Select Committee on Public Administration Appendices to the Minutes of Evidence

Memorandum by the Institute of Healthcare Management (PSR 19)

  The Institute of Healthcare Management would like to take the opportunity to respond to the PASC Issues and Questions Paper. It does so under the broad headings requested although not necessarily in direct response to the sequence of questions therein. The Institutes comments must be taken as relating primarily to Health, unless otherwise indicated, since this is of course its area of interest.

  The Institute's purpose is to enhance and promote high standards of professional healthcare management in order to improve health and healthcare for the benefit of the public.

  Its major objectives are:

    —  To create, sustain and represent a professional community of healthcare managers

    —  To provide an independent voice for healthcare managers, and to protect and promote the status, interests and welfare of the members by ensuring that their contribution to good health and healthcare is recognised

    —  To influence policy, operations and culture in UK healthcare

    —  To provide strong local networks and support for members, especially in times of professional difficulty

    —  To promote professional standard-setting

    —  To promote good practice and professional development

    —  To advance the study of and research in healthcare management

    —  To provide/support the education of healthcare managers

  The Institute is committed to support its members with a personal and professional development framework.


1.   Was reform unavoidable?

  The need to reform the public services seems to have been taken as a given and with this the underlying assumption that they no longer fit for purpose for the 21st Century. Although intuitively the Institute accepts this notion little has been done to demonstrate that there are fundamental failings in the concept or that reform rather than investment will resolve these failings.

  There does not seem to be the high level of corruption that other countries seem to have. Outputs for cost generally seem to compare well. The new District General Hospitals say built during the 60s/70s and 80s did not seem to require PFI initiatives to fund and the economy is supposedly much more sound than at that period.

  Perhaps more needs to be done to convince people and organisations that the reform programme was inescapable.

2.   How have the areas to reform been selected?

  The reform programme is not evenly applied across all the public services—for instance whilst there have been cost constraints in the armed services there has been relatively little structural or managerial change. Hierarchies still prevail when many other employers have found greater employee favour from other forms of management style. The change programme largely unchallenges professional groupings or the basic principles of a Parliament served by civil servants.

  The change programme shows that democratic deficits will still remain in some areas whilst others seem to be heavily burdened with over representation. Quangos rather than elected representatives still predominately govern many of our institutions. However, which service is managed by which form of oversight remains difficult to understand. Social Services is accountable to elected representatives Health to a Quango except in Northern Ireland of course.

3.   Is reform UK wide?

  The impact of devolution on this scenario is also clear. If public service needs reform will it be UK wide or simply country specific. The starting point was similar for all the countries so one might reasonably have supposed if the case for reform were self-evident all countries would be pursuing the same agendas. This seems not to be the case and highlights the dangers of true devolution and the problems of reform if for instance there were to be Regional Government in England. In such circumstances centrally driven and directed reform to standard patterns is impossible but the alternative of local reform and change leads to post code prescribing which seems to be unacceptable to the electorate.

4.   Is there a need for explanation?

  These may all be appropriate differences, challenges and anomalies and be more about priority and pace of change than about concepts of the need for change and reform but perhaps more needs to be done to explain and justify that this is the case. For all its faults the NHS is based on the science of medicine and as a science based organisation it likes to understand cause and effect. What has caused the need for reform what will be the effect of the changes? What seems evident from the short analysis above is that reform is not universal.

  We would suggest that all structural change is largely irrelevant to the consumer/customer/client/patient and that all that really matters is the standard of service they receive at the point of need. It is likely that certain structures are more likely to produce a better end product than others but which and in what circumstances remains to a large extent a political view rather than a researched one.


  It seems popular to suggest that the public service ethic is a thing of the past. There is certainly anecdotal evidence that the motivators for many of the great professions of the past have shifted. Junior doctors finishing shifts on time irrespective of the fact that there are still patients to see. Patients more willing to criticise failures than praise successes. Nurses more willing to sell their extra hours back to the NHS through an agency than directly to their employer. Managers given hours to clear their desks as a new Chairman arrives. These are wounds certainly in the concept of public service but all the evidence to us here at the Institute suggests that these remain the minority position. Surveys of consultants finds them working well in excess of their paid hours. Graduate trainees still express particular desires on entering the NHS to do good for others. Many senior managers work in the NHS despite knowing personal rewards are higher outside. These are very positive indicators. However, the assumption we make is that this is not a public/private issue and that many of the same values do apply just as strongly in the commercial or private sector.


