How sad it has become, when, even in the midst of a national crisis, one becomes heartily sick of watching any news channel, listening to the radio or reading the press. Why? Because we are made to feel that as a country we cannot do anything right. The daily briefings on the Covid 19 pandemic provided an opportunity for rude and disrespectful journalists to ask questions of the Government, Public Health England and the NHS They may see themselves as investigative journalists but they behaved as if they were prosecuting barristers. In many cases it was as if the journalists wanted aspirational targets to be missed, as was evident with the numbers of people tested for Covid 19 in the early stages of the pandemic.
It was interesting to observe how, when PPE was found to be in short supply, nobody asked the question, “Who, in the NHS, is actually in charge of ordering equipment for hospitals?” Can he/she come to the briefing and explain the difficulties they faced in the procurement process?” No, that was not, to be the case.
In an effort to try to understand the process used by the NHS to obtain these resources, one starts to research the vast array of organisations which support the work of the NHS.
Department of Health & Social Care
• NHS England
• NHS Improvement
• Care Quality Commission
• National Institute for Health & Care Excellence
• Public Health England
• NHS Digital
• NHS X
• Health Education England
• Health Research Authority
• NHS Blood and Transplant
• Medicines and Healthcare Products Regulatory Agency
• NHS Business Services Authority
• NHS Resolution
• Human Fertilisation and Embryology Authority
• Human Tissue Authority
• NHS Counter Fraud Authority
In addition to the core NHS services, the following agencies also operate under the NHS banner:
NHS Procurement Consortia Supply
Chain Coordination Ltd (wholly owned by NHS)
NHS Providers
NHS Foundation Trusts
NHS Clinical Commissioners
Clinical Commissioning Groups
Healthwatch
NHS Assembly
NHS Confederation
King's Fund
NHS and Local Authority Health & Social Care Initiatives
• Sustainability & Transformational Partnership (STP)
• Integrated Care Systems
• Better Care Fund
Nuffield Health
Nuffield Trust
This list excludes health specialists such as GP’s, community pharmacies, dental practices, podiatry, and physiotherapy services.
What an extensive list. We have seen a small selection of experts and spokespersons on the media during the corona pandemic, who represent some of these organisations, but what are their functions? Take procurement, for example. NHS Providers, surely they must be the organisation supplying equipment to our health workers, but no, their role is very different. More of them later.
Having survived the necessary but tortuous ordeal of listening to the news or reading the paper, we then endeavour to be public spirited and to follow the guidelines of eminent scientists and elected members of Parliament. However even trying to do the right thing; to do as we are told, becomes open to continual questioning. Analysis of words and phrases becomes the topic of conversation by the media, as if the general public are stupid and cannot define the words themselves. The word “alert” immediately springs to mind. The fact we had to endure nearly a week of debating what this word meant for the general public, shows how the media tried to portray the public as devoid of common sense.
In the midst of this crisis we have witnessed how our front-line workers in the NHs have “taken up arms” against this coronavirus. Like soldiers in the battlefield, they too have been brave in fighting this unseen enemy. We are grateful for their devotion to their profession. Like many, when called upon in a moment of crisis, they have risen to the challenge. We have clapped and cheered them and voiced our support and admiration. “Your country needs you” and they, as one would expect, have risen to the challenge, gone to work and done their job.
There are a large number of personnel working in the National Health Service. In fact it is one of the largest employers in the country. On present day figures there is one member of NHS staff for every 7 people in the United Kingdom and it must be remembered that a large percentage of the NHS funding is assigned to salaries. (2019 figures show salaries accounted for 44.9% of NHS funding).It is a people based profession, where human interaction is central to their work.
However, behind these front line workers there is a proliferation of organisations linked to the National Health Service which is eye watering. As are the salaries of those that head up and lead them. Job titles are impressive but what do these personnel actually do to improve the NHS for the patient and to whom are they accountable? The role they have is difficult and demanding requiring leadership and accountability. This demanding and complex role is well rewarded with a salary and pension contributions in excess of Ministers of State.
It is utterly remarkable how these highly paid Chief Executives appear on our TV screens anxious to put their case forward. They begin sentences with “They” or “it would appear that” or “unfortunately”. Even if the word “I” is used, it is followed by “but”. When we needed strategic leaders, we got “champion commentators” reiterating the problems but offering no solutions.
It is worth remembering that these personnel have been more than happy to accept the salaried post even though the task they describe is completely unattainable “in these present circumstances.” Those of us who have led teams, dealt with crisis and implemented change as part of our everyday work know only too well how difficult it can be to manage a crisis, but this is when leadership skills and accountability are very important.
Many of these personnel have been involved in formulating the NHS Long Term Plan. It has been drawn up by those that know the NHS best, including front line health and care staff, patient groups and other experts. “It is an operational document to support health and care systems with their planning, developed and tested with many stakeholders” One must ask did it have any reference to dealing with a national health emergency?
Nobody wants to orchestrate a witch hunt to find out the names of personnel who were unable to meet the demands of this complex crisis, but we do need reassurance that the lines of accountability are established and effective so that improvements if needed are impactful.
Building a culture of accountability that encourages staff to be active employees helps to move an organisation forward. Blaming other people when you are in charge prevents progress. Blaming people does nothing to help solve the issue. All it does is to seek out an individual or a group of people and point the finger at them. . Blaming creates headlines such as “X must go”. Blaming and ridiculing a person in many cases does not necessarily improve the situation. The process and blurred lines of accountability remain and, in some cases, will be made worse by introducing another layer of management or personnel with poorly defined roles of accountability
What is actually needed is a culture of accountability.
