Here IT goes, again

Health and social care secretary Matt Hancock has announced that he is setting up a new unit to shake up #HealthTech. It says a lot about the man and the team around him that he’s called it #NHSX (you know, like SpaceX, it’s all about one guy and his gang, shooting for Mars).

So, I was putting together some analysis of this development for Highland Marketing this week, and it made me think about all the other, similar, ventures that I’ve seen come and go over something like twenty years of reporting on the NHS and its IT (yes, it’s really that long… and the analysis file is here).

The first NHS IT strategy I ever covered was Information for Health, back in 1998. There’s another blog post to be written about how what it was trying to do is remarkably similar to what NHS IT is still trying to do, but that’s for another day.

For the moment, the point is that IfH led to the creation of a properly constituted arms-length body, the NHS Information Authority, led by a chief executive, Gwyn Thomas, to deliver infrastructure and run model projects for trusts to follow.

The IfH approach struggled, not least because trusts went and spent the cash they were meant to spend on IT on other stuff. So, prime minister Tony Blair himself convened a seminar at Number 10 Downing Street that led to the creation of the National Programme for IT in the NHS.

This was supposed to sort things out by getting in big consultancies, that were supposed to know about project management, to contract with big IT companies, that were supposed to know about electronic patient records, to deploy on a regional basis.

The National Programme was led by a new director general for NHS IT, at the Department of Health. The first director general (2002) was Richard Granger, a bullish consultant who had led the successful roll-out of the London congestion charge. Granger placed some huge contracts, but it turned out that accountancy companies and US tech firms knew less about NHS IT than had been hoped, and NPfIT failed to deliver, at least for trusts.

So when Granger left, a more ‘NHS’, more conservative approach was tried. Matthew Swindells, a former trust chief executive and political advisor, was stepped in as interim chief information officer, to define a ‘clinical five’ or core set of functions that would get medics back on board with IT.

Matthew Swindells, one of the more constant figures in NHS IT

And then, when Swindells left for EPR vendor Cerner, a substantive chief information officer was appointed, Christine Connelly from Cadbury Schweppes (2008). I was going to write that Connelly lasted barely any time at all, but in fact she was in post for three years, before she left in a bout of DH infighting.

After Connelly’s departure, the government decided that what the NHS needed was some of the rigour that the Cabinet Office was trying to bring to the wider government digital agenda. So Katie Davis, executive director of the efficiency and reform group, was brought in (2011).

Davis really did last barely any time at all. She was gone in barely a year, as Andrew Lansley’s contested and misguided reforms of the NHS arrived in 2012. The Lansley reforms divided responsibility for NHS IT between the DH, which was meant to set policy, the NHS commissioning board / NHS England, which was meant to buy programmes, services and products to enact it, and a bunch of delivery organisations.

Despite all the other changes, the NHSIA had sort of continued up to this point, under a variety of names, and latterly alongside a data collection, analysis and publication outfit called NHS Information for Health. The two eventually emerged, as the Health and Social Care Information Centre, which is now called NHS Digital.

Around this point, another prime minister, David Cameron, decided he was very interested in health IT. In particular, he liked the idea of giving data to patients so they could vote with their feet if their local NHS wasn’t up to snuff, while ‘taking responsibility’ for their own health. To promote this ‘transparency’ agenda, he personally appointed Tim Kelsey, a former journalist and government transparency tsar as national information director (2014).

Kelsey then got to head up the national information board, a supposedly powerful co-ordination group to bring together all those post-Lansley bodies. The NIB issued the health service’s current IT strategy, Personalised Health and Care 2020, and also rebooted the NHS Choices website.

But amid the care.data debacle, and the growing realisation that serious competition within the NHS was not going to withstand the massive financial and demand challenges the service was facing, Kelsey left for Australia.

Fortunately for health tech, the health secretary who replaced Lansley, Jeremy Hunt, was into IT, and came up with a plan for the NHS to go ‘paperless’ by 2018. To deliver on this agenda, Kelsey’s replacement, Beverly Bryant (2016) was given a ‘wider remit’ as chief information and technology officer, reporting into Matthew Swindells, who was back as NHS England’s national director of commissioning, operations and information, and is now its deputy chief executive.

However, she was effectively side-lined into the struggling NHS Digital, as Swindells effectively took control of some key elements of the paperless agenda, such as the establishment of a global digital exemplar programme to complete the digitisation of trusts that was still outstanding from IfH and CfH, the Clinical 5 days and, indeed, Paperless2020… I did say there was another blog post to be written.

