29 01 2012

A recent report has criticised the way HIV services in London are commissioned highlighting ‘significant management failings’ and a ‘lack of strategy’ as the root causes.

But as the debate surrounding the government’s health service reforms rumbles on, aren’t these among the same issues which neither side seems willing to grasp?

The recent Pan London HIV Prevention Programme (PLHPP) Needs Assessment report highlighted failings in both management and strategy for the London HIV commissioning group. The organisation spends £2.3m a year with HIV treatment in London costing £500m pa on the 30,000 people accessing care (rising by 5% annually).

The report identified ‘significant failings with the management of the programme’ and stated ‘providers have fallen far short of their activity targets.’ Of those failings the report cites ‘a lack of clarity over leadership’ and ‘inconsistent direction from commissioners’ before going on to say that the programme ‘appears to have evolved over time without any explicit strategic direction.’

It makes shocking reading and yet those responsible appear to be assuming a position similar to that of a threatened ostrich. As an example, Mark Creelman, Director of Strategy (sic) for Inner North West London Primary Care Trusts (INWL PCTs), which lead the PLHPP has stated; “we are working to ensure the programme has the right leadership and the right governance in place to be as effective as possible.”

Mr Creelman goes on to state; “across commissioning and providers, we have a joint responsibility to ensure we’re spending taxpayers money effectively.”

Few of us would argue with that sentiment yet another report into the PLHPP, published last February, showed that of 17 projects commissioned only two merited further commissioning. Nearly a year later the “taxpayers money” continues to fund all 17 projects bringing into question exactly what Mr Creelman means by “effectively?”

At the root of the problem are a number of issues which are also affecting the NHS nationally, issues which do not appear fully understood by the various entrenched positions as the ‘debate’ continues.

  1. Structure is not strategy. Time and time again at macro, meso and micro levels, the NHS (as with many other organisations) addresses weaknesses and issues via restructuring. The purpose of structure is to best facilitate the effective, efficient and economical delivery of strategy. Therefore constant restructure without strategy review and without clearly defined strategic purpose is akin to shuffling the deckchairs on the Titanic.
  2. Goals are mistaken for strategy. This results in a dog’s dinner of mini-strategies at national, regional and local level, all quasi-independent of each other. Few of these strategies are even horizontally integrated let alone vertically integrated thus a structure and psychology of a large organisation split into smaller silos has been allowed to develop and prosper.
  3. Management and leadership have been confused. In short-hand, the role of management is to ensure best use of resource while that of leadership is to take people forward in a shared direction (which includes making tough decisions). The NHS is ‘management-heavy’ and ‘leadership-light’ creating a classic example of an over-bureaucratic entity.

That change is needed in the NHS is not disputed by either side of the debate however both sides are seeking structural change ahead of strategy defining the purpose of that structure. Both sides want to continue committing taxpayers money to structure where goals are funded in silos, genuine strategy is absent and the word “effective” is used in place of ‘effective, efficient and economic.’ Both parties seek to continue a structure over-reliant on management where quality leadership is being cried out for.

That both parties share the view that the NHS requires reform should be a great, shared starting place for the development of quality strategy leading to genuine reform. However the government has chosen to continue the use of the policy of ‘Modernisation’ first introduced by Tony Blair*, consultation has been a sham and the only leadership in evidence has been of the flawed variety taking us to the entrenched positions of today.

A strong, well run, accessible NHS is important to us all. Whether fighting HIV in London or providing health services for a nation let’s bring strategy and leadership back to a table dominated by management and structure before we end up with nothing more than a different version of the dog’s dinner we all currently tolerate rather than enjoy.

*For more on ‘Modernisation’ see ‘Cameron’s NHS? Beware The Moderniser!’ from February 2011.

© Jim Cowan, Cowan Global Limited, January 2012

Read more blogs by Jim Cowan

Twitter @cowanglobal



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