Recently, a colleague described the task of being a leader in the NHS as ‘rebuilding a plane in mid-air with a battery of surface-to-air missiles trying to shoot us down'. Their feelings are far from exceptional.
To take one example of turbulence, whatever we think about the pros and cons of league tables, the way the policy has developed has fitted the ‘shoot first, answer questions later' approach.
When you read this the tables will have been published. It is important the narrative accompanying them avoids unfair blame and is honest about what the numbers do and do not tell us.
NHS chief executives and chairs are, of course, used to irritations, inconsistencies and contradictions. But there are deeper issues at play at present.
There is a sense that the credibility of the 10-Year Plan is already in danger of being undermined by more short-term priorities. The left-shift may be the long-term aim, but day-to-day financial and performance management continue to push rightwards. Central enthusiasm for IHOs seems to depend on who is speaking. The requirement that IHOs have renewed FT status conflates the technical, organisational requirements needed for the latter with the capabilities and relationships needed to succeed at the former. Some leaders are avoiding any mention of IHOs for fear of alienating other partners, particularly those in primary care.
Whether the staging of the 10-Year Plan is seen as ‘three and seven' or ‘one, two, seven', connecting recovery and reform is a priority for both narrative and policy alignment.
The ICB redundancy issue, as I write, has also yet to be resolved but its scale could be dwarfed as trusts look to fund their own redundancy programmes. As we move into autumn with improving but fragile UEC performance, providers are navigating a narrowing path between elective targets, UEC demands, CIP, quality and safety.
As we all know, many of this year's financial and performance plans were a triumph of hope over expectation. As we move towards the halfway point in the year, in many trusts the path is disappearing into impenetrable brambles.
Many providers feel the expectations being placed on them result more from political necessity than credible analysis of what is possible. In the context of commissioning reform there is often talk about contracts being based on ‘should cost' rather than ‘does cost' criteria. Fair enough, but in terms of planning how about an approach based on ‘can be done' not just ‘want to be done?'
Some new and impressive people have been added to the NHSE board, but will they be empowered to ask hard questions? After all, the same board didn't flinch at plans based on trusts achieving virtually impossible CIPs of 6 or 7%.
The answer to the problem of circle squaring is usually ‘productivity gain' but not only are the means to deliver opaque, sometimes NHSE's own processes are the main barrier.
Ideally, the forthcoming planning guidance needs to be based not simply on policy aspiration but the best analysis the centre can make of demographic change and patterns of demand, combined with an account of the relative costs of supporting patients in different geographies and with different NHS assets. This is the national foundation needed for the development of strategic commissioning by ICBs.
If the ask from the centre is possible, leaders will pull out all the stops and gladly take responsibility when things go wrong. But demanding the impossible fosters cynicism and justifies gaming – creative accounting when we need creative solutions.
Greater realism and openness should be part of a reset in the central-local relationship. Could future planning guidance perhaps be accompanied by a compact laying out the principles that should govern the relationships and the expectations of its partners?
One leader said: ‘I can either get beaten up when I put the plans in, or at the end of the year when they have played out.' Let's hold boards and leaders accountable. But what they are being asked to deliver must be achievable, fair and aligned with longer-term sustainability.
