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Editorial Wednesday 9 March 2016: From Trust to trust - The Grand Old Duke Of York, encores and Confucius, confused

The junior doctors are on strike, again. Both sides look entrenched for the long haul. Both claim the moral high ground of patient safety and the public good.

Well, and well some more. The public, as surveyed by Ipsos MORI, seem to remain relatively supportive of the junior doctors.

The summary finds that "The survey of 860 adults in England finds the same proportion (65%) supporting junior doctors strikes as for the previous round of action in February (66%) – as long as emergency care is provided.

"Opposition to junior doctors striking has decreased by five percentage points to 17% compared to last month.

"... the government continues to bear much of the blame for the ongoing dispute. A majority (57%) say that the government is more at fault for the dispute continuing this long, down from 64% in February, and the number saying the junior doctors are more at fault is still low at 11% (13% in February).

"However there has been a ten percentage point increase in the proportion saying that the doctors and the government are both equally at fault (28%) since last month".

What do you do for an encore?
It's not immediately obvious how this row will be de-escalated. Both sides have made it halfway to being The Grand Old Duke Of York: marched their troops up to the top of the hill successfully. Nice aerobic exercise, and all that, but what do you do for an encore?

Mr Hunt thinks he can play the long game. He believes that he has the Prime Minister's support (so it's a good thing there haven't been recent, health-focused meetings at Number 10 to which he wasn't invited). Public support for his stance is a more equivocal issue: it's years to the next general election (albeit just months to the Brexit referendum).

The JDC leadership believe they can play the long game. Their base is thoroughly secure, and the polling shows public support.

(Arguably, you can trace the roots of this conflict to the BMA's membership management challenges around the 2010-12 Health And Social Care Bill/Act: they ended up having to wholly oppose the Lansley legislation, and not in a position even to lobby for sensible amendments.)

Of course, there are evident, semi-covert differences of opinion within the BMA. That is nothing new: there are several tribes within the Brotherhood, whose internal antipathies and tensions are longstanding and deep.

Fitter, happier, more productive
An excellent submission to the health select committee's inquiry on NHS funding by Andrew Street of the University of York points out that arguments that the NHS can't and doesn't increase efficiency can be technically summarised as 'crap'.

Street shows that "Taking account of the amount and quality of care, overall NHS output increased by 47% between 2004/05 and 2013/14 ... Taking account of all staff and non-staff resources, such as equipment, supplies and capital, NHS inputs increased by 31% between 2004-5 and 2013-14".

He rightly adds that "there remains scope for improvement. Productivity has not improved at the same rate across all NHS settings, with the productivity of the hospital sector having fallen by 0.5% between 2012-13 and 2013-14. Our research also shows that hospital productivity varies substantially across hospitals".

Street concludes, "It is unlikely that just by meeting the preconditions for deficit relief that longer-term structural problems will be solved. As part of a longer-term strategy, the payment regime also needs to be reformed ... hospitals also need to take greater responsibility for their financial situation.

"First, they have to take responsibility for costing ... Second, hospitals need to assess both the income and cost implications of what they do ... Third, the rise in hospitals activity is partly but not completely demand-led ... Finally, the move to 7-day services may contribute further to deficits". Amen.

From Trust to trust
Reflecting on the 2016 Nuffield Trust Summit, one session particularly stuck out of a high-quality programme.

Dr Sam Everington, former BMA political junior doctor activist and Bromley-By-Bow Health Centre pioneer, was discussing a simple initiative: his CCG had hired a hospital-based diabetes consultant for a session a week to act as knowledge resource and support to local GPs to manage their higher-risk diabetic patients in the community.

It wasn't the originality that struck me (Partha Kar does something similar in Southampton). What struck me was they'd done it quickly and without putting a big bureaucracy in place.

The magic ingredient to achieving that?


They have been through some real battles against poor-quality colleagues in that health economy, which also had a well-led and well-functioning PCT (and thus was in a minority). I'm told that at one point, Tower Hamlets had more GMC referrals than the rest of the country put together.

There is, in short, a history of clinical co-operation. They trust each other. I'm sure they peer-review each other as well, but they trust as a basis of how they work.

This made me reflect on other health economies who are successful or improving. Trust is a golden thread between every one of them I've ever experienced.

This isn't at all an original observation of mine. Former NHS England Comrade-In-Chief Sir David Nicholson described the loss of trust in his 2015 NHS Providers Annual Lecture: "we will not deal with the problems facing the NHS unless we work on how we can deliver a greater trusting environment to operate in. Part of this issue around trust is the predictability of the system we operate in. If people believe if organisations are operating in unpredictable ways – that, every day, something different happens in a way that people simply do not understand – you undermine trust and undermine the way things operate. Consistency of purpose is critically important to developing trust”.


In the absence of trust, and of people whose judgments are broadly ones in which you can have confidence, then you replace trust with massive, intrusive and often counter-productive over-regulation of finance and quality.

Which is what we've done.

Oonora O'Neill's seminal 2002 Reith Lectures quoted Confucius' saying that "three things are needed for government: weapons, food and trust. If a ruler can't hold on to all three, he should give up the weapons first and the food next. Trust should be guarded to the end: 'without trust we cannot stand'."

You can't transplant or mandate trust. League tables, seminars, round-tables and lectures will not magic trust into being. Trust can only be grown and earned.

And the bad news is that developing trust takes years. It takes effort. And it takes consistency.

When trust is being born, it is fragile, and easily broken.

So we need to go around financially-challenged health economies facing rising demand, in a backdrop where the Health Secretary has chosen to go to war with junior doctors, and we need to start stirring up trust.

That won't be easy.

No time like the present to start. Good luck.