Anatomy of a Farce

The NHS Commissioning Board (NHSCB) prepares to assume full responsibility for the lions share of the strategic leadership of England's health system from April 1st.

As it takes up the reins, ten regional Strategic Health Authorities (SHAs) and 152 local Primary Care Trusts (PCTs) will simultaneously cease to exist.

The equality implications of these massive changes, prescribed by former Secretary of State for Health Andrew Lansley are discussed in a previous blog.

It's an event which the NHSCB has had eighteen months to prepare for, since being brought into existence on 31st October 2011.

Blunders and Procrastination

Yet, as I will demonstrate, a series of blunders and corporate procrastination, mean that the board looks likely to begin operations with only half a national equality team, no full time senior leader for that team with adequate knowledge and experience, and no coherent strategy … short or long term.

Short term, the challenge will be a major loss of local expertise, corporate knowledge and best practice, as PCTs (which mostly had equality strategies) give way to CCGs (which mostly don't). We will return to NHS services being planned according to a one-size-fits-all vision, just as a previous set of managers had begun to move away from that.

Longer term, assuming the NHSCB finds an experienced senior lead on health inequalities and equality, the problem will be a team that was designed without their input, and an organisational structure in which many of the founding policy decisions were made without their influence.

Why this matters

This matters because neither equalities nor health inequalities are secondary considerations for a national health service. They're not 'nice-to-have' accessories which you bolt on to the chassis when you find you have time. They are not something to do in order to avoid the risk of litigation. They two are fundamental to the purpose of a public-funded health service - both politically and practically.

Politically, aiming for equal outcomes and reducing health inequalities are central to the purpose of the National Health Service.

The founding legislation for the NHS made clear in 1948 that it provides health care free at the point of need to everyone. Not some. Not 'deserving' people. Not 'people like us'. Everyone.

This is underlined in the NHS Constitution, whose strap line is "the NHS belongs to us all". There are seven key principles, of which the first states:

The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.

You can't make it plainer than that.

Many of the constitution's other principles reflect the concept of equality too. After all, every one of us as taxpayers (and the dependents of taxpayers) pays for the service.

There are no discounts according to gender, gender reassignment, race, disability, sexual orientation, religion, age, parental, partnership or caring status.

Two sides, one coin

Although Health Inequalities is traditionally considered more of a public health discipline, the elimination of demographic differences in prevention, detection and recovery / survival of health conditions is part and parcel of the bigger picture of health care. Put bluntly, prevention is much better than cure. It costs less, in human as well as financial terms, and the outcomes of early detection are so much better. This is the practical face of why equality matters.

What constantly surprises me is how public health strategists so often ignore diversity in their vision of the causes and determinants of the major illness categories.

The Marmot review, a core strategic review of health inequalities, is light on understanding cultural diversity and the role that context plays. Populations are frequently discussed as though they are entirely homogenous … living the same lives, experiencing the same pressures, moving in the same circles, having the same view of the world. This is why interventions can often miss the mark.

Equalities experts have no difficulty making the connection between diversity and health. They tend not to even think of the disciplines as being separate. When explaining why equality matters beyond mere legal compliance, some of the most potent examples concern health inequalities.

It was therefore to be welcomed that the NHS Commissioning Board should sensibly lump equalities and health inequalities together. It was merely a confirmation of how experienced NHS equality leads already saw things (even if their public health opposites were a bit slower in realising).

So, with so many experienced leads to choose from, how did the NHSCB find itself without a genuinely recognisable equality and health inequalities expert at the helm after 18 months?

I'll explain...

Political distractions

Massive new organisations like the NHS Commissioning Board are populated from the top down.

Planning began in early 2011. The appointment of Sir David Nicholson as Chief Executive Designate was made public in January of that year, at about the same time as the Government published the initial draft of the Health and Social Care Bill.

The Bill would provide the statutory authority for the new NHS bodies. Most observers saw logic in having the Chief Executive of the old NHS being given the role of heading up the most significant part of the new NHS.

Most attention during the middle of 2011 focussed on the controversy surrounding the Bill. This led to the famous 'pause' in the Parliamentary progress of the legislation in the Spring of that year. A Doctor, Professor Steve Field, was appointed to lead a 'Listening Exercise' which initially appeared to criticise the content of the legislation. By the Autumn of 2011, however, the exercise was being denounced by commentators as 'a sham'. This view has persisted.

