Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by senior bureau chief Dave West.
“Make sure the funding follows the plan” is one piece of advice in a useful collection issued by the Nuffield Trust last month, based on the flaws of previous NHS reform efforts and titled Doomed to Repeat? Lessons from the history of NHS reform.
The basic jist of this lesson, as I read it, is: get your money and funding rules behind what you want to achieve (but also, beware of the unintended consequences of your carefully crafted changes).
The first tranches of the new £20bn tied to the NHS long term plan are likely to go into rehydrating the NHS acute trust desert which, after years of scorching financial drought, will rapidly soak up funds just to restore the basics – fix urgent problems repeatedly put off, start catching up with targets, sort out balance sheets – before we see the green shoots of new improvements.
The long term plan will require trusts to get back into balance and move towards their targets – this approach to funding seems pretty consistent with those particular aims.
Next year is billed in the guidance as a “transitional year”. Features of it include a single year contracting round; a hefty tranche of adjustments to payment by results; moving some sustainability funding to the tariff; a rehash of rules for emergency care; and keeping, but rebasing for one year, organisational control totals.
It was quickly highlighted that all this shuffling of the goalposts seems a little out of kilter with the widely extolled policy of ditching PbR, organisation control totals, and annual transactional contracting.
The centre’s case is that neither it, the NHS, nor Her Majesty’s Treasury are ready just yet for complete reform of the financial regime – partly because of the requirement, outlined above, to balance the books.
It is a reasonable justification for another year of treading water. But why complicate things with a big overhaul of the current outdated regime, thereby encouraging another messy and adversarial contracting round?
More and more providers and commissioners have been trying hard to manage their finances collaboratively. They are coming to the end of two year contracts and – happily – in a reasonable number of places have managed to curb the adversarial behaviour; instead encouraging integration and savings that are net positive for the health economy.
For some, this is based on an “aligned incentive” block contract and firm relationships, so is reasonably stable (these folk are particularly baffled, if unconcerned, at the decision to revamp PbR rather than spread their approach).
But for many there is a more fragile contracting equilibrium. Both commissioners and providers are worried about this being upset by fractious renegotiation, which for some could now involve big changes to their financial fortunes, making it hard to ignore organisational interest.
Systems which are hanging together well – or which have ambitions to do so – are hoping, despite the rules, to treat 2019-20 as the first year of a new way of working, rather than dwelling on the old one.
People trying to join up services often cite sharing patient records and connecting IT as one of the biggest helps or hinderers. With technology developing very quickly, regardless of the NHS’s policies, it may also bring other, unanticipated, upsides – and downsides – in the not too distant future.
Our tech correspondent Ben Heather recently revealed some of the tech discussions as part of the NHS long term plan. One was virtual multidisciplinary team working, which could plausibly extend teams’ reach and ability pretty quickly; as could specialists giving more and more advice remotely.
Both managers and clinicians are often jaded from regular attempts to use poor data for performance management; but a step change in accurate clinical information could make it more stark where services are most fragmented, ineffective, and wasteful.
Paul Corrigan, health reform sage and a former Blair adviser alongside Simon Stevens, is prolifically blogging about the long term plan at the moment, including how “data is changing everything” (all his blogs are worth a look).
Also featured in the long term plan discussion is the idea of an app for people to manage their personal health budget from their pocket. That sounds a bit whacky, but could turn out not to be so far fetched after all, twinned with the expectation of a “rising tide” of personalised approaches, and an expanded comprehensive approach.
All of this of course depends on adoption, but it will get harder to resist.
Teaser: This Sunday’s HSJ Bedpan column will feature the thoughts of Paul Mason on how data and tech will upend healthcare, too. You will receive it if you are signed up to Daily Insight.