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Sir Trevor - why freedom is overrated


Blog headlines

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Thursday, 15 November 2018

Sir Trevor - why freedom is overrated

Who did NHS England and NHS Improvement turn to for advice when it came to drafting the chapter on integrated care systems in the long term plan? Sir Trevor Longstay is too discreet to say, but a playful sneer appears on his lips when the question is posed.

Responding to our request for an interview, Sir Trevor refuses to breach client confidentiality but agrees to answer the hypothetical question ‘What might you have advised had an appropriate and suitably remunerated advisory situation arisen?’   

I am a big believer in cascading management theory. Some decisions need to be taken nationally, others should be taken locally.

The crucial point of governance is to ensure that while decision making itself may be devolved, the ultimate decision about the circumstances in which it may be devolved can only be taken by a properly constituted authority. That might be an individual very senior leader such as myself or a national body such as NHS England.

Sometimes it makes sense for things to be decided nationally, such as tax raising, funding arrangements, policy making, planning, regulation, training and education, while other things can be left to local areas – walking groups, care of the elderly, newsletters, décor in GP surgeries and so on.

So while we might agree that change should always be locally determined we also need to understand the sensible limits to local freedoms.

Integrated care systems provide a very good example of the dilemma facing policy makers and regulators. On the one hand, local areas wish to make their own decisions about the form these will take, the manner of their introduction and the timing of their implementation.

On the other hand, too much autonomy inevitably results in leaders who grow too big for their boots and start to believe that they are in some sense “setting the agenda”. At best it results in insolence, at worst in a complete breakdown of discipline.

So how do we square the circle? The answer is to provide very clear limits to freedom and explicit guidance on how and when to exercise it. In my advice to national bodies we came up with three different levels of freedom to be enshrined in a new ICS contract: virtual, partially integrated and fully integrated freedom.

At the lowest level, the holder of a virtual ICS contract would be vaguely aware of being in charge. A partially integrated ICS would have the distinct impression of being in control of its own destiny and a fully integrated contract would put no limits on the leadership’s capacity for self-delusion. 

In all cases the award of contracts and their progression through the hierarchy of local determination will be subject to a robust assurance process with appropriate checkpoints. This mechanism will enable us to bring ICS areas on stream in an orderly fashion, prioritising the just about adequate and only approving the completely hopeless after a due period of form-filling and humiliation.

It is said that when they threw open the gates of prison camps at the end of the Second World War, instead of embracing freedom many of the inmates simply milled around in the compound unable to decide what to do next. The lesson for NHS senior management is clear: keep the gates firmly shut at all times. 

Editor: Julian Patterson