NHS England chief executive Simon Stevens has returned from his summer holiday in the Arctic having adopted the look of an intrepid Victorian explorer setting out for parts unknown. He has the air of a man who knows his eventual destination may never be reached, that his chosen path carries many risks, but who remains steadfast in his belief it is the right thing to do.
No surprise, he is foremost among the national NHS leaders who are now under increasing pressure to demonstrate that the reforms of care models envisaged in the Five Year Forward View are deliverable in the current climate. If they fail, they risk the whole project being remembered as a set of excellent ideas that were too difficult to actually do when all hell broke loose in year two.
The Forward View reforms were designed to make the NHS sustainable. So it is everyone’s misfortune if this critical period in the reform process coincides with a moment of substantial political uncertainty, and in the midst of the unexpectedly rapid crystallisation of the NHS’s unsustainability.
The NHS is not used to being a second order political priority
It was never part of the Forward View plan that, having sweet-talked the government into investing upfront, all the new cash would be instantly engulfed in a financial inferno, and capital would become an endangered species. There was no suggestion the service would go backwards on performance in the middle years, or that the dominant NHS story would be about a strike over a completely different (and much less necessary) set of reforms.
It was certainly never the intention to be dealing with a new prime minister and chancellor who did not sign up to the Forward View deal, whose attitude to the NHS is an unknown quantity, and whose defining policy conundrum is, of all things, how to leave the EU without destroying the economy.
The NHS is not used to being a second order political priority – particularly when it is in this state. The conditions are far from ideal for it to accelerate a radical set of reforms. Yet that is what the sustainability and transformation plan process is supposed to do.
STPs: a necessary evil
Let us be clear, the STPs are a necessary evil. They are more top-down and divisive than the organic development suggested by the Forward View. We have already seen how they have created complications through rows over secrecy, patient involvement and “cuts” – which may well have been better mitigated but were impossible to avoid altogether because of the speed at which reform is being driven.
This has introduced new risks, but it is hard to see what other option NHS England could have adopted. As Mr Stevens admitted last week, he did not get the money he wanted for the middle years of this parliament, so with the financial storm clouds gathering he had little choice but to push as hard as he could before any attempt at reform is swamped.
The purpose of the STPs is to make sure the reform process achieves demonstrable progress in the next six months and embed its approach in the service’s DNA – hence the incredibly ambitious target of getting most contracts for the next two years of service delivery devised, negotiated and signed in the next 15 weeks.
Without this underpinning there will be genuine concern about the Forward View programme surviving the brutal conditions of 2017-18 and beyond.
The chances of success depend much, of course, on the progress secured to date. Nearly two years since the publication of the Forward View – or the Stevens plan, as the government pointedly call it – its influence is a paradox.
Everything and nothing seems to be happening.
Reforms are delivering profound change…
Day to day, the system is acting as it always does – but with even more intensity. Trusts and clinical commissioning groups have never felt more performance-managed. There have never been so many ways to be put into special measures.
For that reason, it is the bits of the future that can best coexist with the present that have the most momentum. The first hospital chains, for example, were authorised before any accountable care organisations.
Chains represent the best chance to take out back office cost and reduce variation as per the Carter agenda. They answer the pressing question of how we cope with having fewer leaders than leadership positions. And, they can be brought into existence by flexing existing foundation trust structures rather than inventing something completely new and untested from scratch.
More fundamental change is also underway
But more fundamental change is also underway – arguably more than at any time in the NHS’s history.
GP practices are rapidly forming much closer connections, setting up vehicles to jointly provide services, and sharing functions. They are exploring partnerships with NHS providers on a scale never seen before. Trusts providing specialist care are working out universally applicable clinical models. In Greater Manchester, the divide between health and social care looks as though it may finally dissolve.
The STPs give us a realistic reason to believe these changes are going to be at least attempted and often expanded, as we have seen from Frimley’s latest plans, in most areas. Support for the ideas contained within the Forward View is also holding up, more or less, meaning there is still an appetite to put it into practice.
…but are still struggling to convince
So why does it feel like the Forward View’s new care models have yet to deliver anything substantial?
There are two reasons: First, national bodies have not yet published any evidence that vanguards are outperforming their peers. With lead indicators like emergency admissions, emergency department waits and delayed transfers still deteriorating, there is a nagging concern that the plan is not working.
Second, while recognising successful reform is always about relationships before everything else, for change to be sustained and reinforced, eventually a contract has to be signed, a new provider set up, accountabilities must change. The old system must eventually be let go of.
There has been a great deal of activity working out what multispecialty community providers or primary and acute care systems will do, and how they might be constituted. But the first real MCP, running on a single contract, employing GPs and community clinicians, accountable for the health of a defined population, providing primary care in a new way is still 18 months away, as it always has been.
Ministers expect half the country to be covered by new care models by 2020. PACS and MCPs will be given three ways of coming into being: full integration, partial integration, and “virtual” integration – the latter essentially being to keep the old system but within a formal alliance. The number of fully fledged new care models will be dwarfed by those still developing.
Changing your clothes while the room is on fire
There are good reasons why setting up a new type of provider is taking a long time. The Cambridgeshire disaster provides a perfect example of what can go wrong.
National leaders cannot afford new governance or contracting models to be in any way flaky. But they have no cast iron way of assuring themselves either will work in the current testing climate. When the whole room is on fire, it takes courage to change your clothes when you have no way of telling whether this will make you more or less flammable.
Soon, vanguards will start becoming contentious, making these governance issues very pertinent. Hard decisions will have to be made. An MCP will carve services out of an unwilling acute trust; a PACS contract value will have to be set; GPs will have to decide which other local providers will be their partners, and which will not; the role of private firms will become clearer; cautious practices will have to be persuaded to commit to a joint venture with the acute trust.
Are new care models still affordable?
Can widespread new care models be paid for? When, less than a year ago, the government committed to providing extra cash for the NHS, the answer appeared to be “yes, up to a point”.
Twelve months on, pump-prime funding has been scant – the transformation funding available to vanguards was about a third of what they said they needed, and there is not yet an equivalent pot to pay for new care models’ extension across the country. Attempts to regain some ground by controlling costs in the acute sector have made some progress with the agency cap, but appear to have fallen at the second hurdle when the focus turned to trimming clinical staff numbers.
The answer now, therefore, to the funding question is “definitely not all of it”. Recognising this fact is part of the reality check the service and its leadership now has to undergo.
Mr Stevens the explorer, with the NHS caravan straggling behind him, now has to pilot the NHS through some uncharted and very dangerous territory.
He might choose a path to a place where the government significantly increases NHS funding, making the delivery of reform so much easier. But who believes in Shangri-La? He must try and avoid the many routes that would lead to disaster.
The best realistic hope is that over the next four years he can find a destination where the reforms are entrenched just widely enough to make another journey of discovery feasible during the next decade. Given where he stands today that will probably feel like victory.