The recent Public article was an entertaining statement of faith that making the NHS more entrepreneurial will be the solution to financial challenges ahead.
Tim Care is right that the NHS must plan for a reduction in previously-anticipated budget growth cumulatively totalling £15-20bn over the coming years. In context, the NHS budget this year is £105bn, and the government has promised real-terms growth every year of this parliament.
Many senior NHS managers will raise an eyebrow at the notion, however, that their legendarily insecure jobs are "risk-averse" and the suggestion that the NHS should take more business risk requires qualification.
How much of the budget should managers risk?
The article suggests NHS managers should "have more of the mindset of entrepreneurs in the corporate world" - but which entrepreneurs? Ryanair's Michael O'Leary? Societe Generale's Jerome Kerviel? RBS's Sir Fred Goodwin?
Care seems unaware of such big beasts of NHS management as Sir Robert Naylor of UCLH (nicknamed "Bob The Builder" for his dramatic private finance initiative remodelling of the trust's estate); Sophia Christie and Andrew Donald of NHS Birmingham East and North PCT, working in partnership with Pfizer to deliver telecare support for patients with long-term health conditions; or Michael Scott of NHS Westminster PCT, developing and copyrighting bespoke commissioning data software.
Entrepreneurial GPs have formed successful companies in the urgent and emergency care sector – some for-profit; others effectively co-operatives. There is also the impressive Central Surrey Health – a community nursing co-operative, which has been running for some years with great success.
The article cites the example of the Heart of England NHS Foundation Trust, which took over the Good Hope Hospital. This is true, but very much half the story. Good Hope was the first NHS hospital's management franchise to a private sector company, Tribal in 2003. While Tribal's two-year tenure saw the hospital's quality rating improve slightly, it couldn't solve the financial problems: hence the board requesting the foundation trust takeover. Hardly a triumph for entrepreneurialism
Moreover, a description of the semi-independent NHS foundation trusts as "the perfect vehicle" for entrepreneurialism merits consideration.
William Moyes, former head of Monitor, which regulates foundation trusts, has expressed his disappointment that the 130 foundation trusts were not more ambitious or innovative. It's also worth noting that while foundation trusts have tended to be the highest performers in annual quality and financial ratings, 12 of the 22 trusts with conditions on their licences with the Care Quality Commission were foundation trusts.
The article also calls the NHS "an ailing organisation". As diagnoses go, this is specious. Parts of the NHS are not good enough; it can still be indifferent to patients' experience of services; and occasionally, it delivers truly terrible care. Overall, however, the NHS's record over the past decade in delivering on a wide range of challenging government targets is impressive – admittedly, at a time when budgets were growing.
Those budgets will now shrink, which will force reforms. That need not be a bad thing: as former deputy chief medical officer professor Aidan Halligan notoriously wrote in 2006, "working patterns, practices and customs are at the heart of many capacity issues, and have never been challenged".
Entrepreneurialism could play a part of the next stage of NHS improvement – but the next stage is about creating 'win-win' deals
Entrepreneurialism could play a part of the next stage of NHS improvement – but the next stage is about creating 'win-win' deals along pathways of care for patients between the various organisations and sectors of healthcare and social care.
The skills needed will be those of negotiation and navigation, based on lots of data and analysis to prove quality and safety. Some entrepreneurs are good at this stuff; others are win-at-all-costs figure-fiddlers. Until they have bust a bank or broken a business, we tend not to know the difference.
A key lesson of public service reform is that one size does not fit all. Faith-based solutions – whether in the benevolence of big government, or in the allocative efficiency and informative perfection of markets – should be left out of serious strategies.
We should keep our minds open about the potential for entrepreneurialism to help improve the NHS - but not so open that our brains fall out.
Andy Cowper is the editor of Health Policy Insight
From Bubb's Blog
From Whitehall Watch
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