Thomas Cawston on Simon Stevens’ transformation from being an enabler to a commander with the General Practice Forward View

When it was published, the Five Year Forward View struck a very different tone for a government report. At its core the forward view was not about new models of care, a radical upgrade in prevention, the renewable energy of communities or even about £22bn.

What set the so called Stevens plan apart was its collegiate approach and a new vision for system change. There would not be one size fits all or a thousand flowers blooming, but instead a pragmatic “third way” of locally led transformation, enabled by a gentle guiding hand from the centre.

Instead of ministerial directives and unbending regulations, the NHS’s national leaders would harness the ingenuity and innovation of a new generation of system leaders to transform local services.

The way forward for general practice

Yet 18 months on, this vision for change may have already run its course. Nowhere is this clearer than in NHS England’s General Practice Forward View.

The General Practice Forward View is a very traditional Department of Health command paper

The new roadmap for primary care reveals less about the future direction of general practice than the journey of Simon Stevens and his NHS England. While the Five Year Forward View tried to be a different kind of beast, the General Practice Forward View is a very traditional Department of Health command paper.

In place of reform from the bottom-up is the old instruction to deliver. The strategy has dedicated pots of money for each part of the new deal for primary care.

Alongside the new national funds are the old recruitment pledges (or targets) for doctors and other clinicians. Investment will be targeted in the nationally mandated innovations and services.

Section by section NHS England details timelines, objectives, expectations and targets. Two years ago diversity of ideas and approaches were encouraged, now NHS England is offering decidedly fewer options for local leaders. Once again, one size does fit all.

National strategies

National strategies were meant to be out of fashion, but it is now increasingly clear that the old DH is alive and well and now based at Skipton House. The latest GP strategy comes in the wake of similar grand projects for cancer and maternity care.

No doubt the newest addition to the National Director club, Claire Murdoch, will soon be presenting her own forward view themed strategy for mental healthcare.  

Across the board, Simon Stevens, the “enabler”, has been replaced by Simon Stevens, “the commander”. Following the creation of a handful of vanguards, the new models of care programme was meant to fuel itself.

Yet the “fast followers” have not come forward fast enough. There were once many paths to new models of care, but now with the Sustainability and Transformation Plans, there is a single national gateway.

Just like how the Better Care Fund allowed all parts of the country to be one of Norman Lamb’s integrated care pioneers, STPs have nationalised the vanguard programme. While the rhetoric of decentralisation and devolution is all the rage, across all fronts the centre is striking back.

STPs have nationalised the vanguard programme

For Stevens 2.0 the second phase of his reign has arisen from the challenges in delivering his initial vision. No doubt a limited transformation pot to fund the double running of services, the lack of change management skills and a fragmented system all played their part.

As the provider sector has been consumed with its own financial, accident and emergency and workforce crises there has been little headspace for reform. In some quarters, including in No 10 and in “Team Simon”, frustration and impatience with the slow pace of reform might also have led to the return of command and control. 

Anxiety in the Treasury that the NHS finances might one day shatter the Chancellor’s forecasts has also made it all too tempting to return to “grip”.

The “forward view” might still be the favourite phrase of NHS England but in many ways the system is returning to old habits. Champions of DevoManc and other devolution deals remain confident that the health and care system is entering a new era of local leadership.

Yet for many providers in the front line its back to business as usual. The national bodies have claimed that the directional approach is only a short term expedient, but tough finances could well be here to stay.

Time will tell which Stevens will prevail: the architect of the Five Year Forward View or the author of the NHS Plan.       

Thomas Cawston is a Senior Account Director at Hanover Communications, he was previously Head of Health at Policy Exchange and Research Director at Reform