The Ward Round: Bureaucratic barnacles

“But wouldn’t that ruin the hull?”, asked a perplexed colleague, following the health and social care secretary’s "Future of Healthcare" speech last week, during which he called for a “layer of bureaucratic barnacles” to be “stripped away to streamline the vessel underneath”.

There were many other analogies during the speech, but this was the one that was repeated – and arguably mattered – the most. According to Mr Hancock, bureaucracy stands in the way and disempowers frontline staff “who just want to get on with caring for patients”.

He rattled through seven "lessons" that emerged from the pandemic and described how some of the emergency regulatory measures brought in helped to empower staff, when usually there are assumptions “someone will do the wrong thing unless they have layers of management peering over their shoulder”.

This conflation of bureaucracy and management, although disappointing, is not surprising. There have been multiple attempts, often announced by senior ministers, to "cut red-tape" and remove the tiresome bureaucracy that burdens the NHS.

“The layers of management trope needs a more sophisticated analysis,” said the Nuffield Trust’s chief executive Nigel Edwards after the speech.

Managers in Partnership chief executive Jon Restell responded: “Staff need managers. Patients need managers. You need managers. Better to talk about freeing up managers to focus on staff, patients and service improvement, rather than waste very finite time looking up to you.”

It is unclear what precisely Mr Hancock is referring to when talking about beating bureaucracy; it could cover a number of things. If it means abolishing clinical commissioning groups, this can only be achieved through government legislation. And that is most probably delayed until next year.

It is fair to say, however, the urgency of the pandemic sped things up and gave people the tools and permission to get things done at pace. But it also made organisations less accountable, and power even more centralised.

But suggesting that less bureaucracy is the golden ticket to staff empowerment is misguided. Lack of training and career progression, stagnant pay and poor culture must be tackled first and foremost.

Part of the plan

The latter – poor culture – is a key part of the People Plan, announced alongside Mr Hancock’s “bureaucracy busting” call for evidence. Although trumpeted as the People Plan, the document published last Thursday was actually the first part of it – the section on workforce numbers and crucially money has been kicked into the future.

There was clearly pressure from above to publish something this side of the spending review, and there is plenty of good, ambitious – and overdue – content within it. For example, the chapter on "belonging in the NHS".

This section sets out clearly how “urgent change” is needed within the health service, as currently the way a member of staff or a patient looks determines how they are treated.

“We must work systematically and give these issues the same emphasis as we would any other patient safety-related concern,” the plan said.

It sets out various measures to be taken by employers, including boosting the diversity of talent management and tackling the ethnicity disciplinary gap. However, as noted by some after its publication, it was light on how these important things should be implemented.

There were some specific new measures also worth noting in the "looking after our people" chapter – closely linked to the People Promise – such as launching an NHS violence reduction standard by December 2020 and the need for trusts to appoint a new "wellbeing guardian".

The Department of Health and Social Care has confirmed the rest of the People Plan would be published later in the year, once the government spending review has confirmed future NHS education and training budgets.

Helen Buckingham, director of strategy at the Nuffield Trust, described the difficulties that come with splitting the plan in two: “If you are working in an area where there is a significant shortage of staff it is going to be extraordinarily hard to address all the cultural issues set out in the plan, when you haven't got the staff to deliver the commitments patients are expecting or to do it as well as you could.”

“We all need to stand back and think about how we do things differently, but ultimately if the NHS is going to cope with the demands placed on it, it needs more people.”

But, while waiting for the rest of the plan, local systems are expected to make progress on the wellbeing measures set out, while also being told in the phase three guidance to ensure non-covid health services must return to “near-normal” performance before winter.

Many, if not all, employers will agree wholeheartedly with much of the People Plan. But plenty of "what", not enough "how", and a lack of new money may clip their wings before they can even get started.