When Bryant understandably left, again for a supplier, this time System C, she was replaced by another central government recruit, Sarah Wilkinson from the Home Office (2017). But Wilkinson has been all-but invisible, and seems to have spent more of her time slimming down NHS Digital than doing much with the agency.

Instead, it is NHS England that has implemented the Wachter Review‘s recommendations to appoint a chief information and a chief clinical information officer and to run the GDE programme. And it is NHS England that has pursued the Empower the Patient programme to come up with a new NHS App.

Now, though, Hancock has arrived at the DHSC with a reputation for ‘digital’ and a determination to be seen to be ‘doing something’. NHSX is clearly a manifestation of that, and it looks set to be led by yet another government digital tsar, this time Matthew Gould from Hancock’s former department, Culture, Media and Sport.

Last year’s NHS Confederation annual conference waits for the health secretary to speak

Health tech journalists often say, when a prime minister or a health secretary with an interest in IT moves on, that the NHS was fortunate to have someone with that interest in charge of it. The quick review above suggests that’s correct, in that health tech policy and initiatives are closely associated with specific incumbents of Number 10 Downing Street and Number 18 Whitehall.

However, once they move on, so does the persistence and attention that might make them successful. This effect is magnified by the tendency of prime ministers and health secretaries to bring in their own, supposedly charismatic, leaders to head up their agendas. Because once their sponsors go, they tend to go as well.

Over the past twenty years, the cycle has got faster. Tony Blair was associated with NPfIT, and Richard Granger led CfH for at least five years. His substantive appointment, Christine Connelly, lasted three. David Cameron’s tsar, Tim Kelsey, did about the same, but his successors barely registered before they left. Hunt’s paperless agenda has had stable leadership within NHS England but not outside it; and it’s now being challenged by Hancock’s media savvy, app happy team.

This is destabilising. Many health tech vendors find Hancock a breath of fresh air, but they realise his impact will last only as long as he does, which may not be long, given Brexit and his own CV of rarely staying in ministerial or cabinet jobs for long.

It’s also complicating. Each abandoned approach leaves behind another layer of complexity to the health tech scene. Across the piste, some of NHSIA’s functions are still going within NHS Digital, while some of CfH’s contracts are still running. The GDEs are well entrenched, but non-exemplary trusts were told in the NHS Long Term Plan to continue to aspire to a ‘core’ level of digital maturity.

There’s the wreckage of the ‘transparency’ agenda in NHS England’s attempts to make local health and care records fit for population health management. The NHS is still running NHS Choices, albeit under a new name, to feed that whizzy NHS App. And now Hancock wants cloud-first, internet-first, digital-first services.

It’s possible that NHSX will turn out to be a bold initiative that cuts through all this clutter, comes up with a rationalised IT strategy for the NHS that can be funded, prioritised and delivered, and that Hancock and his preferred X-man will stick about to see it done.

It’s just that you wouldn’t bet on it. Which is unfortunate. Over twenty years, health tech has been too dependent on politicians looking for an eye catching initiative with which they can be personally associated, and with outsiders brought in to enthuse or shake-up the troops. It’s not worked, and it’s not what got man to the moon.

The NHS’ own plan 2.0

Jeremy Hunt on an NHS protest poster (picture: Rohin Francis on Flikr: https://www.flickr.com/photos/rohinfrancis/22277630191/in/photostream)

I’m going to a health conference on Thursday that has been organised by the think-tank Reform. Health secretary Jeremy Hunt is the keynote speaker.

If we find ourselves playing conference bingo, we can expect to hear him say that “we gave the NHS £10 billion” (depends how you count), “that was more than the NHS asked for” (nope, it definitely wasn’t), and “we’re funding the NHS’ own plan” (erm…)

If he has something more substantial to say, then there’s a lot for him to talk about; most of it stemming from the progress or otherwise of ‘the NHS’ own plan’.

The NHS’ own plan

This is the ‘Five Year Forward View’ project, drawn up by NHS England’s chief executive, Simon Stevens, to close a gap between flat NHS funding and rising demand and costs that could reach £30 billion by 2020-21.

It worked on the basis that, if the government put in £8 billion, and social care and public health funding was maintained, and the NHS was able to keep on top of its efficiency agenda, and it used some cash to ‘pump prime’ new ways of doing things… it should be able to find the other £22 billion.

