What NHS England isn’t telling you, and more indispensable insight for commissioners. By senior bureau chief Dave West.
Several dozen senior people in health and social care – including local trust and system leaders – have attended roundtable events hosted (separately) by Theresa May and Jeremy Hunt in recent weeks.
All but the most cynical will have enjoyed a few moments basking in the warmth of apparent consensus and shared ambition for change – as will others involved in “NHS at 70” discussions in coming weeks and months.
There’s lots to agree about. The Five Year Forward View, yes, but going further too, of course. Integration – but this time it will mean something to real people. Did we forget about staff last time? How embarrassing! We’ll sort that out.
Social care, that’s definitely part of the plan now (and it will even have its own separate plan, too). Naturally, we all agree there is way too much unwarranted variation, Ms May – it’s unwarranted after all. Let’s talk soon about why we haven’t quite cracked that in the past seven decades. Technology – it’s going to be really helpful, definitely within 10 years. We should invite Mr Parsa in again some time!
In fairness, the roundtables touched on more contentious topics too, and it’s good news that the centre of government appears to be waking up to health and care reform at last – because there are some big problems that need political answers (the previous similar exercise one delegate recalled was a famous Lansley plan “crisis summit” in 2012).
However, as the warm feeling faded those around the tables will have reflected on what is going to come of this process. Many would like to see a bold break from current impasses. Will it live up to the promise, or are they engagement fodder to another short term political patch up job?
In particular – for those wanting to advance the integration agenda, of which there are many – what might the long term plan do to help and what are some of the policy dilemmas?
The biggest issue is resourcing, for both health and social care. As David Pearson, of Nottinghamshire County Council and integrated care system, said in relation to the latter: “Reform is important but if we don’t get a sustainable funding settlement it will be rather like indulging in landscape gardening while dealing with an earthquake.”
Then when money comes, will it be available for the kind of proper pump priming and double running of transformation that never appeared after the forward view? This includes access to capital, which despite numbers being thrown around has been very difficult, as Greater Manchester’s Jon Rouse has said. Will funds earmarked for technology get extra protection from raids to protect the bottom line?
Resources also include staff, and workforce figures confirm a failure to date to build up community based services. Both health and care will need to depend in the short term on a huge migrant workforce, too.
Organisational control totals are frustrating system working and have raised the curious prospect of areas like Greater Manchester having to come off the national ICS list. Scrapping the regime looks likely, but throwing it out altogether would mean the Treasury and regulators loosening grip.
How will new funds be doled out? Putting them behind health systems would be a strong signal and a lever for integration, but another camp favours direct payments from the centre to hard pressed provider trusts.
Is this the moment when, after about a decade of asking, payment by activity is finally abandoned as the mainstay of acute care contracts? The “accountable care organisation contract” has survived judicial reviews but is hardly ready for universal adoption. More practical perhaps are variants of “aligned incentive”, shared risk, block type contracts.
As HSJ has argued, prevention is a priority for new cash.
The funding and access issues of social care look highly unlikely to be solved on the same timetable as the long term NHS plan publication, and they could undermine its chances of success.
A legislative attempt to try to bond the NHS to social care also seems unlikely before the next general election – though the long term plan could tee up the possibility of future legal change.
In the meantime, the government might try to get cleverer with financial levers.
One possibility for coaxing health and social care together would be an expanded/rehashed version of the better care fund, involving allocating and earmarking budgets across the two. If this is pursued, there will be wariness about BCF pitfalls including two leaky buckets double counting, poor relationships and overemphasising NHS driven targets and initiatives.
As well as funding flows, some would like to see the NHS national targets regime overhauled to support integrated care.
Axing the emergency department or waiting list targets remains about as politically saleable as a bucket of sick.
But the alternative, which might be back on the agenda, is trying to create equally high profile targets that are not all about quick acute care – the idea being these would dilute the skewing effects of current targets. The sort of thing on offer might be a standard for getting out of hospital within a given time once a patient is well enough; rights to community support or primary care; or building on the current mental health standards.
Planning, commissioning and regulation
In the absence of legislation to recreate a system level planning organisation, the centre could turn to further accelerating clinical commissioning group mergers, which are already picking up pace. There are more and more single CCG chief officers, and in some cases single CCGs, in charge across whole sustainability and transformation partnership or ICS patches. Some think these planning units should become even bigger as the role of active commissioning recedes.
In this way these phantom structures start to get a more corporeal existence – making it a lot easier, their leaders might argue, to change services to remove variation, for example. They can also more easily take over regional functions from NHS England and NHS Improvement, if the regulators have the guts to loosen the reins.
This won’t please areas where people think they are making progress through CCGs on a sub-STP basis, often with a stronger local government connection and political support. The counter argument is that the more local NHS presence will be fulfilled through local integrated providers.
Meanwhile, the Care Quality Commission has begun inspecting health and care systems, and there is a suggestion it will be doing a lot more of this in future.
The how and the what
The Five Year Forward View endorsed “horses for courses” not “one size fits all”, but acronyms like MCP, PACS, ACO and ICS have too often been treated as an “end” rather than a “means”, fuelling frustration that integration projects feel intangible, as well as slow and hard work.
There is pressure now to define the service offer nationally in more basic terms; say what patients can expect (see above); and talk more about the technology, staff and buildings that will be needed. The difficulty, a familiar one, will be balancing that with huge local differences in circumstances.