Professor Judith Smith Professor of Health Policy and Management and Director of Health Services Management Centre
Simon Stevens left the NHS Confederation audience in no doubt. The deal is sealed with the Government about an additional £8bn for the NHS by 2020. There will be no extra money beyond this, efficiency is the name of the game, and the Five Year Forward View is the plan to achieve this. The stark clarity of his message was in contrast to the more cerebral and conceptual examination of the long-term challenges facing health systems that Simon gave to the Confederation in 2014. Whereas last year managers might have been forgiven for leaving the conference saying ‘what exactly does NHS England expect us to do?’, this time the message was crystal clear – you must work with partners locally to develop new models of care, and you need to get on with it now.
To respond, local leaders face three challenges. First, bringing together providers, commissioners and patient groups to debate and plan the configuration of services that makes sense for local health needs within the available financial envelope. This is easier said than done in a post-Health and Social Care Act NHS, but the sub-text to Stevens’ speech last week was that collaboration to get on quickly and make sensible plans was the name of the game, reaching beyond the fragmentation resulting from removal of strategic health authorities. We can expect to see virtual health districts (re)emerging, as implied by the announcement of ‘success regimes’ for specific health economies last week.
The second and more difficult challenge is to win the hearts and minds of NHS and social care staff, local people, and politicians for the plans developed by new virtual health districts. With finances tight, demand rising, and the Five Year Forward View emphasising a focus on primary and preventative care, plans for change will almost always mean pain for hospitals, or at least a significant change to how they work and where. Care models such as multi-specialty community providers and primary and acute care systems might excite health managers and policy wonks, but they will surely anger local people fearing the dumbing down of their district general hospital.
Perhaps the hardest task for the NHS and its managers is how to actually make the changes implied by the Five Year Forward View. We know from research that managers and clinicians tend to focus lots of time and effort on planning and debating new models of care, finding it much harder to shift to, and sustain, actual implementation. So many change programmes run out of steam after a couple of years, as new pressures and priorities distract and attract local managers and national policy makers. NHS history is littered with re-engineering programmes, care collaboratives, and other attempts at what we now call ‘new models of care’. This time, the pressures to change are so acute that we must heed advice from the NHS Leadership Academy, Health Foundation and others about the vital need for managers and clinicians – especially those leading frontline clinical services – to acquire, hone and apply sophisticated skills in service improvement and change.
The challenge is not just local. Listening to Simon Stevens last week, I was struck by the tone, as well as content, of what he was saying. There was talk of ‘getting a grip’, ‘sorting out’ and ‘dealing with failure’. This is understandable given the urgency and scale of what faces the NHS, but it made me ponder how far the more bottom-up and permissive approach espoused by the Five Year Forward View will endure.
If local health economies are to enact bold plans, win support from staff and the public, and finish the painstaking work of changing how, where and when services are delivered, they will need serious and sustained political, policy and practical support. What will not help is undue central intervention borne of political impatience, or multiple policy imperatives that distract both managers and clinical leaders. Perhaps the greatest challenge is faced by NHS England and the other arm’s length bodies. They will of course need to monitor and challenge local progress in meeting financial, quality and service targets. At the same time, they call for diverse local health services that challenge traditional patterns. The exam question for NHS England and its partners is: will they be able to hold on while letting go? Herein lies a challenge that goes to the heart of NHS management culture.