Editorial Wednesday 28 September 2011: Failing better
The NHS is traditionally bad at failure.
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Or perhaps we should say that the NHS is bad at dealing with and facing up to failure. It's impossible to claim that a system that let the well-known incidents of appalling care at Maidstone And Tunbridge Wells, Mid-Staffordshire, Bristol and Stoke Mandeville is bad at failure.
The NHS is good at denying the existence of failure. The culture left NHS managers with two core rules: don't blow up the money and keep down any noise that might embarrass the minister. Centralisation of power didn't help this much. Quality regulation hasn't worked - and whistleblowing enjoys the pariah status that it does.
It was not a surprise, in following HJS journalist Sarah Calkin's invaluable coverage of the Mid-Staffs Public Inquiry, to learn that NHS CE Comrade Sir David Nicholson fancies a bit of renationalisation in the event of failure.
Calkin rightly notes that this is at odds with the liberation theology of Andrew Lansley (saviour, liberator), and the DH's highly curious failure regime (which our analysis showed permits Monitor to agree over-tariff payments for providers without commissioners' consent).
It's far too tempting to riff on notorious former Communist Nicholson's politics here. The meaningful question is about how the NHS of the future plans to handle failure.
A farewell to centralism
The new world of Mr Lansley's reforms is predicated on a farewell to centralised command-and-control - and especially to planning.
The NHS management structure has avoided failure through bail-outs, tricky finance and covering up awkwardnesses with compromise agreements that insist on confidentiality.
As the downward pressure on tariff continues, and there is increased and sustained scrutiny on referrals to acute care, providers will falter.
More to the point, while clinical commissioning groups will work well and make a real difference in some areas - those where PBC has traditionally had some traction, and mature relationships have built up across the health economy between commissioners and providers - in other areas, they will fail to be authorised, or once being authorised, then fail.
There is also the intrinsic risk to the system of failure - that is to any major, system-wide change programme, especially one "so big you can see it from space", in Sir David's lively phrase.
It is unclear that mergers or takeovers will solve these problems. In the past, they have no higher a success record in the NHS than in the world of business.
And it is very unclear that the proposals in the Health And Social Care Bill for managing failure will be improvements on the traditional denial-and-silence approach.
Failures lie ahead, and it would be reassuring if we could feel confident that the system will fail better.