  This point leads nicely into the next set of questions posed in the consultation document. The Institute of Healthcare Management has developed for its members a code of behaviour and at the request of its members made it compulsory as a part of membership. A copy of the shortened version is enclosed with this submission for completeness.[5] The significance of this can be found when one relooks at the membership of the Institute and the large numbers working in sectors of health outside the NHS. These managers have had no difficulty in signing up to values that embody all that one would expect to see at the heart of the public service ethos—honesty openness etc. This would seem to us to indicate that it is overt standards that should be the issue not the employment base of those exercising those standards. The medical profession have the same core values wherever they are employed this should be able to be applied to other areas. Lawyers work in the public and private sectors so do qualified accountants. Moreover a lot of services provided within the public service are provided by outside contractors and have been for years. There should be much greater clarity about the boundaries of that provision if it were really that important.

  It has to be accepted though that involvement of the private sector brings a set of players to the table whose interest in outcomes may be very different to that required in the greater good. Shareholders and investors need to see returns and this means that non-profitable lines have to be avoided or discontinued. This inevitably means the pursuit of goals which at best improve the lot of a sub set of the population rather than the overall population. Health has many potential non-profitable lines particularly as it veers towards chronic conditions and social care. Moreover the argument goes that if the private companies can provide and make a profit then the public sector should be able to provide and convert the profit into more services on the ground. These are difficult arguments to overcome since the implicit assumption is that the private sector management teams are stronger than those in public sector. If this is the case there needs to be a stronger evidence base to confirm it.

  It is clear from most international comparisons that the potential exists for Health needs to outstrip the ability of the public purse to meet those needs. This must be true in several other public services especially those with strong reliance on family and carers free input to provision as families disintegrate in divorce and distance. (As an aside do carers automatically espouse public service ethos and standards or are they private sector providers?) Many countries have recognised that the challenge for them is how to devote more resources to health and other underfunded public sectors. It is more usual to find non-public sector sources of funds to meet the gap elsewhere in the world. this could be from individuals self-insuring or employers collectively contributing.

  The point here then becomes whether it is moral to have mixed economy fund raising but only public sector spending. Many would argue that we need a lot more investment in Health in the UK. This must at some point mean alternative funding sources or much higher taxes in this sector also. If the former route is chosen the argument for purely public sector provision based on a notion of a public service ethic is impossible to sustain. If old people in England have to give up their savings and property to fund their care in the later stages of their life it cannot be acceptable to suggest that the money has to be spent in the public sector. Indeed if we are unable to fund care for our elderly from the public purse is the concept of a provider being bound to such an ethic a little hypocritical. There must be choice. This may imply that the discussion is all too late and putting the clock back is not possible.


  These are extremely difficult issues but we would argue the issue is again not a conflict about expenditure in the public or the private sector but of standards protocols and procedures governing all investment decisions. It proved difficult in the early 90s during the conservative experiments with self governing Trusts for elected representatives to say that they were unable to answer the national questions since the local Trust had made their own decisions. It is difficult to see that this has or could reasonably change unless and until there was a very local democratic process for the allocation of money and accountability for its spending. This would mean much greater local government or regional government or elected members of all public service spending bodies. In saying this it also has to be recognised that those structures that serve democracy and public accountability well like committees, working parties, audit trails, paper records, bureaucratic processes and so on are not necessarily the same structures that ensure innovative and imaginative service delivery. In other words the very consequence of a highly accountable structure is one that is not customer focused. It spends too much time looking up to the accountable body and its external monitors and not enough delivering the public the service it wants. If these dilemmas are genuine ones then it would be normal to suggest a compromise—a balance between ability to act be responsive deliver modern services and the ability to account for ones actions. Solutions based on compromise need very careful thought and perhaps this has to remain in the less than ideal box.

  So far as the NHS is concerned there is a massive monitoring industry running to scores of bodies with a remit to inspect and comment? If this is part of the compromise it is burdensome and inhibits good managers from developing their organisations and diverts valuable time from doing to answering monitors questions about the doing. It is difficult to see the accountability argument is stronger than the wasted effort argument.


  It is unfashionable to suggest that the pendulum is swinging too far the other way and in the age of consumerism that there is a danger in too much power going to the consumer. We will not suggest this but we will point to the dangers. It is popular to suggest there are none that all public involvement is good and good at whatever the cost in terms of time as well as money.

  The GMC has in the view of the Institute made remarkable strides to modernise its public involvement but it now sits somewhat uneasily between a public who may feel it has not gone far enough and a profession that thinks it may have gone too far. There should be universal praise for the model it has produced but it has been mainly criticism. The public is not always the reasonable person that attends committees and advises. Some attack public servants in increasing numbers. Some vandalise public buildings. Those involved with complaints in the public service have noticed an increasing use of litigation. The fault for this is often laid at the door of an unresponsive public sector who only respond to the law but it is possible that there are elements of anger, greed and revenge creeping into the public's view of its public services.. A no blame culture is not one that all public sector employees would recognise as existing where they work.

Stuart Marples FIHM

Chief Executive

Institute of Healthcare Management

November 2001

5   Ev. not printed. Back

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 21 June 2002