With all that attention on the politics, few observers outside of the NHS noticed how much change was already underway without any legislative debate at all.

PCTs and SHAs were merged into larger clusters (a plan that had been on Department of Health shelves for some time), shedding publicly accountable boards, directors and duplicate management structures in one stroke. This happened in the October of 2011.

Building begins

At the end of October 2011, the first appointments to join David Nicholson began to be announced, starting with the Chair, Professor Malcolm Grant.

With Chief Executive and Chair in place, and operating under legislation designed for 'Special Health Authorities', the nascent NHSCB was in a position to begin receiving and spending public money to set itself up.

During this time, in the day-to-day NHS world, SHA and PCT managers were consumed first with the rationalisation of 152 PCTs into 50 'PCT clusters' and 10 SHAs into 4 'SHA clusters'.

The new commissioning board operating structure was rumoured and hinted to be on its way around the beginning of January 2012 … without that, there were no posts to appoint. It finally saw the official light of day in February 2012.

The proposal was for the following directorates to operate under the Chief Executive:

• Medical
• Nursing
• Operations
• Commissioning Development
• Improvement and Transformation
• Patient Engagement, Insight and Informatics
• Finance
• Policy, Partnerships and Corporate Development
• Chief of Staff

This structure is dated 2nd February 2012, although internal advertisements for the Chief of Staff, and various secondment opportunities started appearing across NHS inboxes in mid January.

Comfort blankets and 'Immaculate Induction'

What happened next may surprise those who are not familiar with the way these things are organised.

News of appointments of the Directors chosen to head up the directorates began to appear in mid February 2012, two weeks after the structure was published.

As is so often the case, these directors were not apparently people who had applied for posts that were advertised competitively. They had essentially been tapped on the shoulder. Many were senior managers in the Department of Health or Strategic Health Authorities who had already been working with Nicholson.

This process of tapping people on the shoulder has been common, historically, in the NHS. Rather than conduct an open and competitive search for talent, leaders select people they already know and have worked with.

If Andrew Lansley thought his gigantic reorganisation was going to change the faces in charge of the NHS he would have been disappointed. People bring their 'comfort blankets' with them when they move jobs.

In the absence of strong governance to prevent it happening, leaders will pick the faces they know. The excuse here was the lack of time to do otherwise. So all the £3Bn reorganisation of the NHS was actually going to do was reshuffle the existing pack.

This is also why it is notoriously difficult to break down established imbalances in management demographics. Leaders appoint people in their own image. White people appoint the people they know and identify with most closely … who tend to be white. Men go for men. And women go for men too.

I refer to this process as 'Immaculate Induction'. People get born into a new organisation without any of the messy business usually associated with transparent, competitive, recruitment.

Those who imagine there is any benefit in sacking Sir David Nicholson would do well to study the historic associations in his board and senior management team, as they are all people chosen after his own image. This list of the main appointments by the summer of 2012 will help you check this out. Lop off one head and, like the mythical Hydra, there are many more just the same.

Anyway, I digress...

The appointment of Jim Easton as Director of Improvement and Transformation (the directorate that matters first to this story) was announced on 16th February as one of these director-level immaculate inductions. Easton was the National Director for Improvement and Efficiency at the Department of Health, so the new role was similar to his existing one.

Improvement and Transformation

Following his appointment in February, Jim Easton's first main task would be to flesh out the design of his directorate, which was intended to include the responsibility for leadership on "reducing health inequalities and promoting equality".

During the next 3 months SHA Equality Leads (some of the most senior managers leading on Equality in the whole NHS) variously tried to advise how they thought that function could best be achieved within the Directorate; however Easton played his cards close to his chest.

It was in May that a post of 'Director of Equalities and Health Inequalities' was first advertised. This was one of four senior manager posts reporting directly to Jim Easton and would have been central to designing an equalities function in the organisation.

As far as I can determine, several senior and experienced NHS managers with the relevant qualifications applied. However, by the end of May it became apparent that Easton had decided not to shortlist and interview anyone. His other three senior appointments were filled but nobody was apparently qualified enough in Easton's eyes to warrant interviewing for the post of equalities and health inequalities lead.

Advertised again

In mid June the same post was advertised again. Under the complex rules for enabling people with jobs at risk to have preferential opportunities to apply for posts, the second advertisement was open to a larger potential group of NHS staff to apply. Some of the same managers applied a second time and this time everything went quiet for a month.

