Cutting the bull****

Thursday, March 04, 2010

Before you can recruit the right people you must create the right environment, says Calum Paton, professor of health policy at Keele University, who chaired Public Service Events' NHS Recruitment, Training and HR conference

From my years of experience as a student of the NHS and as chairman of one of England's largest hospital trusts, I can say with confidence that successful policy for the workforce and for recruiting, retaining and developing human resources requires a marriage with successful health policy overall. What is more, as in more than a few marriages, there is a third party: both of these just-stated desires depend upon the right sort of political environment.

This is not just a piety. Consider the last 30 years – 1983: manpower freeze, yet also the Griffiths Report, requiring innovative recruitment; 1990: the director of personnel for the NHS told us we had too many doctors, and implied that many of them were insufficiently motivated (a nice double-edged sword, that); in the early 1990s: local pay, to accompany the "first" internal market – which came in with a whimper and went out unnoticed and unlamented. With the dawn of the New Labour government came a belief that there were too few doctors, nurses, and other clinicians. Then came the deficit crisis of 2005/06, when Health Secretary Patricia Hewitt told us that trusts had been employing too many people – to meet government targets, it seemed!

And now we have what might be the "Arctic scenario" for the NHS, when the frontline – that phrase beloved of all political parties at election time – can only be preserved by swingeing cuts in the back office. That, by the way, is the managers, administrators and those the tabloids call pen-pushers, the same managers required, by the same governments, acting this time post-election, to implement their cyclical waves of reform.

And of course the back office also includes the regulators and the Department of Health itself. One example of how it is easy to be "penny-wise and pound-foolish" is the new GP contract. This was, I am reliably informed, loosely negotiated not only because Health Secretary John Reid wanted to play the good cop to his bad-cop predecessor Alan Milburn, but crucially because Labour's 2004 Gershon Review of efficiency in the public sector had ridden a coach and horses through the department's resident expertise in the area. Therein lies a warning – what the NHS now faces, after the election, makes Gershon seem like a pre-election splurge.

But for this conference, the warning is not just about money, it's about the need for stability. This is anything but a plea for what Tony Blair once notoriously called "the forces of conservatism" (he meant the doctors) in the public sector. But it is a reminder that the most successful organisations – private and public – set policy at the top, leave much of the strategy to the middle levels, and present the frontline with key objectives which do not change too often and of which there are not too many.

In trusts of any kind, what are the key challenges in creating the right environment irrespective of national policy's tendency to move in ever- decreasing circles?

Cooperation and long-term joint objectives for commissioners and providers, as we call them in England (but not in all of the UK); investment in staff (the key lesson, such as there is, from the more successful health maintenance organisations in the US and especially from its Veterans Administration is to invest in senior clinical staff to manage patients more actively – the key tradeoff for Kaiser Permanente is more senior medics and shorter lengths of stay); ensuring that financial strategy and HR strategy are made together and "owned" by the board, and also – where possible – understood if not always agreed by the whole organisation.

This leads me to a key suggestion: "When it comes to cuts, start with the bullshit!" Not everything is possible, especially in the short term. Higher pay may mean fewer jobs and a need for fewer organisations and therefore fewer reorganisations (or, if not, deficits – as the government found out the hard way in 2005/06.)

I have a suspicion that, even now, the NHS breaks even by central diktat rather than self-sustaining local improvement – with a few honourable exceptions. And the lesson there is to learn from those health economies (it cannot be individual trusts) that achieve clinical objectives, financial balance and as happy a workforce as conceivable in the circumstances. Transferring lessons can only be done, if at all, thoughtfully and carefully. But it's a place to start.

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