NHS Reset: The value of public scrutiny in resetting the NHS

Even as we are managing and dealing with this immediate COVID-19 crisis, we need to take the time to understand how we will want to work and relate to one another after it has begun to recede. NHS Reset forms part of the conversation and tallies with our thinking at the Centre for Public Scrutiny about what the future might hold – and about how this crisis can, and should, cause us to question some of the assumptions and certainties which we used to hold about the structures and systems, and the associated governance, within which we work. 

As an organisation, our preoccupation is governance, and the vital role it plays in improving outcomes and the behaviours and attitudes which influence good governance. Before the crisis hit, the NHS was already in the middle of undertaking the most recent in a series of substantial governance shifts with the development of integrated care systems (ICSs). The question is whether these new governance models are fit for purpose in the world post COVID-19.

Our immediate difficulty in answering this question lies in understanding what that world will look like. Will it be one where our action on COVID-19 leads us to conclude that a centralised, national approach makes us more resilient and better able to cater for people’s needs? Or might it teach us that a more distributed, localised approach is likely to look more effective?

In order to answer this question we will need perspectives. Those of us who are professionals – in whatever sector we work – will come to our work with that professional perspective. It will be partial and incomplete. The views of those in other sectors, and working in different contexts, are likely to be different because their perspective on this crisis will also be different. The crisis will look and feel profoundly different for those working in acute care, to those in primary care and those involved in the operational delivery of social care – either in people’s homes or in a residential context.

We need a way to gather and reflect on these different perspectives. For most, there will be a form of operational debrief of the crisis once it has begun to recede – but it would be a missed opportunity if we were not to integrate some of this future-gazing into that exercise. One of the shortcomings of the way that we have sought to understand previous crises is that our reflection of them has tended to be highly operational in nature – did the resources go the right way at the right time? Did we make decisions in the right way? These encourage us to second-guess past actions and can quickly become a blame exercise, rather than to learn lessons and design different approaches. 

What we will need to ensure is that a debrief process is designed to force us to confront uncomfortable truths about how we thought the world ought to be, and to compel us to design new approaches which may well need to look very different.

At the moment, though, we need to recognise that just as we might want to lift our sights to create a future which looks very different to what we have now, we will also feel a pressure to return to “business as usual”. It will feel attractive to slip back into old certainties, to work within familiar systems and to carry on with work which, we can tell ourselves, was merely “interrupted” by the crisis. The challenge is to make sure that we don’t do this – however tempting it will be.

How, then, do we have these conversations? Mutual challenge between partners is a good place to start. NHS Reset is leading the way here. Partners must, however, be drawn from a wide spectrum, reflecting the way the public now want to live their lives and access public services. It should include local government – in public health, social care but also in the wider spread of services provided by councils. Partners in other critical services and in the voluntary sector. Local people whose voluntary activity, street by street, will have given them a new insight into the lives and needs of their neighbours. In the past we have – rather clunkily – “consulted” with these people on our objectives but the first step needs to be to recognise that a more responsive health service requires more candour and frankness – and for us as professionals, more uncertainty.

Those in leadership and governance roles will have to create space for that uncertainty and the competing priorities and tensions that arise from it. It will involve using our collective resources as professionals to convene debate and discussion, rather than to create and implement plans in the way that we used to. In our local government work, this space of contention is one in which local elected councillors operate. They could well be your close partners as you come to understand and interact with this new world. 

The good news is that the structure of the ICS agenda does provide us with the framework for this rethink and reset – in priorities and relationships. But that structure can only take us so far. We also need to commit to the behaviour change necessary to shift our mindset and approach. That will not happen naturally. We hope that NHS Reset can be used as a tool to shift our collective assumptions about the form and practice of governance, about the nature of leadership, about the relationship between local and national power and about the way that the services we provide reflect the needs of people’s lives.

Ed Hammond is director of campaigns and research at the Centre for Public Scrutiny. Follow the organisation on Twitter @CfPScrutiny