Then, in August, the news slipped out that Jim Easton had again decided not to shortlist and interview anyone for the role. He had had no such difficulty finding suitable appointments for the other three very senior posts in his team.

At the end of August it was then rumoured that the post of Director of Equalities and Health Inequalities was to be advertised externally (though it never was, as far as I can determine). True or not, the rumour implied that, within the whole pool of NHS managers subject to the reorganisation, it was judged that there was nobody even worth interviewing internally.

At about the same time, the dedicated web site set up to manage transitional job advertisements collapsed under the strain. The transitional appointments process was beginning to get chaotic.

Immaculate induction … again

In the first week of September 2012 it was formally announced that Jim Easton had decided not to appoint anyone as Director of Equality and Health Inequalities, as he believed he could not find a single candidate with the ability to cover both. If the rumour of recruiting externally was true, he had presumably changed his mind.

Instead, he announced that a Chief Executive of a South West NHS Trust called Paula Vasco-Knight would be seconded one day a week as champion for equalities. Alongside her, the Deputy Medical Director, Professor Steve Field (who had headed the Health Bill's 'Listening Exercise') would carry Health Inequalities within his brief. Field had been appointed to the NHSCB the previous month.

Later the same week, further details of the operations structure for the regional and local area offices of the NHSCB became available. Within these, it was apparent that there was no provision for equality or health inequalities management in either.

No room at the Inn

It's worth pausing at this juncture to digest the import of this revelation.

At that point the NHS Commissioning Board still had no plan in place for any strategic or operational work on equalities or health inequalities at any level.

At the level of Local Area Teams (LATs) there would be no equalities expertise to advise or scrutinise the plans of CCGs. Thus, there would be no places in the structure for any of the NHS's existing PCT E&D leads who were unable to find roles in the rest of their local health economy.

At the regional office level, there would be no posts in localities that would suit most of the SHA E&D leads.

And, nationally, the whole NHS Commissioning Board had no experienced equalities specialist on board, save the two part timers filling-in.

By mid September, the SHA E&D leads who had not already retired or resigned contacted Jim Easton and Paula Vasco-Knight to express their concern about the lack of any information. Without any plan for a structure, managers couldn't make informed decisions about whether to apply for the dwindling number of other posts outside of the equalities field (in order to be assured of at least the chance of a job) or whether to hang on.

It is a rule of the process that if someone accepts a post they've been offered then they can't pursue one they would rather do if it subsequently comes up. People were therefore making decisions between saving their employment and gambling that they could continue to work in equalities, which was their speciality and vocation.

Board failures

Coincidentally at this time, the Health Service Journal reported that the Commissioning Board admitted to having a serious lack of diversity among its senior level appointments to date.

At yesterday’s public board meeting in Newcastle human resources director Jo-Anne Wass said its latest information on the proportion of appointees from different backgrounds “does not make for easy reading”… “This is a really significant issue,” Ms Wass said. She said the board had already taken action including training recruiting managers and contacting minority ethnic candidates in leadership programmes. But she said: “I’m not sure they’re enough… clearly more needs to be done.”

The fact that the board had these problems clearly pointed to the damaging consequences of failing to recruit a properly qualified person to lead on these issues and advise the board. Experienced E&D leads had long ago warned David Nicholson and other leaders of the risks of losing managerial diversity in any reorganisation. It's such a well recognised risk that the board could have planned how to avoid it happening. Now they were being confronted with what happens when you manage without equality expertise.

Make do and mend

In early October, a further month after SHA E&D leads had expressed concerns about the lack of plans for an equalities function in the NHSCB, Paula Vasco-Knight contacted individuals to assure them that she was in discussion with Jim Easton about creating a set of non-specific roles.

There still wasn't a strategy or even a plan for a team. This was simply an attempt to simply provide some sort of 'lifeboat' jobs that senior managers with considerable expertise in equalities could apply for.

Days later, the Health Service Journal revealed the news that Jim Easton was resigning from the Department of Health and NHSCB to become the Managing Director of Care UK Ltd.

The following month, on 6th November 2012, the board announced that Easton was not going to be replaced. Instead, his Improvement and Transformation Directorate would be broken up, with the functions reallocated to the remaining Directors. Equality and Health Inequalities would become part of the Policy Directorate, under Bill McCarthy.