The Forward View only came out in October 2014, but a fair bit of this is already off track (see posts below). The government did announce £8 billion for the NHS in its 2014 budget (and then back-counted another £2 billion, to get to the £10 billion figure).

But as Stevens has told several Parliamentary enquiries now, the money is not going in smoothly (it doesn’t feel like it, but this year is a relative ‘year of plenty’ – there will be virtually no funding increases in the next two years). To make things worse, the acute sector has fallen over a cliff.

The King’s Fund, another think-tank that tracks NHS finances closely, reported in February that hospitals will miss their £580 million deficit target this year, and are likely to overspend by £820-920 million.

Director of policy Richard Murray argued that, at best, this will wipe out the ‘sustainability and transformation fund’ money that would otherwise be available to ‘kick-start’ change. At worst, it could eat up reserves and even push the NHS overall into the red.

Meanwhile, investment in public health by a Conservative government always sounded like a non-starter and, as major news outlets have been pointing out, social care faces a crisis all its own.

In fact, it’s so bad that the King’s Fund’s pre-budget statement reckons that if Chancellor Philip Hammond has any money that he doesn’t need for his Brexit fund, it should go into social care.

STPs: neither sustainable nor transformative?

So, the mood music against which the Forward View has to be taken forward isn’t promising. But what about the plan itself? Ideas for turning the Forward View into reality have been put forward in 44 ‘sustainability and transformation plans’.

These got off to a bad start. NHS England tried to hold them back so its comms teams could vet them for ‘positive messages’, but councils went ahead and published them anyway.

This led to accusations that the plans had been drawn up “in secret” that have proved hard to shake off. Not least because papers and activists have picked over them looking for hospital closures and job losses – and these are easy to find.

Just this week, the BMA put out a blog post arguing that without more money, the plans were not only “doomed” but “a way to dress up cuts to public services.” Saying that plans that have yet to start have already “failed” seems a bit much. But there are reasons to worry about the STPs.

Reorganisation by stealth

For a start, there are signs that NHS managers are doing what comes most naturally, which is to focus on management.

Stevens told his most recent appearance at the Public Accounts Committee that the STP ‘footprints’, which are rapidly acquiring the accoutrements of administrative areas, such as leaders and key performance indicators, would in due course become ‘accountable care organisations.’

In other words, bodies that take responsibility for the health (treatment or long term care) of a local community, and get paid according to the size and health profile of that community (rather than services run or treatments delivered).

Stevens admitted this would end the purchaser/provider split for the first time since the internal market was introduced by the Tories in the 1990s; which is a big thing in health policy circles.

All of this is happening without the centrally-dictated reorganisation that has been repeatedly inflicted on the NHS, most recently by former health secretary Andrew Lansley.

Most people in the NHS would say “and thank goodness for that.” However, the fact that the latest reorganisation of the health service is less visible than most doesn’t mean that managers are not being distracted by it.

Fuelling public anxiety?

Also, the lack of public clarity on what is happening seems to be adding to public concern. Just this weekend, there was a huge march in support of the NHS at which there were many cheers for speakers who claimed that it was being ‘privatised.’

Yet the STP changes are, if anything, moving in the opposite direction (unless the conspiracy theorists are correct, and the ultimate ambition is to create ACOs that can be taken over by US corporations – which is frankly unlikely, given the margins and more likely losses on offer).

Be bolder, people

More substantively, the STPs are big and complex; and yet it’s hard to escape the feeling that they are nothing like bold enough. As I live in the county, take Hampshire’s STP.

It talks about the need to: resolve long-standing issues with care on the Isle of Wight, sort out Portsmouth’s struggling A&E, resolve the very public crisis at Southern Health and Care NHS Trust (which suffered another blow this week when the CQC announced it was going to prosecute), and work out what to do with the small district general hospitals in Winchester and Basingstoke.

Also, about the need to: keep these organisations on top of their efficiency savings agendas, while introducing new, more integrated ways of working underpinned by a big expansion of its existing shared care record / IT platform.

Delivering on any one of these imperatives would be a major achievement in five years, but there is neither time nor money to treat them as sequential issues. And what the STP lacks is a sense of how its different elements can be done at once, to support each other.

Never mind a vision of what a safe, modern service, with a digital front-end and highly trained staff in expensive buildings only where they are really needed, might look like – for the available money.

