Saturday, August 20, 2011

NHS Reform: Soup & Insight

Waiter! I don’t like this Fish Soup.

Oh! That is the F.H. Special. Suppose to be good.

I’ll give you the P.C.T. version. Much better.

Waiter! It is the same soup.

O.K. Let me get you the HSCB one. The latest and the best.

But it is still the same soup.

Well The Shrink found that out too. I experienced the same when I was Medical Director.

If anyone should think that they have changed, think again. The control is from up high.

The Shrink: Insight

I'd always thought the Chief Executive to be influential. I was naive. The Chief Executive has great influence over a great many things, but it's finite and in some ways is actually quite narrow. I'd not really appreciated the constraints that Monitor and CQC and SHA and DoH and others shackle the Chief Executive with. The Chief Executive has responsibility but Executive Directors have their own portfolios and they, not the Chief Executive, sort those. After deciding how things shall be, the Chief Executive then has tiers of managers whose Chinese whispers distort the detail and implementation of the intentions, horribly. Can the Chief Executive direct me to prescribe Mrs Smith olanzapine 5mg velotab at night? No. That's a clinical not a managerial decision, the Chief Executive has no direct influence on what clinicians do in their work.

National drivers constraining the Chief Executive's options. Local commissioners directing the Chief Executive's choices. Tiers of managers running with the Chief Executive's wishes yet effecting implementation (or not) their own way. Managerial decisions' boundary with clinical decision making (and no direct managerial influence in this). Good grief. I'd not really thought through what a grim position it is to hold, having all the responsibility yet with much less opportunity to effect detailed sophisticated systemic change than I'd considered. Worse, I erroneously presumed that the Chief Executive is boss and can sort everything. Most folk do.

I lacked insight into the situation.

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