This is what we should have seen within these organisations which bear the tag “NHS”, but in too many cases it was sadly lacking. A big gap was evident between those who headed up the organisation, the authors of “vision statements “and the deliverers. Those that were involved in the procurement of resources had little understanding the distribution strategies and the “end-user”
So, let us ask these simple, but necessary questions... We mutter them while we watch our TVs or when reading the paper. These are surely the type of questions we have all been asking ourselves as this pandemic unfolded.
Is everything the fault of Government? Surely the role of Government is a strategic one. The Government allows the NHS to organise itself and to appoint personnel to head up these organisations. The NHS Executives are paid high salaries but we are told “we need to recruit the best”. We therefore expect the best.
When a national crisis arises, this is when those who head up departments should rise to the challenge. Their skill, their years of expertise and training should help them deal with the situation, proposing solutions to deal with a quickly changing landscape.
It has to be said, however, that as a country we have not faced a situation like the Covid 19 crisis ever before. It was obvious that as the pandemic unfolded, as the media began to jostle for the next “big issue” to form their headline. The knives were sharpened, a scalp was needed, who could they force to resign?
As the journalists and political commentators asked questions, so did we.
Who is accountable for purchasing PPE for individual social care settings? Is it the owner of the care home, is it the manager? Are the lines of accountability clear within the privately owned organisation? Is the Government responsible for purchasing all resources they use?
Who is accountable for infection control procedures in the private care home settings? Is the inspection of this by the CQC rigorous and demanding in the inspection of care settings?
How any organisations ( national and local ) and professional bodies offer support to care settings, is the advice conflicting and confusing ? What guidance or advice has been offered as a result of previous inspections by CQC on infection control? How routine, extensive and thorough are training regimes in these expensive settings? Who is responsible for implementing and monitoring infection control in the care setting and where is this documented to enable timely support or intervention?
Who is responsible for discharging patients from hospitals to care homes, bearing in mind , many Care Plans that are agreed with clients in care homes, specifically state, they do not want to die in hospital and have DNR (Do not resuscitate ) on their care plan. Their wishes have to be honoured. The truth is harsh and difficult, but it is the truth. Hospitals cannot cure the infirmities of old age, neither can their families; that is why so many elderly people are in care homes.
It may be that there is a team of people involved in this process but as part of their responsibility are they not aware of the standards that are required, the processes to use, and the results that they have to achieve? The line of accountability should be clear and transparent to all who work in the organisation. Obtaining the required results with employees is the reasons we have teams and why we have managers and leaders in organisations, and, it would appear, why so many leaders are paid such high salaries.
NHS Providers have featured extensively in the media over the last 12 months. But, what do they do?
Their website states:
NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate.
This is an organisation which was created in 2011 and was formerly a part of NHS Confederation (see below). NHS Trusts pay a membership subscription (tax-payers money). NHS Providers in fact is a registered charity which operates under the less glamorous title “The Foundation Trust Network.”
Their accounts show that in 2019/20 they received subscriptions totalling £4.8m. They also operate a training facility to provide courses for NHS Trust Board Members.
NHS Providers claims to represent people who work within the NHS but if we were to ask an employee “How does NHS Providers, assist and improve your everyday working practice and improve outcomes for patients? “ The answers would be lacking in detail. The budget for this organisation is massive and the person who is in charge is in receipt of £230,000 per annum.
It is also worth exploring the role of the organisation entitled “NHS Confederation.”
Their website states that they are:
“The authentic voice of NHS leadership. We are the only membership body that brings together, and speaks on behalf of, the whole health and care system.”
Sound familiar? This organisation’s budget of £17.9m and receives £3.6m through membership subscriptions, and £11m through contract delivery. One employee is shown to have been paid between £240,000 and 249,999 in 2019.
The answer to all problems within the NHS is more staff, more consultants and more resources. One cannot argue that more resources will always be useful at the front line, but isn’t it the way resources are used, the real question? How do we use personnel, organisations and processes more effectively to deliver the desired outcomes?
Where better to look than our Armed Forces? When the country had to deal with an outbreak of foot and mouth disease, it was the army that helped to organise and deal with the situation, working with the then Ministry of Agriculture and farmers. During extreme weather, dealing with flooding and the re-establishing of bridges and roads, it is the Military that comes to assist.
Thankfully it was their skills and expertise that were called upon to help with some of the logistical issues we faced with Covid 19.They helped plan and build the Nightingale Hospitals, they organised the procurement and distribution of PPE across the country, they assisted in setting up “ mobile testing stations” and they helped drive ambulances.
There will inevitably be an investigation and report into our response to the pandemic and rightly so but many of us have already formulated in our minds the “concluding paragraph”
Our NHS is too big; it is top heavy with remote decision makers. There is a proliferation of publicly funded quangos, masquerading under the banner of NHS, and which are little more than talking shops. There is a massive void between those that write the policies and those that carry them out. The proliferation of organisations within the NHS requires some radical restructuring.
A leaner, flatter structure is required, where the line of command is known to all. Those that have risen through our armed forces have done so because they have experience as “foot soldiers”, they can adapt quickly and effectively to a changing situation, operating in a culture of trust and accountability. The Armed Forces cannot and do not need to “buy in “a Sergeant or Captain to head up a division. Those that are positions of influence have developed their knowledge, skills and expertise by working alongside their colleagues; working in effective teams to overcome issues. The line of command is known to all. Accountability is key. They are less tolerant of inefficiency of time and resources. And, like the NHS, their performance saves lives.
We have to hope that, as the need for the military input lessens, there will be time to reflect upon what we have learnt from this response to the pandemic. We have witnessed some great acts of courage and professionalism from the front line workers in the National Health Service, of that, there can be no doubt but we must be prepared to reflect upon how the chains of command across this complex organisation served their employees in their time of need.