IT’s just not happening…

Just to stress, Hampshire’s STP is not alone in this. Kingsley Manning, the former chair of NHS Digital, wrote a column for HSJ recently in which he argued that the STPs generally fail to engage properly with productivity, and with how IT might drive that.

Instead, he noted, they tend to tick off analytics, shared care records, and digital services as nice things to have, rather than as programmes that will deliver the kinds of improvement in workforce productivity that have been seen in other service industries.

Mind you, when it comes to IT, it’s not just the STPs that are struggling. Last week, my former employer, digitalhealth.net reported that one of the biggest trusts in the country, University Hospitals of Leicester NHS Foundation Trust, had been unable to get its electronic patient record plans past NHS Improvement.

It wanted to spend around £25 million on a US system called Cerner Millennium and, while that’s a lot, it seems incredible that neither the company, nor the trust’s IT department, nor its general management, could get together a business case for it in an organisation spending £860 million a year, and employing 14,000 people.

(Of course, NHS England might have helped, but it seems to have become hopelessly distracted by trying to get a handful of ‘global digital exemplars’ up to snuff with £100 million that, HSJ reported this week, the Treasury probably wants back).

The NHS’ own plan 2.0

As commentator Roy Lilley noted in his newsletter this week, this kind of thing does not tend to worry the activists and medical staff who joined last weekend’s NHS march. They just want more money for the NHS and for their local services to be ‘saved’.

It would be unreasonable to expect otherwise. But Lilley is right; even if this government was going to find more money for the NHS (and all the pre-budget briefing is that it won’t – although social care might, might just get something) it needs to be spent effectively – and that means differently.

Stevens is working on a big reboot of the Forward View. So, if Hunt is going to do more than play conference bingo on Thursday, he’ll need to say something about what ‘the NHS own plan 2.0’ looks like.

Also, how the NHS’ regulatory structures are going to get behind it and start getting managers to think like, well, managers; and how politicians are going to sell all this to a hostile staff body and a very worried public. What’s the betting?

Briefing against the NHS boss: Maybe time to rethink that, Prime Minister?

The FT’s take on Simon Stevens’ appearance at the public accounts committee; where he made cheeky use of a story in the Daily Mail, which briefed against him in November.

Well, that was lively. NHS England’s chief executive, Simon Stevens, was up in front of the Commons’ public accounts committee yesterday (watch here on Parliamentlive.tv).

As he headed into London, he would no doubt have seen an “exclusive” in the Times, claiming that “aides” to Prime Minister Theresa May had “privately criticised” him for being both “insufficiently enthusiastic” in carrying out his job and unduly “political” in flagging up some of its challenges (story, paywall).

May is starting to get a reputation for this kind of thing; the Times story came just a few days after the very public departure of Sir Ivan Rogers, Britain’s EU ambassador, who was duly briefed against for being insufficiently enthusiastic about leave.

But if there are risks in her government starting to look like the kind of thin-skinned and petty-minded administration that lashes out whenever a public servant presents it with inconvenient facts, her “aides” seem to be unworried by them.

The Times story was hardly accidental. Indeed, it was hardly an “exclusive” as the Daily Mail was given pretty much exactly the same thing back in November.

Instead, it looked like an attempt to use the PAC hearing to re-run a hare that had failed to get running (but which I blogged about at the time).

Doing the math (again)

 If the “leaks” were an attempt to bring Stevens to heel, they not only failed, but directed huge amounts of press attention onto fine details of NHS finances that are, in fact, well known; but which are now being presented as new and worrying.

The PAC hearing was part of a short series of hearings on the financial sustainability of the NHS, prompted by a National Audit Office report. The NAO (a financial watchdog that reports to the PAC and gives it unusual clout for a select committee) has been running yearly reports on the financial sustainability of the NHS for some years.

This year, for the third year running, it concluded that the NHS finances were not sustainable. In doing so, it went into exactly how much money the government has promised to give the health service over the next five years.

In what turned out to be his last autumn statement, in 2014, then-Chancellor George Osborne said this was £10 billion. He also claimed this would “fully fund” the NHS’ “own plan” for sorting out its financial woes, the ‘Five Year Forward View’.

This is a plan that Stevens wrote, which says the health service can find £22 billion by 2020-21 from further “efficiency” and bringing in new models of working.

Since then, the NAO – and many other bodies – have shown the £10 billion includes £2 billion that had already been announced for 2014-15 and £3.5 billion shifted from running bits of the Department of Health and public health.

