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Editor's blog Wednesday 19 January 2011: Sir David Varney weighs in on risks of the Health Bill reforms

The day is getting livelier already. There is a heavy police presence on Whitehall, including riot police. I'm just not that scary.

And to add to the gaiety, the liberal think-tank Civitas has just published a report by Sir David Varney on Risk, 'Equity And Excellence'.

Who he? Sir David Varney was: chair of Barking, Havering and Redbridge NHS University Hospitals Trust (January-June 2010); advisor to the prime minister on public service transformation (2007-2009); chair, HM Revenue & Customs (2004-2006); chair, MM02 (2001-2004); chief executive, British Gas (1996-2000); and has held various posts at Shell, including head of oil products Europe (1968-1996).

Varney's recent six month tenure chairing Barking, Havering and Redbridge means that when it comes to the NHS, he is not unaware of the issues.

His document cites the classic On the Psychology of Military Incompetence by Norman F. Dixon. The author advanced 15 characteristics of military incompetence:
1. An underestimation, sometimes bordering on the arrogant, of the enemy;
2. An equating of war with sport;
3. An inability to profit from past experience;
4. A resistance to adopting and exploiting available technology and novel tactics;
5. An aversion to reconnaissance, coupled with a dislike of intelligence (in both senses of the word);
6. Great physical bravery but little moral courage;
7. An apparent imperviousness by commanders to loss of life and human suffering amongst their rank and file, or (its converse) an irrational and incapacitating state of compassion;
8. Passivity and indecisiveness in senior commanders;
9. A tendency to lay the blame on others;
10. A love of the frontal assault;
11. A love of ‘bull’, smartness, precision and strict preservation of ‘the military pecking order’;
12. A high regard for tradition and other aspects of conservatism;
13. A lack of creativity, improvisation, inventiveness and open-mindedness;
14. A tendency to eschew moderate tasks for tasks so difficult that failure might seem excusable;
15. Procrastination.

Varney notes drily, "I have found that characteristics 1, 3, 5, 6, 9, 10, 13, 14 and 15 are usually present in failed projects or programmes across the public, private and voluntary sectors ... The crucial point is the White Paper does not focus on the potential risks the reforms create and how these risks might be mitigated. Instead, the document appears to believe that noble ends will suffice. It pays little attention to the history of NHS re-organisations, nor does it have much time for reflection on lessons learnt".

Eating strategy for breakfast
Varney adds that "The White Paper’s executive summary ends with the statement: ‘This is a challenging and far-reaching set of reforms which will drive cultural change in the NHS’. There are circumstances where structural reforms can drive cultural change, but in my experience they tend to be in organisations that have a clear authority structure and confront issues that are amenable to known technical solutions. ... It is much less common to observe structural reform driving culture change when problems are apparently intractable across many organisations, institutional barriers exist (even within organisations) and authority is diffuse – as in the NHS. In these circumstances, cultures in fact can be powerful shapers of intended reforms.

"Indeed, in the last 20 years, I have more often seen existing cultures undermining structural reform, than supporting them or being influenced by them; the privatised utility sector is a canonical example. The risk of this happening in the NHS with the reforms proposed is not assessed by the White Paper".

Redisorganisation, again
Varney observes on the abolition of PCTs, "the elimination of such commissioning organisations at a time when the NHS is required to meet such efficiency savings
represents a significant risk that has not been properly assessed. I doubt, for one, that there is any real quantification of the implications of the productivity ambitions. These ambitions are certainly greater than the private sector has delivered on a sustained basis.a A particular danger is that short-term gains are made at the expense of longer term ones".

Varney concludes by writing, "When all risks are placed together, I am left with the feeling that for the White Paper to deliver as promised would constitute something of a modern miracle. As Peter Drucker once observed: ’the trouble with miracles is not, after all, that they happen rarely; it is that one cannot rely on them’."