What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West

Confront the difficult decisions? Here’s your chance, Simon

The overriding message from Simon Stevens and Jim Mackey to STP leaders in recent weeks has been exhortation to press on with difficult service changes. To “confront - not duck” the big contentious reconfigurations which have long been on the cards but never delivered.

NHS England has also piled up more fuel for what it hopes will be the sustainability and transformation plan engines of change, by stressing that specialised services configuration is absolutely on their agenda.

Getting on with reshaping secondary and tertiary care is a welcome direction for commissioners; notwithstanding wariness about how some STP provider leaders will handle the task, and the sometimes implausible patches covered.

Yes, some commissioning groups will join opponents of particular changes. This is a critical issue and, as discussed in a previous newsletter, the scope for them to block anything looks set to be substantially narrowed.

But the dominant thoughts in most readers’ minds will not be how to block change – rather substantial incredulity about the likelihood of making it happen.

The barriers to doing so are well known, as is the argument that forcing decisions through was made virtually impossible by the Health Act 2012 reforms.

Most health economies are scattered with tales of schemes foiled before they got to see the light of consultation, or scrapped embarrassingly in public even after blood, sweat and tears have been shed.

There are huge disincentives working against anyone standing up and having a go (not to mention the potential for a post-referendum government meltdown to make things virtually impossible).

National leadership for reconfiguration, although far from sufficient to eliminate all difficulties, can help, and is important for setting the tone. The willingness of the powerful to dispense their political capital for the cause, as well as persuading some would-be opponents to give way, tells local leaders that someone will be fighting for them.

Simon Stevens, recognising this dynamic and with major hospital rationalisation rising to the top of his to do list, last month said he wanted to offer “safe harbour” to leaders who take the right but unpopular decisions.

The NHS England chief has until now been cautious about reconfiguration. Indeed, some of his first statements in the job gave rise to national media coverage suggesting he was out to save “cottage hospitals”.

Even “success regime” areas, meant to be the front line of do-or-die urgent radical change, have received instructions to tread carefully, and tread slowly (and it’s not only Essex which has felt this).

Mr Stevens has notably dodged specific language about reconfiguration. Contrast this with Sir David Nicholson, who throughout his time at the top of the NHS spoke fairly frankly about it, and called directly on politicians to support changes.

In last month’s interview, pressed on what difficult decisions may typically involve, Sir David’s successor would only refer awkwardly to the “disposition of hospital services”. We might see his message harden through the summer.

Another opportunity is approaching for Mr Stevens and NHS England to lead the way, too.

If anything represents the archetypal difficult reconfiguration it is paediatric heart surgery. The history of failed attempts at centralisation goes back - at least - to the report on the Bristol Inquiry scandal of 2001. In 2013, the latest concerted effort to reconfigure was abandoned following legal challenges.

Over the past year NHS England has returned to the task of earnestly engaging with providers, clinicians, patients, and public on the future of all congenital heart disease services. They have been given exhaustive consideration. Greater provider networking is being embraced with the aim of better spreading specialist expertise.

Despite all this, the critical step still remains - a decisive move, a difficult decision, is needed to close a small number of units.

By common standards, this should not be a hugely difficult reconfiguration. Yes it is a sensitive service, but very small numbers are affected, whole trusts will not be destabilised, no major capital investment is required. There will be high profile opposition but also, probably, some high profile support. It is entirely within NHS England’s commissioning purview; and the organisation’s work so far means it knows that, if terrible incidents occurred now on certain sites, it would be unable to refute that it knew they did not meet its standards and - over an extended period - did not act.

The decision over whether to press ahead with centralisation will come back to Mr Stevens this month. We’ll soon find out whether he will lead the way, and take this chance to make his own difficult decision.

The Commissioner’s reading list

This will be a weekly pick from the barrage of publications, articles and Tweets which may interest commissioners.

  • Karin Smyth, elected as a Labour MP last year, was in her past life a manager in a CCG and primary care trust. She is a member of the Commons public accounts committee, and has written for HSJ about her frustrated quest to locate accountability in the post-April 2013 NHS structure. 
  • NHS England has published details of the indicators that will be used for its new 2016-17 CCG assessment regime (and a manual on how it will work). The very thought will turn a lot of readers off. But looking at what national bods would like to try to measure can be both instructive and amusing. Sensible sounding new indicators include a population emergency-bed-day rate, a measure of inequality in emergency admissions, and a new one for the proportion of deaths taking place in hospital. However, indicators which are as likely to provoke ridicule as they are to create useful insight include one attempt to map provider Care Quality Commission ratings on to CCG areas, another to score CCGs’ progress with new models of care, and a measure of “working relationships” based on the annual CCG 360 stakeholder survey.
  • Ben Dyson, a senior civil servant who has won more confidence in primary care and commissioning than most, has moved to become director of strategy at NHS Improvement. Hopefully he can help the provider regulator take more of a whole system view. Steve Kell, Bassetlaw GP and until recently NHS Clinical Commissioners co-chair, meanwhile, has noted that NHS Improvement lacks a “person clearly in charge” of improvement in general practice.

Dave West, senior bureau chief

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