Despite this, May has repeatedly used the £10 billion figure in speeches about the NHS. She did it back in October, and was told off for it by the opposition and by the UK Statistics Authority. And she did it again this week, in her much-heralded speech on mental health, adding that it was “more” than the NHS had asked for, for good measure.

It’s baffling that May continues to use the £10 billion figure, when it’s been disproved so often, and it wasn’t her government that came up with it. But she does, and then her supporters get antsy when experts do the math in public.

The November briefing against Stevens seems to have been prompted by his appearance at the Commons health select committee, which is running its own inquiry into NHS finances, covering more or less exactly the same ground as the PAC (and which I also blogged about).

At the hearing, he was careful to hedge around the question of whether he had, in fact, got what he asked for from the spending review.

However, he did have to agree that the money is not being distributed in the way that the Forward View asked for – most is going in this year; there will be barely any increase next year or the year after, when spending per head of population will, in fact, fall.

And at an earlier PAC hearing, he noted that some of the other assumptions made by the Forward View are not bearing up in real-life.

Most obviously, the plan assumes that if the NHS is to close its funding gap by 2020-21, money will need to be spent on public health – to start cutting demand – and on social care – to help keep the ageing population out of hospital. Yet public health spending is being cut, and social care has a crisis all of its own.

Coming out fighting

So, when Stevens got to Parliament yesterday, he didn’t really say anything new to generate headlines. He just went further than he’s done previously in spelling out what the government has done on NHS funding; and seemed to enjoy himself doing it.

In response to an opening question from PAC chair Meg Hillier, he said it would be “stretching it” to say the NHS had got “more money than it had asked for”.

He contradicted the DH’s permanent secretary, Chris Wormald, when he said an OECD report had shown the UK spends about what most countries spend on health; pointing out that comparable, rich, European countries spend much more per head of population.

He cheekily held up a story from the Daily Mail, the paper that took the bait on the November briefing against him, and said he agreed with it that the NHS “trails the rest of the EU for medics, beds and scanners”; implying that more of all will be needed.

And he had a neat little swipe at the Time story, saying he had been “running a little campaign” to stop cuts on social care and doing so “very enthusiastically, I might add.”

What does the boss think?

 It would be very interesting to know what health secretary Jeremy Hunt thinks of all this. He is now England’s longest serving health secretary, after being re-appointed to the job by May in aftermath of the Brexit debacle.

But his career has been associated with that of Osborne, who May publicly dumped as Chancellor in the same reshuffle. There were rumours on the day that he was off as well – he arrived very late at Downing Street without his NHS badge on, and there were reports in the BBC and papers that he had been sacked before he reappeared with it back in place.

It’s not inconceivable, then, that he might welcome Stevens’ digs at a Prime Minister unlikely to feel warmly towards him, and unlikely to promote him; he told the NHS Confederation’s annual conference last year that health would be his last political job.

Also, Hunt has shown remarkable commitment to the NHS, and might see the headlines about a “winter crisis” and hospitals on “black alert” that have been constant since Christmas as evidence of a crisis too good to waste when it comes to putting pressure on Downing Street for more money.

After all, most spending departments rebel against Treasury constraints at some point, and May has hardly shown herself to be an adept at keeping ministers or officials in line.

Never mind the £10 billion, what about the £22 billion?

 Still, the bigger question is whether the NHS can use the money it has got – never mind any new cash – effectively to address the long-term pressures on it.

The NAO has cast doubt on this, pointing out that the Forward View is not a strategy and does not come with worked through delivery plans with budgets attached. Local health economies have been asked to draw up ‘sustainability and transformation plans’ to put it into action.

But these are only just being published, and are of variable quality (post). The PAC got to this point late in what turned out to be long hearing, after Twitter had lost interest and the papers had gone off to write their stories.

Its MPs were told, by Jim Mackey, the chief executive of NHS Improvement (the regulator that decides whether trusts can operate), that a consolidated and more detailed plan would be available by March or April.

He also said there would be new ‘key performance indicators’ for the STP footprints to meet, with financial control targets for their commissioners, trusts and other organisations to meet together to follow in a year or so.

The centre needs to get a grip on money and targets, if it is to impress on the NHS that STPs are the only game in town, because hospitals overspent to the tune of £2.4 billion last year, and hospitals are publicly saying they are no longer meeting key targets, such as the four hour see, treat or admit target for A&E.

