Interview by Andy Cowper, editor, Health Policy Insight

Matthew Swindells left the Department of Health in April 2008 to become - after the mandatory DH purdah interval - Managing Director for Health at Tribal Group: a significant player in healthcare consulting and the FESC market for commissioning.

Swindells had been seconded from NHS management (as chief executive of Royal Surrey County Hospital Trust) to become special adviser to Health Secretary Patricia Hewitt in 2005.

Interestingly, and perhaps surprisingly, he then survived the inevitable ‘regime change’ of special advisers when Alan Johnson took over at the DH in the summer of 2007. Indeed, Swindells was appointed interim chief information officer of the DH, and with it was given the politically sensitive task of reviewing NHS informatics: an appropriate role for a man who had previously been head of IT for Guy's and St Thomas’ NHS Trust.

In vivid contrast to some prevailing attitudes in the DH, during his time there Swindells proved amenable to debate and communication with the media. His new role provides him with a significant platform for his views on health policy and delivery, as commissioning moves centre-stage.

Matthew Swindells will be writing a regular column for Health Policy Insight.

HPI: What opportunities do you see for healthcare – public and private - arising from the economic downturn?

These will be difficult times; it is dangerous to pretend anything else. If there is a silver lining it will be that decisions around quality and productivity that have been ducked for too long will have to be taken. The availability of money to bail out poor and efficient services has allowed the NHS to avoid tough choices for the past couple of years.

The financial constraints should give purpose to clinicians and managers who want to drive change. It should also create an environment whereby proven but disruptive service changes, like Healthcare At Home and disease management, get the chance to prove themselves.

"Decisions around quality and productivity that have been ducked for too long will have to be taken. The availability of money to bail out poor and efficient services has allowed the NHS to avoid tough choices for the past couple of years".

HPI: Will the downturn marginalise or emphasise health policy?

In the short run, all the politicians are chasing a economy football and ignoring the NHS. This should be the perfect conditions for the NHS – it has always said, “If only we had lots of money and no political interference we could transform the service.” This is that moment.

"When the growth runs out in two years’ time, if the NHS hasn’t prepared itself for ten years of austerity, then services will start to fail. Waiting times will rise, rationing will reappear and public confidence will start to fall."

However, the world will change dramatically if it revels in its generous settlement; doesn’t take tough decisions quickly; and absorbs itself in internal discussion. When the growth runs out in two years’ time, if the NHS hasn’t prepared itself for ten years of austerity, then services will start to fail. Waiting times will rise, rationing will reappear and public confidence will start to fall.

Through inaction, the NHS could put its own future back at the centre of the political stage in two years’ time.

HPI: When would you expect to see commissioning begin to make a difference?
I think we already are.

What I see around the country is increasing numbers of PCTs starting to understand the needs of their population and developing services which address those needs.

There is a long way still to go, but we have models in mature health systems where commissioner are no longer “victims of hospital bullying”, but are full partners in the local community.

It is also my experience, that hospitals enjoy and benefit from working with sophisticated commissioners.

HPI: What would be the signs commissioning is having little or no effect?
Let me put it a different way. What five things should we be able to see in a PCT that is starting to commission well, in a year’s time?

The PCT should have good enough information and systems avoid endlessly debating invoices with their local providers and focus on tracking coded information and what it tells them about the quality and appropriateness of the care that is being delivered.

They will be putting disease management rather than demand management programmes in place.

They will be monitoring quality along the clinical pathway, both within hospital and in the community; and taking action to address poor quality.

They will be commissioning community services rather than managing them.

They will have an understanding and dialog with their local community that is more than symbolic.

HPI: Does primary care have the tools it needs to make practice-based commissioning meaningful?
I think all the tools are there, or PCTs can create them.

The issue is that PBC is a complex organisation development programme, not a thing.

I can’t imagine how a PCT thinks it will drive sustainable change in the NHS without engaging local primary care clinicians in the challenge, and that means devolving part of the decision-making and the associated budgets to those clinicians and allowing them to make choices.

HPI: How can the Care Quality Commission differentiate itself from the Healthcare Commission?
I think the CQC needs to be on the front-foot in protecting patients and guaranteeing quality. It is a tough task, but they need to be in a position of gathering and analysing timely data to see trends and intervene before a disaster. Advising on what good practice “would” have looked like isn’t enough.

The first service that they change or shut before a health risk gets out of hand will mark them out as different.

"The CQC need to be in a position of gathering and analysing timely data to see trends and intervene before a disaster ... The first service that they change or shut before a health risk gets out of hand will mark them out as different."

HPI: Improving productivity, quality and outcomes have been stated policies since 1976’s ‘Priorities For Health And Social Care’. Why will it be different this time?
In the realm of quality, I don’t think we’ve ever been here before. I see a huge step-change in the focus on quality since the appointment of Bruce Keogh and the publication of the Darzi report. Much of the NHS is now running ahead of the Department. I think the challenge will be to get from good intentions to real change, but the auspices are good at the moment.

