It’s time for real leadership to step up. Mike Farrar looks at the first eight things that need to be dealt with now if the reforms are to work.
After 18 months of political trench warfare over the health bill, the Westminster bandwagon is moving on. But for the NHS, this is the beginning, not the end.
The reforms have become a big problem for the government. The legislation was accused of lacking intellectual and ideological cohesion. It created complexity and most people felt it established difficult implementation processes even when it tried to support some sensible principles.
Most of all, the reforms lack the confidence and support of a huge number of NHS staff just when we most need their engagement and commitment.
But if we fail to make the reforms work, it will be patients and the public that suffer. And it is this challenge that I believe will motivate and inspire NHS leaders to do the right things for the service - whether existing leaders or people new to the fray.
So it’s game on for us. There should be no doubt that this will be among the toughest projects the NHS has ever taken on. Here are the top eight key things that need to be addressed quickly if we are to succeed:
1. Leaders from clinical commissioning groups, providers and health and wellbeing boards (HWBs) need to get together regularly and resolve strategic issues across health economies. Just because there is no bit of the system tasked with this, does not mean that leaders should not fill the space.
Some believe the regulator will fulfil this function, but it will only step in once services fail. An NHS that changes only on the back of catastrophic service failure will never be acceptable to the public.
2. CCGs must be allowed the freedom to act and, where necessary, encouraged to be bold in their redesign of services. They have huge potential, operating under clinical stewardship and in partnership with HWBs.
3. Ministers, local politicians, and the NHS Commissioning Board must back leaders who need to redesign services, even when it heralds reductions in hospital-based services or changing the shape of community, primary and social care.
4. Monitor must back them too. It must avoid its regime to prevent and tackle failure becoming overly cumbersome, creating inflexibility and inertia as people struggle to understand its bureaucracy.
5. Payment and pricing structures need sorting out so providers have incentives to change the shape and size of services where this will improve patient safety or productivity. Providers must not be forced to pursue growth-only solutions that keep them filling hospital order books rather than pursuing innovative services.
6. Commissioners from different parts of health and social care must work together. It will be almost impossible to integrate provision if commissioning becomes disintegrated. We need the NHS Commissioning Board, with its primary and specialised services budgets, to work closely with CCGs, which will hold their community and secondary care budgets. They in turn must work closely with local government, which will now hold budgets for health improvement alongside social care.
This is not about hierarchy or power. It is about joining up intentions, incentives and rewards so patients have seamless care.
A family with a disabled child whose condition goes through chronic and acute phases will despair when they realise that all these six budgets are in play. Coordination will be critical to their child’s quality of life.
7. National bodies must ensure NHS organisations and suppliers receive consistent and coherent messages. Otherwise, we risk chaos. I propose that the national bodies meet each month and share business plans and any service requests they make, including outcome frameworks.
They must look together at their impact on an NHS which has far less management capacity than before to implement their requirements.
8. Finally, the NHS needs to develop a new model of leadership and a new culture of engagement and empowerment. There is a great opportunity for this as new clinical and administrative leaders emerge in the coming months and years.
We will need thinkers to be valued as well as doers. We need leaders who can speak truth to power; who engage emotionally as well as rationally to help change behaviours inside and outside the NHS. And we need a culture built not on command-and-control but on mutual respect and empowerment of the frontline. Leaders will have to make sense of the reforms for patients and staff locally, while safely steering at strategic level.
I have selected just eight areas as starters. More will emerge as each month passes, but all are capable of remedy if we are bold and care enough to right the ship as it veers off in unhelpful directions.
The politicians have moved on, and it is down to us to make the new system work. There is no one else to do it.