But even if Stevens and Mackey can get back on top of things, there is, as one MP pointed out, a timing issue. It’s simply not clear how the NHS can get from where it is to where the Forward View says it could be, given the huge shift in finances, structures, mangement thinking, and public support that would be required to get it there.

Yesterday’s politics and right-wing press twitting were fun; that question is deadly serious.

 

Reading between the lines, the PM and the Daily Mail have it in for NHS boss Simon Stevens

The Mail Online, 20 November

There’s an astonishing story in the Daily Mail today. It says Downing Street is “gunning” for Simon Stevens, the chief executive of NHS England.

The paper says Theresa May is furious for “telling MPs that the Prime Minister had exaggerated the amount of extra money promised for the NHS” while appearing at a health select committee hearing.

Specifically, it claims Stevens annoyed the PM by telling the committee she was wrong to say the NHS would get “an extra £10 billion a year between now and 2020-21 – up from the £8 billion promised by former Chancellor George Osborne.”

Also, that he’s seen as stepping out of line by making a bid for more money, ahead of this week’s Autumn Statement on Wednesday.

The story may be true

There doesn’t seem to be any reason to think this story is not true. The paper likes May much more than her predecessor, David Cameron, and she has gone out of her way to support its line on, say, Brexit.

So the remarks as reported are likely to have been made. What’s astonishing is that Stevens didn’t say what the paper/Downing Street claims that he said.

NHS finances are complex, and set out in the blog post directly below this one. The basics, however, are that Stevens drew up a plan in 2014 that said the NHS was facing a gap between funding, demand and costs of £30 billion.

He reckoned it could make £22 billion of efficiency savings, with a lot of change, and a following wind, leaving the government to come up with £8 billion. Osborne duly obliged, claiming in last year’s budget that he was “fully funding” what he was quick to call “the NHS’ own plan.”

Things then get complicated because various ministers have claimed the government is in fact putting in £10 billion; counting an additional £2 billion Osborne had already announced for 2014-15.

The health committee reckons it is actually putting in £4.5 billion, because £3 billion is being transferred from the budget for things like running the Department of Health and public health. And one think tank reckons it should be as little as £800,000, because the Treasury has done some creative accounting on inflation and dating.

The health committee went into all this; and Stevens had to confirm the £10 billion to £8 billion and £8 billion to £4.5 billion figures.  He didn’t make the claim attributed to him today. At most could be accused of being forced to do maths in public.

Certainly, journalists have since asked May to do the same kind of maths, and she’s found that embarrassing. But that’s another issue.

The ‘facts’ are not

Stevens did tell an earlier public accounts committee hearing that the money was not being phased in as he asked, and that public health and social care spending had not held up as his modelling demanded. Which raised eyebrows among mandarins and policy wonks.

But he has absolutely not made a public bid for more money. In fact, he almost certainly wants to avoid any suggestion that there may be a bail-out on the way for the acute sector (hospitals), which overspent by £2.4 billion last year, and have been told to accept swinging ‘control targets’ to avoid a repeat this year.

Any hint of a bail-out would make hospitals and their commissioners less inclined to get into the difficult business of change that is being proposed by the sustainability and transformation plans that are supposed to turn Stevens’ ‘Five Year Forward View’ into local action.

As set out directly below, there are plenty of indications this project is not going well, but Stevens does not want it being derailed from the start. Also, when asked a direct question at the health committee, he said that if there was any money going this autumn it should go into social care, which has a financial crisis all of its own.

Ok, what’s the alternative?

The other reason that the Mail’s story is astonishing is that it’s hard to imagine who May thinks is going to take over from Stevens if he goes. Stevens was a Labour advisor at the turn of the century, but when he was recruited to take over from Sir David Nicholson he was working at United Health in the US.

It’s safe to assume that he took a massive pay cut to come back to England. In doing that, he also took on a job that amounts to trying to persuade the NHS to sort out a financial crisis that Nicholson warned it about in 2008 and that it largely failed to tackle.

Stevens isn’t as well-loved as Nicholson, and he can address conferences like he’s read too many management consultant text books in airport lounges, but he must really believe in the health service to have taken on the challenge.

If May and her advisors think there are loads of candidates willing to step into Stevens’ shoes, they are likely to find they are wrong. Indeed, before this morning’s intervention, the general assumption was that the government would be only too keen to keep Stevens in place.

