Will 2016 push the NHS over the edge of chaos?

Complexity theorists point to the importance of system environment on organisational performance – at one end of the spectrum there is a stable and low change setting, at the other an unstable and high change setting. Since 2010 the NHS has been anything but stable, and the NHS community must be desperate for a spell of stability in 2016. Unfortunately, it is likely to get the opposite – turbulence bordering on chaos.

First, there is the ongoing financial turbulence. The pledges of protection for the NHS budget during the 2015 general election have swiftly unravelled. The widely promised extra £8bn would have been delayed by the Treasury but for the calculated intervention of NHS England boss, Simon Stevens, who managed to get some frontloaded concessions. Even so, the settlements anticipated between 2018 and 2020 are historically low and the £22bn of efficiency savings are still expected to materialise. On top of this, public health spending is being cut, social care continues to be financially crucified and calls for transformation funding to ease the process of change are going unheeded. Meanwhile, patients and service users continue to turn up in their droves and carers quietly buckle under the strain of unsupported care.

Second, there will be further provider turbulence. Difficult decisions on the rationalisation of hospital services cannot be postponed indefinitely, nor can the financial plight of almost every acute provider. Pressure on hospitals to merge or form chains will intensify even in the absence of any evidence that this results in more sustainable organisations, while community health services will be increasingly outsourced to the private sector. General practice is exposed to the same environment and will be subject to more large federations. Meanwhile, social care provision, which is already almost entirely privatised, is likely to witness the first significant market failure since Southern Cross in 2011. On top of all of this there is a workforce crisis in every part of the system.

Commissioner turbulence is no less pressing. The future of CCGs is uncertain, with NHS England set to distinguish between minimal and maximal models – the former largely confined to contract monitoring while the latter takes a lead on service redesign. Those designated minimalist cannot be expected to survive for long, especially where they have a low score on the new ratings to be introduced by the health secretary. Commissioning support units are similarly unstable. NHS England wants all CCGs to have formally tendered for commissioning support by April of this year via its lead provider framework, but few are likely to comply despite threats of breaching procurement law.

This turbulence facing both commissioners and providers is now calling into question the wisdom of the entire purchaser-provider concept. The accountable care models envisaged by the Stevens vanguard programme, the Greater Manchester devolution experiment, the focus of NHS England, CQC, Monitor – and in future, NHS Improvement – on systems rather than organisations, will all lead to a weakening of the distinction. In any case, the bold aspirations of commissioning have been dealt a blow with the spectacular collapse of the £800m older people’s services contract in Cambridgeshire and Peterborough. What remains unresolved is where the residual Lansley requirements on competition law fit into this trend.

The main policy response to all of this turbulence is better partnership working but, paradoxically, this may well turn out to be merely a further cause of turbulence. The problem is not the principle but the practice. Partnership working is a fragile plant that grows in fertile contexts where it is carefully nourished by local champions – essentially a bottom-up process with the potential for scaling-up. There is little political patience for this organic process. In its place, we have grandiose plans drawn up at the top table and cascaded down to the frontline with no public or patient involvement. Typically, these are laden with wholly unrealistic efficiency assumptions. The flagship Better Care Fund, for example, has been reported to be not only routinely missing its targets but actually harming local relationships and giving integration a bad name. The new requirement for all areas to produce local integration plans by 2020 will bring a wearying sense of déjà vu.

The days of organisational separateness are long gone. We are now in a milieu of complex adaptive systems where change is constant and stakeholders need to be adaptable and flexible. The difficulty arises where the environmental turbulence is too fast and too great. Complexity theorists refer to the concept of the edge of chaos characterised by spontaneous processes of self-organisation and innovative patterns – a description that could almost have been written for the world of vanguard models. However, organisations at the edge of chaos can easily tumble into an unstable zone where they do not innovate, they disintegrate. This is the big worry facing the NHS and its partners in 2016.

First published in the Guardian