NHS targets reveal the limits of pressure from the top

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Roula Khalaf, Editor of the FT, selects her favourite stories in this weekly newsletter.

The writer was director of the strategy unit in the Department of Health from 2000-2004. Matthew Taylor, chief executive of the NHS Confederation and previously head of the Downing Street policy unit, also contributed

Keir Starmer’s recent decision to focus on the delivery of measurable improvements in public services means that the focus now shifts to how this will be done. One source of advice is his predecessor Tony Blair’s book On Leadership in which Blair argues for adopting a route map for governing based on a small number of priorities. This, he writes, should include a narrative on the “why, what and how” to define the agenda for at least one term — and ideally more where major changes are planned.

Blair argues that leaders should build a strong centre and appoint talented people to support them in driving change. He invokes the work of the delivery unit he set up in Downing Street as an example of how to get results.

But caution is needed in relying on these disciplines to change the UK’s public services. Take reforming the NHS. The positive influence of Blair’s delivery unit was clear: it brought a focus that had been lacking. In so doing, it contributed to improvements in areas such as waiting times. These were sorely needed and overdue.

Less well recognised is that this approach also gave rise to perverse incentives. Data was gamed and, in some cases, misreported to avoid sanctions for underperformance. Areas not covered by government targets received less attention. This is one reason why the shift to care in the community, now promised by health secretary Wes Streeting but which has been government policy for two decades, has never materialised.

On the front line, the delivery regime created a culture of compliance and risk aversion, inhibiting innovation. Leaders and staff working in the NHS were disempowered and sometimes felt bullied by politicians and those acting on their behalf.

The Blair government learnt from these mistakes and sought to develop a system with the capacity for continuous self-improvement. It recognised that this can come from three sources. It can be driven by top-down strategy, regulation and resource allocation or by culture, professionalism and peer networks. Finally, it can come, bottom-up, from patients and communities.

To change a system and to keep doing so, these drivers need to be aligned and balanced — otherwise, top-down pressures drive out the capacity of leaders to learn from each other or respond to the people they serve.

This is particularly relevant today, with a new government saying that reform will have to do more of the heavy lifting in the NHS than investment, given the state of public finances. To date, the role of collaboration (and of local engagement from patients) is largely missing from the political rhetoric, although there is a narrow focus on consumer choice and financial incentives.

But its value is evident where NHS organisations do work together with their peers and partners — for example, in collaborating to cut waiting lists and times and reorganise specialist services.

Streeting has said on several occasions that for every problem in the NHS there is a solution somewhere else. The challenge is to act on this insight and support leaders and staff across the NHS to find more effective ways of making the right links.

Yes, delivery is essential, but it does not have to come from a strong centre that hoards power and tightens its grip on those providing services. Health and social care make up a complex ecosystem in which command and control from the top is likely to be frustrating and ultimately futile. There is more than one way of achieving results.