In terms of productivity, we have some way to go. If the NHS rises to the challenge of the recession, whilst maintaining a focus on quality, this could be a great moment for the NHS. But there are risks, as I mentioned before.

HPI: Is it your impression that clinicians have faith in the new proposed quality and outcome measures?
I think clinicians have some optimism that the approach of evidence-based clinical measures and real engagement in how to use them will deliver change that they can support.

The challenge for the NHS will be to get the balance between those quality performance measures that are applied from outside and those which are used to facilitate clinician-to-clinician discussions and improvement.

Both approaches are valuable in driving change, but it will take a certain elegance of handling to walk the line between “clinical targets” and “cosy self-regulation”.

"I don’t believe in the concept of an unmanageable hospital ... Most of our worst-performing hospitals are not small isolated organisations, desperately trying to meet the needs of their community against all the odds. They are big hospitals, still not applying known good practice."

HPI: “Ever tried, ever failed. Try again. Fail again. Fail better” (Samuel Beckett, ‘Worstward Ho!’). What should be done in the case of the sub-set of NHS organisations which are still failing? Is it plausible that bad management remains the root cause?
I don’t believe in the concept of an unmanageable hospital.

There may be some hospitals where the catchment area doesn’t generate enough activity to support safe of financial viable services in particular specialties, but the occasions where this is also a hospital with an isolated community who have no alternative services is tiny.

Most of our worst-performing hospitals are not small isolated organisations, desperately trying to meet the needs of their community against all the odds. They are big hospitals, still not applying known good practice.

HPI: What would be the signs that the new NHS Co-operation and Competition Panel is having a real impact?
When the confidence of the market has risen to the point that a private company will open a service for patients because they have analysed the need, developed the service and believe that if they deliver a good service, well-marketed at a viable cost, they can make a business.

HPI: What would make a real difference to getting delivery from NHS Connecting For Health?
In my opinion The National Programme for IT needs two things: a change of body language and a change of technology.

It needs to move away from presenting itself as THE SOLUTION which sweeps everything before it and to view itself as a tool for service improvement and a platform for innovation. I believe it has made big strides in this direction in the past year.

In technological terms, it needs to “open up”. The creation of a plural provider environment makes the two closed LSP systems a hindrance to government policy and the delays in implementation necessitate changes to allow local organisations to take medium-term investment decisions now which won’t be invalidated by NPfIT.

In technical terms, NPfIT needs to create interoperability between the two LSP systems so that they can live comfortably side-by-side (and as a by-product, create the standard that would allow other products to integrate as well), and it needs to describe clearly how local systems that meet the programmes data and security standards can be integrated with the local care record.

HPI: From the perspective of a former manager and former policy adviser, are there intrinsic limitations to the changes the DH can lead?
The recognition the NHS is a system not a single organisation was a huge step for the DH. The DH can lead any sort of change; what it can’t do is control it.

"The limitations of the DH’s power are obvious in the fact that we still have failing hospitals and under-doctored areas after years of DH instruction."

The NHS has demonstrated that it responds directly to direct instruction, and not always cleverly. The limitations of the DH’s power are obvious in the fact that we still have failing hospitals and under-doctored areas after years of DH instruction.

My view is the DH needs to focus on creating the environment of innovation and improvement; ensuring that there is enough talent in the system to take advantage of that environment; and being clear about what is expected.

The question, “how do we want the system to respond when a hospital service fails?” is different one to “what should the DH do?”

HPI: If you were going to work in the NHS again, where do you see the greatest opportunities?
The NHS offers greater opportunities to make a difference than any other employer. The opportunity to transform the lives of a community through brave and world class commissioning or to improve clinical outcomes and patient experience in a hospital are fantastic.

The NHS is still a land of opportunities.

HPI: What was the best policy initiative you were associated with as a special advisor?
There is an enormous amount that I am proud of in my two years. It would be easy to say the smoking ban, which seems so simple now but which was a huge battle when we did it.

"We created a coherence around the reform policy and moved towards 'free choice', which gave the NHS platform to ‘self-generate’ reform going forward."

But, I am also proud of the determination Secretary of State showed when the NHS ran into deficit. I think that the potential the NHS has now to prepare itself for the recession comes from the difficult decisions that were taken at that time.

I also believe that we created a coherence around the reform policy and moved towards “free choice”, which gave the NHS platform to ‘self-generate’ reform going forward.

HPI: What was the worst or most misunderstood policy initiative you were associated with as a special advisor?
I think Commissioning A Patient-Led NHS set back the rest of the reform programme, because it overwhelmed everything else for a number of months.

The core policies of SHA mergers, PCT mergers and separating PCT provider and commissioning arms have, I think, proved to be the correct policies – which could lead me to claim that it was simply misunderstood or ahead of its time.

But picking that moment to drag the NHS back into structural change was a straightforward mistake.