Simon Stevens’ speech at the King’s Fund this week has been described as his most important since he returned to the NHS.
The NHS England chief executive delivered a volley of major policy assertions and hints, sending a clear message that he remains in charge of national decisions and will reshape and reinterpret the rules as necessary.
Mr Stevens also revealed an intention to use the fast approaching national planning round to kick off a comprehensive re-plumbing of the health service.
This is his first multi-year planning process and, covering four years, will take us to the end of the Five Year Forward View period.
Stevens’ comments ramp up interest and energy ahead of what will be an important step towards implementing his vision. They also raise some important questions:
Don’t we need to wait for the spending review before planning?
Critical factors including annual funding envelopes, the size of the better care fund, and availability (or not) of additional transformation money will not be known until the 25 November comprehensive spending review. Prior to the chancellor’s announcement, individual area’s allocations cannot be set, and we will not know the full extent of what the government requires of the NHS over the Parliament.
Mr Stevens’ intervention shows that, regardless of all this, he will not be waiting for the government before setting key planning parameters. A letter from national bodies on first steps is expected any day. Mr Stevens is also explicitly linking reform of NHS services to the review by saying part of local funding may be made dependent on agreeing joint plans.
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Can Stevens really withhold funding for areas which don’t plan together?
The NHS England chief indicated he was considering making part of local funding - for both commissioners and providers - subject to local health economies agreeing joint four year “shared sustainability and improvement plans” by the summer.
It is not unusual for the centre to hold back part of allocations and to make its release dependent on approved plans. Contract rules could also be changed to link provider income to signing up to new joint strategies.
Such a move might simplify the many financial incentives in the system - something Mr Stevens is known to be keen on - as well as giving national bodies strong control over funding flows and the shape of joint planning.
The success of this approach in coming years, however, will depend on whether Mr Stevens successfully secures additional “transformation” funding in the spending review to put in this pot, or whether it would have to come from a top slice of the £8bn real terms increase the service is already expecting to receive to pay for growth.
Finances are now so tight in so many areas, it would be extremely difficult to top slice much from allocations in the latter scenario. Refusing to release funding growth for services in severe distress could visibly damage care access and quality, and could be virtually impossible to justify.
It is hard to see how NHS England could on the one hand tell the chancellor it requires at least £8bn just to stay above water, while at the same time as indicating some of it might be held back from the front line.
If there is extra money above the £8bn from the Treasury, this proposal looks much more achievable.
What is a ‘nascent health system’ or ‘population health oriented geographically based partnership’?
Mr Stevens said: “Alongside the routine order of practice for 2016-17, we’re going to ask different parts of the health service to come together in nascent health systems, population oriented health partnerships, so that by the summer every area of the health service will have an agreed sustainability and transformation plan to 2020.”
What he means by these groups will be critical. The King’s Fund predicts these are a “step towards establishing accountable care organisations or accountable care systems”. What is clear is that they will mean commissioners have to work very closely with incumbent providers, with all having to sign up to shifts in activity and funding flows for coming years. These will have challenging implications for some providers.
However, NHS organisations have independent leaders, statutory duties and priorities, all of which have hampered joint planning efforts in the past. Bad relationships are particularly notorious for getting in the way. It is not yet clear how Mr Stevens envisages these barriers will be overcome or how directive he will be.
What size will these health systems be?
This is another big unknown. In 2013 commissioners and providers were told to group into “units of planning” and draw up five year strategies. In some areas these were formed across multiple organisations and large populations, but most clinical commissioning groups and providers stuck to planning on their own. Organisations may be more inclined to work together than they were two years ago, but past experience suggests it will not be straightforward.
In addition, in attempting to define health systems, or “partnerships”, for planning and strategy purposes, the NHS has found there is no single right footprint: some services are best planned for tens of thousands of people; others have to be considered regionally or nationally - pointing to what some are referring to as “multi-layered” planning.
So will joint planning really be any different this time?
NHS organisations have been told to bridge their divides and plan together before, so the question arises whether this will really be any different.
A number of factors suggest it could well be. Most importantly, in Mr Stevens we have a very influential national NHS chief, who is secure in post, and has shown he can set aside long standing rules and conventions. NHS Improvement - under Ed Smith and Jim Mackey as chair and chief executive - will be fully signed up.
Soundings from behind the scenes suggest that this time Mr Stevens and colleagues “really mean it”, and intend to see a step-change in planning, pressing hard for cultural barriers to be overcome.