A structure

Finally, after another month had passed, a revised structure for the Policy Directorate emerged with, at long last, the structure for an Equality and Health Inequalities team, jointly overseen by Steve Field and part-timer Paula Vasco-Knight.

Reporting to the two would be one 'Programme Director for Equality and Health Inequalities'. This person was to have two 'Senior Manager' posts, four 'Project Coordinator' posts and four 'Equality and Health Inequality Leads' spread around the footprints of the four former SHA Clusters (North, South, Midlands and East, and London). The latter four posts were to have specific remits for specialist areas:

• Children and young people
• Inclusion
• Workforce
• Planning delivery and system alignment

As there was still as yet no strategy, it is not clear what rationale lay in choosing these specific roles, unless particular people were already envisaged. It hardly looked like a structure whose functions were fitted to an evidence-based strategy.

By now it was Christmas 2012 though. PCT and SHA E&D leads who had not already found posts were having formal consultation meetings with HR managers, as legally required three months before the prospect of redundancy.

New year, new hope

The first working day of 2013 saw the advertisement of the first of the Equality and Health Inequalities team posts.

The following week more appeared.

As February arrived, details of some of the more junior posts began to emerge, and slowly it was becoming possible to piece together a picture of the team.

However, mysteriously, by mid February there was still no indication of whether anyone had been shortlisted for interview for the top job to lead it.

Still no leader

Finally, the news emerged that nobody, once again, had been considered suitable enough to shortlist for interview to lead the NHS Commissioning Board's equality and health inequalities team … an identical decision to the one taken by Jim Easton seven months previously.

The explanation for this remarkable decision (given the amount of NHS equalities talent of national calibre) was that no candidate could be found strong enough to embrace both equalities and health inequalities.

This is a remarkable piece of reasoning really, since although it's true there are many health inequalities specialists who have no clue about equality and diversity, the reverse is not true. Equality and diversity specialists usually know a great deal about health inequalities. And if you don't shortlist and interview your most senior specialists in the field you're not going to find out whether they might fit the bill or not.

So, a team of ten managers has been recruited without anyone to lead them, or any reasonable prospect of being able to find one given such an apparently impossible specification, and no strategy yet in place to show whether the right skills have been recruited in any case.

And the leaders making this decision have deprived some very experienced talent of the chance to demonstrate whether they could have done the job or not.

Anatomy of a farce

There are some who would be less generous than me in analysing the anatomy of this particular farce. Like all cock-ups, a story like this is just laden with the potential for conspiracy theories … mostly because of very poor communication throughout.

Personally, I prefer to be less suspicious … though the conclusions to be drawn from the history in that case are no more complimentary to the personalities involved.

None of them … Easton, Field, Vasco-Knight ... emerge looking like competent leaders.

If you believe (and I don't) that it's genuinely impossible to find a manager in the whole of the NHS who is capable to grasp both equalities and health inequalities strategically at the same time then the logic would be to redesign the structure to recruit the best of both.

The starting proposition is patently absurd though.

In my experience, senior equalities specialists in the NHS routinely discuss and understand health inequalities … and they have the grounding in diversity to diagnose how best to address them through strategic influence of NHS leaders and community stakeholders.

The function of a strategic lead is to choose people beneath them who can sweat the details. If there are gaps in their own detailed knowledge then that is immaterial. It's why we have teams. The job of a senior leader is to see the big picture, whatever the problem - familiar or not.

Through bungling and ineptitude, those who pass as leaders appear not to have grasped that.

Post mortem

In an organisation that took the words of the NHS Constitution seriously, you would have expected the NHS Commissioning Board to have accorded somewhat more priority to securing recognised expertise in both equalities and health inequalities at an early stage in the design of the organisation … when it could have had the most effect.

As I said before, this is not something you bolt on as an optional accessory. Equalities expertise is fundamental to strategic planning.

One consequence of failing to get the expertise on board early enough is that the senior management which the board has now recruited appear to be whiter and less diverse than ever before. This was wholly avoidable.

In an organisation that treated its own staff with consideration and respect, long serving and dedicated professional managers would also not be left wondering if they had suitable jobs to go to till the last gasp.

Instead, equality and health inequalities have somehow fallen behind in the organisation's priorities and ended up being the last to be addressed. This was also wholly avoidable.

So, in the months ahead I will observe with interest how the team that was almost not formed, looks like a refugee camp for displaced managers, and still hasn't got a leader gets on.

I won't hold my breath.