It's the people, stupid

Well, the noises coming from the Department of Health are encouraging. Increases in real time NHS funding, cutting administrative waste, reducing manager numbers, devolving power to local levels to stop the top-down micromanagement culture so prevalent these past years. Not much detail has emerged yet to put the flesh on these ostensibly attractive bones but it is early days.
The potentially most exciting announcement is the creation of an independent NHS board outside political control. How exactly this might work will be the cause of much discussion, debate and disagreement in the weeks to come but the priciple is sound and has long been advocated by this author. The difficulties lie in ensuring non-political appointments, equitable distribution of power between it and government - an impotent board would be mere window dressing but an entirely unaccountable one would soon become corrupt - and above all, the sticky question of 'Who guards the guards?'. Many will be left unhappy at the end of this process but I believe it could be a large step in the right direction.
My hope is that the new board will have the power, foresight and gumption to tackle the very way that money flows through the NHS. The internal market, created in 1991, revamped in 2002 and seemingly beloved of both Labour and the Conservatives before them is inherently flawed. Applying free market business principles to an essentially closed market does not make sense. At no time was this better highlighted than Labour's disastrous attempt to introduce Independent Sector Treatment Centres (ISTCs) into the equation to generate competition with the NHS. As they cashed in on non-performance related start-up and subsequent payments, generous tariffs and the ability to cherry-pick the easiest, low risk cases with no responsibility for any ensuing complications the rest of the medical world gazed in wonder as to how this could possibly have ever been thought to be a good idea. Sure enough, the impact on quality was minimal, the effect on morale devastating and there is now good evidence, to take one area at random, that their introduction continues to jeopardise training as junior doctors see the 'easy' cases where they traditionally learnt their craft, vanish to the private sector.
But the biggest reason that the internal market failed is the human factor. In a truly free market organisations are free to choose the best people for the job and can replace them if they fail. Whilst this holds true for the medical and nursing staff of the NHS, it most manifestly does not for the managerial cadre as the best of them naturally gravitate to the private sector with its higher pay and bonuses and the choice for the public sector is akin to picking the wheezy fat boy for one's sports team at school when all the athletic types have already been chosen. Of course there are exceptions and there is a cohort of managers who both have talent and value service above personal gain but those with this laubable combination of skills and views are the distinct minority.
The new NHS must not just be a slimmed down version of today's but there must be a
sea-change in the approach to staff recruitment and retention. Even the name - 'Human Resources' - suggests a depersonalisation of the subject since the happier days of 'Medical Staffing'.
It is the people that make the organisation and the knowledge and skill-base that exists within the NHS is unparalleled and should be allowed far more freedom to provide the service. Management teams drawn far more from the ranks of clinical staff will be able to run a much more efficient service as they understand the issues rather better than a 'professional health service management trainee'. And they will know that the artifical constraints imposed by the internal market, the arbitrary division of primary and secondary care, makes no sense. Given this power to change I predict that the service will transform out of all recognition leaving the politicians little more to do than claim the credit for it.
But first they need to remember: it's not principally about the economy. It's the people, stupid.