A leading expert on public sector management and reform says the large number of small NHS boards is an anomaly – but is warning the government’s promise to review the structure of the NHS by the next election will be tough to deliver.

Richard Kerley, Emeritus Professor of Management at Queen Margaret University, says embedded cultures within the NHS, coupled with the policy of no compulsory redundancies and inevitable political battles against any proposed closures, will hamper any attempt to reorganise boundaries and responsibilities.

In its manifesto ahead of last May’s Scottish Parliamentary election, the SNP promised – as it had in the run-up to the 2016 election – to rethink the structure of the country’s 14 regional NHS boards.

‘As we create the National Care Service, we will review the number, structure and regulation of health boards – and other related delivery services – to remove unwarranted duplication of functions and make best use of the public purse,’ the party pledged.

Many of the proposals for the National Care Service directly impact the NHS at local level,  including a proposal for GPs to sign contracts with new community health and social care boards instead of NHS boards.

Professor Kerley, who is co-chair of the Scottish Centre for Public Policy, says reviewing the NHS and social care provision at the same time would be “a hell of an onion to bite into”.

Nevertheless, he says the current structure of 14 NHS boards that vary in population from well over 1 million people in Greater Glasgow and Clyde to just 22,000 in Orkney, is open to question – not least when it comes to hospitals:

“I think that the position of health boards, particularly the smaller health boards, is anomalous.

“If, in effect, you are a health board that runs one substantial hospital, which is what some of the very small boards do, it calls into question why you have a health board at all and what it does.

“You might argue that hospitals should be the direct responsibility of the health department in Edinburgh or Glasgow. Why do we have the anomaly of having geographic areas, when so much of health is now about sharing facilities across geographies because, if we want the best treatment for particular conditions, it is going to be focused in a centre of expertise? That centre of expertise is never going to be the hospital in Elgin or Stornoway.”

Already Scotland’s cancer services are delivered by three regional networks with specialist centres in Inverness, Aberdeen, Dundee, Edinburgh and Glasgow. There is a similar pattern of regional heart centres each delivering cardiology interventions for patients from a number of NHS boards.

Professor Kerley, whose proposals for structural and voting reform of Scotland’s local authorities more than 20 years ago formed the basis of many of the council reforms since, argues that change is difficult when attitudes and hierarchies are embedded:

“My starting point would always be that making a structural change, an organisational change, never ever addresses the issues of culture and assumption and behaviour and status that flow in many different ways in many different organisations.”

In the NHS, he says, this is demonstrated at senior levels within medical specialisms where, for instance, integration of health and social care is not high on their agenda:

“The way I've always put it crudely – brutally, actually – is that the neurosurgeon and the cardiothoracic surgeon don't really care if the patient that they are operating on at the moment is going to be released back into his or her own home without adequate support for them. That’s not because they are brutal, or unpleasant or uncaring people, but because the focus of what they're doing is either the brain or the heart, and the rest of it is forgotten. Once that patient has been opened up, fixed, closed up, comes out of anaesthetic and is out of the door, beyond a quick follow-up afterwards, in most cases, that’s it.”

Professor Kerley says that this culture has shaped the overall organisation of the NHS for many years with hospital specialists getting the glamour, attention and resources at the expense of areas such as treatment for mental illness and long-term conditions of the elderly.

It also contributes to the challenges of running smaller hospitals that cannot offer the same career progression and support for people working in specialisms as their larger, regional centre counterparts.

Despite this, says Professor Kerley, the political challenge of downgrading or closing smaller hospitals means that they are kept open even when those working in them doubt their viability. Meanwhile, those seeking to deliver health care closer to home – he cites a GP practice that worked to reduce the flow of geriatric patients into its local hospital – are not always thanked:

“A GP told me, ‘I'm being told by colleagues, if you keep people at home, we're not getting the business we need in our ward’.

“There are multiple systems at play here, in which there are multiple forces at play, which is very hard to reconcile.”

Richard Kerley says one of the biggest challenges for any government seeking to reorganise the NHS in Scotland will be the current no redundancy policy.

The result, he says, is that every reorganisation hits a ‘logjam’ of people who do not want to move to new jobs, so can find themselves without a role but continuing to be paid.

 

This is the second of two articles. The first examined the creation of a National Care Service based on an interview with Professor Kerley looking ahead to the challenges facing the Scottish government in health and social care in the coming years.

Richard Kerley is Emeritus Professor of Management at Queen Margaret University and Co-Chair of the Centre for Scottish Public Policy is the lead author of a provocation paper by the Centre: Is there a National Health Service for Scotland – or do we have an empty umbrella? and of the Routledge Handbook of International Local Government.

 

Read more: Budget: Major increase in social care spending; Government denies move to take GPs out of NHS; Scottish doctors at forefront of heart care

 

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