Is transformation of the NHS possible?

NHS reorganisation

The Sustainability & Transformation Plans are running out of steam, thanks to the Government’s squeeze on NHS finances. An attempt to think about how to develop a better and sustainable care system has turned into a financial rescue plan for hospitals. At the end of March STPs will be “refreshed” but it is hard to have much confidence in the outcome. The NHS may simply default to its standard operating procedures. Anticipating this Don Redding, of the charities’ coalition ‘National Voices’, has argued in a Health Services Journal article about STPs that the current problems of the NHS will not be solved by “more doctors and more kit”.

We agree with him that the ideas for change in the 5 Year Forward View and the generic Sustainability and Transformation Plans should be welcomed. But whilst the fundamental principles underpinning STPs are widely agreed, such agreement shrinks when the principles are translated into actual changes which challenge vested interests.

It is easy to rehearse the wicked issues that need to be overcome: an unstable base struggling day to day, lack of adequate funding, an incoherent legal background from the discredited Health and Social Care Act, poor workforce planning, lack of investment funding, overoptimistic assumptions about demand management and cost reduction, overoptimistic time scales, lack of leadership, lack of change management capacity.

A fundamental problem is that all efforts to move the emphasis away from hospitals to community-based services have had little impact*, from the ‘Primary Care led NHS’ of the nineties to the assorted plans of the noughties. It is easy enough to see why. Specialisation in medicine and nursing has absorbed NHS resources so much that not only has there been dwindling investment in general practice since 2008, but a generalist-shaped hole has appeared in hospital medicine, where the complexity of the case mix in terms of frailty, dementia and comorbidity outruns the expertise of clinicians. That’s before we reach the problems of discharge.

The NHS is becoming a classic stalled bureaucracy, in which as Don Redding says “physicians want more physicians, GP leaders call for more GPs, emergency doctors want more emergency doctors, acute providers want protection from reform, and the NHS debate in politics and the media remains fixated on hospitals”. The emerging disaster around social care is relevant only if it impacts on hospital discharges.

Within many STPs hospital fixation is being reinforced by leadership from the acute sector. The traditional NHS top down approach (management by shouting at people) seen in the STPs, with decisions made behind closed doors by unaccountable managers, will not be good enough. We need to know unambiguously who to hold to account for decisions about spending and priority setting, across the system. STPs sit outside the actual legal framework for accountability and many challenge current legislation around competition and choice. Keeping eyes closed and fingers crossed is not sufficient.

We need a community based model with far more emphasis on prevention and early intervention – dealing with the determinants of poor health, rooted in community engagement. If so then STP leaders should not be from the acute sector but should be recognised community leaders. If we want shared solutions with local authorities, then they must be central, not an afterthought on the margin; STPs must be part of the core strategy of every council. Strategic direction and oversight for care services must come through elected representatives.

The approach in the 5YFV based to changing services rather than structures and focusing on relationships rather than organisations is a huge cultural shift but aside from a few outposts of hope (as in Manchester) there is little sign that this will work any better than redisorganisation. So as well as our list of wicked issues (like finances) we have some questions to which others may have answers.

  • Where do we find the necessary community leaders for the STPs?
  • What will it take to bring local authorities into a central rather than a peripheral role?
  • Will elected representatives be willing to take responsibility for decisions about care?
  • What coalition of interested parties could drive the transformation?
  • Who will assemble this coalition, given that top-down approaches seem unlikely to work?
  • How will the future NHSE/NHSI/DH/Department of Communities & Local Government manage the challenges from established interests? Investing in large scale community services that could lift the siege of the acute hospitals may mean not investing in the hospitals themselves, especially if economic growth is slow, and this is likely to have political consequences.
  • Is GP training fit for future purpose, and if not how can it be changed?
  • Where will the nurses come from? Will more wish to work outside hospitals?
  • How can we shift care outside hospitals to a high wage, high skill economy from a low wage, low skill one?

The reset has to be far more than the outcome of marking the STPs against financial and other templates. Without a real shift in attitudes to accountability and governance extending far beyond the traditional NHS enclave STPs will go the way of World Class Commissioning, Shifting the Balance of Power and the rest. They will be business as usual with more hype.

Richard Bourne & Steve Iliffe

* Care in the community is hardly a new idea. If we look further back long stay “hospital services” for the very old and mental health patients were moved into the community. But this took many years, had mixed outcomes and resulted in the shift of many services from public to private and from free to means tested.