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I know you like a fact or two… so, here’s a little treat for you.
In the last two years, the NHSE head-count has gone from 24,000 to 13,200.
It makes Pat McFadden’s ambition for cutting the civil service look positively anaemic.
Nevertheless, our Great Leader plans another cull. Why? Surely, that’s where the knowledge base is, where the legacy understanding is. That’s where the memory and the skills are.
As usual, the explanation is not what you’d expect.
The lovely people employed by NHS England are not civil servants. NHSE is an arm's length body of the DH+, meaning its employees are public-sector-workers rather than civil servants.
That creates a key difference in their employment status. NHSE staff are employed under NHS contracts, not civil service terms...
... they don’t have the same job protections as civil servants.
They still have employment rights but their dismissal process is generally less rigid than that of civil servants, who benefit from additional protections under civil service rules. Redundancy payments are likely to be less generous.
In plain English, NHSE people are easier and cheaper to give the heave-ho and aren’t unionised. That's why the not-so, Silly Boy will keep the civil servants in the DH+.
‘Ah’, I can hear you say ‘…hasn’t NHSE become bigger and bloated and a bit of culling is no bad thing?’
No, is the answer.
As part of a previous efficiency drive coupled with trying to sort out the mess left by the Andrew Lansley reforms, other arms length bodies, the likes of Health Education England and NHS Digital were subsumed into NHSE, swelling their numbers.
NHSE set about rationalising them into departments and that is where the first rounds of job-cuts came from.
Was, or is, or why are there duplication of jobs in the DH+?
Because...
... the ambition of the Lansley reforms, to keep the operational work of the NHS at arms length from Ministers, never worked. They couldn’t let-go so they created a replica management structure at the DH+ to try and keep a handle on what was happening.
He wants to run the NHS from his desk in Whitehall, pretending he is devolving power. In so doing Streeting is creating a dilemma for himself.
On the plus side, centralisation benefits;
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Consistency and standardisation; ensuring uniform policies, quality control and strategic alignment.
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Efficiency in decision making; quicker responses as fewer people need to be consulted.
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Cost control; easier to manage budgets and prevent inefficiencies.
On the other hand you get;
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Bureaucracy and slow execution; decisions take longer as they require approval from the top.
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Lack of local adaptability; top-down policies may not fit local needs.
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Low employee morale; staff may feel disempowered, leading to disengagement and inefficiency.
Devolved power means; faster decision making, the ability to adapt and be innovative as people are more engaged.
On the other hand; expect inconsistencies, ‘postcode’ decisions, service variations and the likely loss of strategic alignment.
It's a dilemma for all national organisation and in the case of NHS England, the tension between central control and local decision-making is a challenge that has defeated far more experienced politicians than Streeting.
His mate, Alan Milburn tried shifting decision-making closer to the front line with his Primary Care Organisations, some no bigger than a bridge club.
Eventually, at horrible cost, they morphed into PCTs and because of bureaucratic bloat, lack of autonomy, money and poor performance they went they way of all of Milburn's madnesses and were abolished in 2013.
On balance, a strong ‘head office’ with a devolved structure like Integrated Care Systems can help improve responsiveness but with the greatest respect to the luckless souls trying to make ICBs work;
- there are too many of them,
- there’s not enough management talent
- 19 of the 42 ICBs are currently receiving financial and managerial support and…
- the system is mired in £7bn of debt.
The solution?
Go back to 1974-1996. For 22 years the NHS in England was organised into 14 Regional Health Authorities… responsible for overseeing healthcare delivery.
They were big enough to impact what we call today, 'population health'. Resource allocation could be meaningfully weighted and...
... they were few enough to get all the Regional bosses around one table for the Secretary of State to grip what was going on.
They weren’t without problems but with today’s data, technology and real-time numbers…
... they’d be a gift to the Secretary of State, but would expose him as the boss…
… and then we’d see how good he really is.
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