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Strategically speaking

Annie Gunner Logan

At a conference in Edinburgh last week, the Cabinet Secretary for Health and Wellbeing held forth about the newly-minted Public Bodies (Joint Working) (Scotland) Act 2014, passed by the Scottish Parliament only days before and set to usher in a new era of integrated health and social care services.

The venue for the event was the splendid RCGP building in Queen Street, where (as the speaker from the RCN pointed out) the auditorium seating is so steeply raked that it looks like a room where anatomy students might assemble to view a dissection. And indeed there was, in a manner of speaking, a corpse on display: that of silo working.

When it was my turn to speak, I suggested that with luck and a fair wind, the new legislation may also hasten the demise of any further talk about public sector – as opposed to public service – reform. We can but hope. I also noted that, not for the first time, the integration project had been likened to a wedding: however a wedding typically involves only two partners. From a third sector perspective, what we’re looking for here is full-on polygamy.

But back to the Cab Sec: Alex Neil was on typically robust form, and left the conference in no doubt as to the importance placed by government on joint strategic commissioning as the key process that will make (or indeed break) the integration project and the delivery of the national outcomes.

I happen to agree, yet the immediate hurdle to be overcome is that commissioning is, in truth, a much-maligned term. Many of our NHS colleagues shrink from it, as vampires from the light of day: it reminds them of the bad old days of the purchaser-provider split and there is a remarkably persistent view, encouraged no doubt by the ongoing NHS reforms in England, that it’s a weasel word used to camouflage service outsourcing and privatisation.

From the perspective of care and support providers, commissioning can often become entangled with procurement processes, especially competitive tendering. Some of our local authority colleagues appear unwilling, or unable, to distinguish between them. No wonder brows are furrowed at the mention of the word.

But Mr Neil wasn’t talking about any old commissioning: what lies ahead is strategic commissioning. As luck would have it, a mighty tome on strategy has just been published to help us interpret our task. Written by Lawrence Freedman, an erstwhile foreign policy adviser to Tony Blair, Strategy: A History weighs in at an impressive 750 pages and takes in the military, political and corporate worlds.

I’m not going to pretend to have read the whole thing, but I did enjoy Alex Danchev’s entertaining review of it in the Guardian, and it provided some stimulating food for thought.

For starters, it seems that Churchill was a great enthusiast for strategy. His wartime approach, we learn, was known as the KBO strategy: Keep Buggering On. Anyone who has spent any time at all in health and social care may find that there’s a familiar ring to that one. Freedman provides a critique of a range of other strategists including, rather appetisingly, Che Guevara, who apparently failed to forge effective alliances. More bells ringing there, I think.

But the most helpful observation, I feel, is this one: “Strategy is more a coping mechanism than an assertion of total control…[it] starts with an existing state of affairs and only gains meaning by an awareness of how, for better or worse, it could be different…strategy is best understood modestly, as moving to the “next stage” rather than to a definitive and permanent conclusion. The next stage is a place that can be realistically reached from the current stage. That place may not necessarily be better, but it will still be an improvement on what could have been achieved with a lesser strategy or no strategy at all.”

At the beginning of last year I was invited by the Joint Improvement Team to read a number of local partnerships’ RCOP joint strategic commissioning plans, and it’s hard not to conclude that some of them would have benefited from an understanding of strategy along these lines. Most of them set out all the usual stuff relating to vision, mission and so on, but few of them got into the nitty-gritty of planning for the “next stage”.

If we take Freedman’s view of strategy as being concerned chiefly with “the incremental, the provisional, the aberrant and the contingent” rather than a blueprint for the flawless delivery of some grand design, then it becomes a little less daunting and more manageable.

We could of course look elsewhere for enlightenment. I am indebted to Mary Frances at for bringing to my attention a recent interview with ex-army MP Rory Stewart which, according to Mary, “included a sharp critique of strategic jargon. Looking back 10 years, his priorities for state-building in Afghanistan included things like rule of law, and financial and civil administration.

And, then you would say, well, how do you do that? Well, I’d say, by a mapping of internal and external stakeholders, definition of critical tasks – all this jargon talk. And I’ve only now just begun to realise these words are nonsense words. I mean, they have no content at all. We should be ashamed to even use them.”

He goes on to describe the language of strategic plans as ‘complete abstract madness’. ”

Clearly, we’re in for fun times ahead.

March 2014