Trotting out Osborne’s “NHS’ own plan” line gives ministers cover whenever there is a suggestion that the health service might fall over this winter, prove to be financially unsustainable in the long-term, or need to get rid of a lot of ageing, clinically unsafe, but much loved local hospitals.

Indeed, MPs on the health select committee have tended to express a cack-handed kind of sympathy with Stevens; asking if he is being set up as the “fall guy” for when the Forward View fails to deliver, as some unhelpful voices are starting to say it will.

Meantime, Labour moans that Stevens is covering for the Tories’ failure to spend adequately on the NHS, that he really wants to make cuts or that he wants to privatise large chunks of it (and yes, the last two are contradictory).

Worrying… on so many levels

We have to hope that May and her advisors know the facts, and were simplifying for effect in their comments to the Mail. If that’s the case, what are we to make of the story?

One interpretation would be that we have a Prime Minister who is so thin-skinned that she is prepared to lash out at a civil servant for answering Parliamentary questions, if this in turn makes journalists ask her difficult questions. This would not be good.

Another is that Downing Street realises the NHS is in deep trouble, that the government is going to have to find more cash for it or face protests on the streets (or both), and that it’s getting its retaliation in early by setting the press pack against the man in charge.

This would be worse. Any check on the Forward View and its STP process will make it less likely to succeed, when the odds are turning against it anway. And one thing we can be sure of is that the government has no alternative plan; and no capacity thanks to Brexit to develop one.

STPs: the NHS’ sustainbility and transformation plans are branded ‘secret’ and look like they’re in trouble

The Guardian leads with a sustainability and transformation plans ‘cuts’ story

The NHS is well and truly back in the news, thanks – if that’s the word – to the sustainability and transformation plan process.

The STPs are supposed to address the NHS’ immediate financial woes and implement locally the big ideas in the ‘Five Year Forward View’. This, in turn, is the big plan that was published two years ago [my blog post] to try and close a gap between funding, demand and costs that could otherwise reach £30 billion by 2020-21.

There are 44 STPs being drawn up [HSJ map] by NHS commissioners (the clinical commissioning groups that plan and purchase care locally), trusts (which run hospitals and mental health services) and local authorities (which are responsible for social care, which has a funding crisis all of its own).

So far, you would have to say that the process is not going terribly well. To put it mildly.

When is £10 billion for the NHS not £10 billion for the NHS?

Firstly, there are two increasingly public rows about the financial background against which the STPs are being drawn up.

The first concerns whether the government is funding the Forward View, as it claims. In its best case scenario, the plan assumed the NHS could find £22 billion of efficiency savings; leaving the government to find the remaining £8 billion.

In last year’s budget, then-chancellor George Osborne claimed he’d done a bit better, and that he would “fully fund” what he was quick to call “the NHS’ own plan” with £10 billion.

However, a succession of Parliamentary health select and public accounts committee hearings [my blog post] have established that it’s only possible to get that figure by counting in £2 billion for 2014-15, which had already been announced.

In addition, as Prime Minister Theresa May has been forced to admit [Guardian] in the past couple of weeks, the remaining £8 billion includes £3 billion that would previously have gone on things like running the Department of Health and paying for public health programmes.

May has said this is because the government is focusing on the ‘frontline’ NHS – but that in itself that sort-of admits it has diverted, rather than found new, money for the service.

Meantime, the £8 billion figure is also generous because the government has, unusually, counted the ‘extra’ in 2019-20 prices (rather than base year prices) and only factored in general inflation (rather than NHS inflation, which is always much higher, because of the high cost of new drugs and treatments).

Also, the way the money is being phased means most of the cash is going in this year (2016-17), when it will get a real terms funding increase of 3.7%. It will only get 1.3% next year (2017-18), 0.3% the year after (2018-19) and 0.7% the year after that (2019-20).

In Parliament, Stevens came close to saying this was not, in fact, what he asked for. He also pointed out that his plan relied on funding for public health and social care being maintained.

Don’t panic, Mr Hopson:

This brings up the second row. Despite repeated questions from MPs, Stevens was not ready to say that the logic of his comments is that the plan cannot be delivered.

Indeed, he told MPs that questions about what would happen if the STPs ‘failed’ made no sense, because the NHS will be bigger in 2019-20, whatever happens, and those areas will be delivering something.

Naturally, he didn’t spell out that ‘something’ might be a service in which there is more rationing, longer waiting lists, a bigger backlog of maintenance, and perhaps lower quality care.

