Early impressions on the Department of Health witnesses.
I wanted to put up a holding blog to let you know there is more to come! This is a busy time of the year dealing with the harvest, but also the hearings over the last couple of weeks have been so dense and so interesting that it is quite hard to know where to begin.
I feel the need to work on the material slowly and carefully to do it justice.
I will say that hearing from the two ex ministers, Andy Burnham and Ben Bradshaw, and hearing from a number of people from within the Department of health has been a real education.
We are all used to seeing Ministers called to account at the dispatch box whenever there is some scandal within their realm of responsibility. This gives the impression that they are intimately involved with the detail of decisions. I think this is in large measure an illusion.
Listening to the explanations of how a particular decision was signed off has made it very plain to me that things are not remotely the way they are portrayed in the press. In many cases it is nonsense to think in terms of blaming a minister for following the carefully made recommendations of his advisors.
A minister sits at the centre of a huge web of information. They can at the end only know what is fed up the line to them, and information is filtered and refined at many stages before recommendations are passed by the civil service to the minister. The question that has been asked all the way up the line on the Midstaffs question, is if things were going so badly wrong at the hospital how is it that no one knew. It is pretty clear that the minister could not have known. No one close to the hospital saw a problem, so there was nothing to ring any alarm bells at any level.
In the Midstaffs case, most of the dealings with the hospital were not a matter for the department of health. The Health care commission, the Care Quality commission, and also Monitor are all set up with the explicit intention that they should act as independent regulators. The minister cannot, should not, and does not involve himself in their operations. In the case of Midstaffs the ministers were concerned and they or their advisors asked questions and offered support, but they also respected the independence of the regulators.
One thing that should be clear is that a minister is not there as an expert. That is not their function. They are there essentially as an ordinary people, elected by us in order to represent us and to ask questions on our behalf.
It is clear that the Department of health contains many incredibly skilful civil servants with a deep knowledge of both their specialist fields of knowledge and of the constraints on action.
In the event of some public crisis is the minister that is sent in to bat. In the matter of carrying out policy the civil service will do what they can to carry out the ministers bidding, but they also have a role to advice ministers against ill-considered actions. It is good for us that this is the case. People often comment on the way that big scandals or tragedies tend to bring about illconsidered and ineffective legislative responses. That is often what happens when public and press pressure override the natural caution of the civil service.
There is a tension. Many of the things that we need government to set in motion, improvements that will give us better services, forward thinking proposals, are ideas that are worked through and tested for years. Ministers often think in a much more short term manner. They need to be able to stand up at the ballot box and answer hostile questions today. They need to be able to fight for scarce resources. They need to be able to persuade the press and the electorate that they are doing a good job, with eye catching initiatives.
If we think of “Yes minister” there is the sense that the civil service can at times prevent things from being done, I am not sure that that is how it is.
At the inquiry We have been looking at four themes, Foundation trusts, Quality, The Patient voice and Commissioning. What is striking with all of these is the degree of continuity that exists.
Foundation trusts began under the last Conservative government, continued and developed under Labour, and have now been given additional impetus by the coalition. They have been seen as desirable by all parties because they all recognise that there is a genuine need for organisations to manage their affairs more closely themselves, in accordance with local need. (Ministers all probably also want to ensure that when a hospital scandal blows up, as they do all the time, that a Foundation trust is a sufficiently independent entity for the minister to be able to say "This is not my responsibility"). Ministers all recognise that there is an element of unreality in the claim that your hospital can be “run” from Whitehall. Midstaffs has revealed some serious problems with the Foundation trust model, but these will need to be resolved, because this is the direction of travel.
Quality, if you listened to the press in the run up to the election, and to the current government was the discovery of Andrew Lansley, but we discover that Sir Liam Donaldson has been working on the agenda of quality continuously since 1998, and that there are many very well developed tools for developing and driving up quality, some of which are now going to be dropped, or placed within new organisations. Much progress has been made, but like many of the big challenges faced by successive governments it is very difficult to do. There are real breakthroughs now. The idea of measuring quality has been made possible by the development of impressive new statistical and information tools, and made essential because of the political imperative of listening to the patient voice.
The Patient voice, is also claimed by Lansley as his creation, but again it has been a growing pre-occupation of the last decade. The success of the midstaffs pressure group in attracting the political patronage of the conservative party has now meant that ways have to be found to pick up complaints more effectively. This is another area where everyone agrees that it must be done, but no one has yet found an effective way. The methods are still evolving, but the information technology to help do this job is very likely to be in place within the next few years.
These are good developments, It should make government much more responsive. No doubt if it all works out much credit will be taken for it, but it owes much more to developments in the wind and the skill of the civil servants than it does to any genius on the part of ministers!
GP Commissioning is the big new idea of the Lansley Health reforms, but it has been emerging since 2002 as practice based commissioning, These have acted as trial runs for the reforms that will happen in some form.
The civil servants are showing us how much can be done by evolution.
I am left after hearing from the civil servants with a strong wish that we could calm down the noise around politics, the need for big initiatives, big changes, eye catching stories for the press. We can do all of the things that need to be done without the big structural changes.
So far, the ministers in this government have been in a mad tearing hurry. If they could slow down do less and listen more maybe we would all be better served.