms will do what the coalition government hope.

There's a fabulous leader in the Observer today, detailing all of the major issues, inconsistencies and ideological drivers of the coalition government's approach to health. I urge you to read it:

a regressive and potentially harmful new approach to public health being pursued by the coalition government which has much of the medical establishment worried and with good reason...

Those who make or sell drink, cigarettes and unhealthy food can scarcely believe their luck. By contrast, many doctors, children's charities and campaign groups are deeply perturbed. Barely 10 weeks into office, the coalition seems to have made it a priority to dismantle key elements of what most doctors thought was a settled consensus on key public health measures. Labour's use of intervention, exhortation and regulation has now been junked in favour of a reliance on individual freedom, personal responsibility and industry behaving itself...

The approach adopted so far by the government is deeply worrying and potentially dangerous. It also exposes big flaws in government health policy. If doctors' judgments are deemed so vital by last week's white paper to improving their patients' treatment, why ignore the same medics' views on public health? ...

Everyone knows Britain has huge health problems caused by smoking, drinking and poor food. The coalition's path so far is not just the wrong direction of travel; it is also utterly inadequate as a response to the scale of the problems we face. Rethink the state's role in this difficult area, by all means, but remember that without government action, public hygiene would still be Victorian, immunisation and disease screening nonexistent, and pubs the horribly smoky places of not too distant memory. Ideology should never trump common sense in matters of life and death.

The coalition today couldn't confirm or deny that it was going to keep or scrap the two-week cancer guarantee.

Some quick observations:

• It was David Cameron who used cancer statistics comparing Britain to Bulgaria for political gain as part of the general election campaign
• It was the Tories who complained vigorously about leaflets Labour apparently sent to people with cancer during the same campaign. The leaflets suggested the Tories would scrap a Labour guarantee on how quickly patients could see a cancer specialist. Which, erm, turns out to be true.
• I believe (link to follow) that the coalition government said today decisions about targets will be taken by the relevant NHS body. Whether this fits in with the idea of a post-bureaucratic age, I'm not sure, but it sure sounds a bit like Andrew Lansley before saying that neither government nor [the NHS] should be dictate the decisions made. That sounds like politicians not being willing to bear responsibility for their actions.
• Via David Cameron, Simon Burns and then the PM's spokesperson, the coalition today first put its left leg in on cancer targets, then put it out, then in-out, in-out. They've done this before - look at how the hokey cokeyed on the tax breaks for married people

One of the particularly interesting areas of government over the next few years - in a train wreck sort of way - will be the Department of Health.

Andrew Lansley is apparently regarded as someone who knows his stuff when it comes to health, having been Shadow Minister for several years. I'm not so sure. He seems to be in hock to the medical unions and has a dubious record when it comes to social care. He's a tribal politician and also seems to believe his own press - not a great combination, especially given we all know what happens when ego and ignorance combine in an unholy, but unfortunately typical alliance.

As an example, take the resignation of Sir Richard Sykes over the government's decision to halt a wave of hospital reorganisations. In response, Lansley apparently wrote to Sykes saying:

[N]either the government nor NHS London should dictate the decisions made.

If Lansley really believes this, then who does he think should dictate decisions made about the NHS in London?

I was struck by Robert Brook's recent note on boring innovation:

Oh, sorry — didn’t I say? Ah, yes, innovation has a budget. And a timescale. And a board — you know, just to check that we’re innovating in the right way. Nothing too ... er ... innovative.

Wait a minute, I’ve just got to update this Gantt chart.

And we’re back. Innovating! Innovating while the budget allows! Oh dear this is dreadful. And, of course, Johnnie Moore is quite right when he says that innovation has been made dead boring by management thinkers — and, with perhaps tongue slightly in cheek, suggesting that managers want to suppress creativity.

Of course, he's right. Innovation needs space to be allowed to flourish. There is a very good article in the latest edition of the NHS's (!) In View magazine on this that I've been meaning to blog about for some time. (I can only find a link to a pdf version - see page 10 of this pdf.) Its conclusion is relevant to Robert's post:

Established companies can avoid falling into the classic traps that stifle innovation by widening the search for new ideas, loosening overly tight controls and rigid structures, forging better connections between innovators and mainstream operations, and cultivating communication and collaboration skills.

Innovation involves ideas that create the future. But the quest for innovation is doomed unless the managers who seek it take time to learn from the past. Getting the balance right between exploiting (getting the highest returns from current activities) and exploring (seeking the new) requires organizational flexibility and a great deal of attention to relationships. It always has, and it always will.

As an aside, and without wishing to diminish what Robert wrote, and certainly not wishing to take the piss (I respect and value Robert's writing too much to do that), his post on innovation did bring to mind Supertramp's Logical Song:

When I was young it seemed that life was so wonderful, a miracle, oh it was beautiful, magical / But then they sent me away to teach me how to be sensible, logical, responsible, practical.

I think there's a bit of Supertramp in all of us.