This would be political suicide. Also, the whole point of the STPs is to avoid this scenario and Stevens is determined not to let the NHS itself think there is any alternative to restoring financial control and delivering on the plans.

However, others are happy to oblige. Chris Hopson, the chief executive of NHS Providers, reminded the health select committee that the acute sector (hospitals) finished last year £2.4 billion in the red – or a billion more than that, without some creative accounting.

This forced NHS England to throw most of its planned sustainability and transformation fund into the acute sector black hole this year, dramatically reducing the amount of money available for investment on projects that might save money in the long-run.

Despite this, and 2016-17 being the NHS’s “year of plenty”, Hopson said the “NHS was struggling”. Worse, he argued demand, NHS constitution commitments, targets, and funding could no longer be squared and something would have to give.

Worse, he argued areas were drawing up STPs in which they simply did not believe. Hopson was out this week making similar points ahead of next week’s Autumn Statement.

He told the Guardian, Today programme, and other outlets that May would have to “rip up” the government’s plans for the NHS and either find more money or “risk it becoming unable to function properly.”

So far, Hopson’s a lone voice. The country’s big three think-tanks have come together with their own statement for the present chancellor [Nuffield Trust website], Philip Hammond.

However, they are calling for more money to go into social care, on the grounds that it’s in an even worse state, and improving things would help hospitals discharge elderly people stuck on acute wards for lack of anywhere else to go.

Not live from Leeds:

While all this has been going on, NHS England (the body that runs the NHS’ planning and purchasing set-up from Leeds), has been trying to keep a tight grip on the STP process.

Working with NHS Improvement (the body that decides whether trusts are financially fit to operate) and the Care Quality Commission (a quality inspectorate), it managed to keep the first cut out of the public eye.

These had to be submitted in June, just as everybody was off on holiday – and then, of course, mightily distracted by Brexit. But it signally failed to keep the second cut quiet. Since the plans were finalised at the end of October, a bunch of councils have broken ranks and put them on their websites.

NHS England didn’t want the plans published until its communications teams had made sure they contained “positive” messages. It didn’t seem to stop and think that councils are not beholden to NHS’ PR-wallahs.

Or that elected councillors wouldn’t be able to live with any suggestion that they were ‘hiding’ or tacitly supporting the closure of local hospitals, which the early STPs tend to propose – or, more accurately, revive, since many have been under ‘threat’ for years.

So, in North West London, the STP has been published with a rider from local councils saying, flat out, that they just don’t agree with hospital rationalisation plans.

Secret – a tag that’s going to stick

The way the plans have come out is unfortunate, because it has established the idea that the STPs have been drawn up in ‘secret’; an idea reinforced this week by the King’s Fund think-tank.

It sent a couple of junior analyst to follow the development of four STPs, and issued a short report full of the kind of wonk-speak that these reports tend to contain about the difficulties of working across organisational boundaries and the need for leadership.

In noting that the fast pace of STP development had left little room for staff or public involvement, however, it left open a gap for a slew of headlines about how “NHS bosses are ‘trying to keep cuts secret’” (BBC) or “NHS cost-cutting plans are ‘kept secret from public and media’” (ITV).

Chief executive Chris Ham must be kicking himself; and has indeed been out and about trying to say that while the process is tough, it’s the NHS’ only hope [Public Finance magazine].

Too late. The ‘secret’ tag will now follow the STPs into every local paper, focus attention on the ‘cuts’ and ‘closures’ elements, and ensure the NHS is firmly on the back-foot when it comes to making the case for them.

This morning, the Guardian duly led its Saturday paper with a story analysing 24 STPs that was headlined “A&E, cancer and maternity units to close in major NHS overhaul.”

“Thousands of hospital beds are set to disappear, pregnant women will face long trips to give birth, and a string of A&E units will be downgraded or even closed altogether, as part of controversial NHS plans to reorganise healthcare in England,” it said; before quoting campaigners on how this would be untenable locally.

Back to the politics of the 1990s

This is an absolute gift to Labour and campaign groups such as 38 Degrees. The first has a ‘national day of action’ on the NHS today, and the second has a big “Save our NHS” petition on its website that claims “the NHS isn’t getting the cash it needs” while  “the government is letting money-hungry private companies carve out profits from treating the sick.”

Expect future reports from Oxfordshire, where former Prime Minister David Cameron’s presence as a constituency MP probably saved the Horton Hospital from an almost inevitable downgrade that is now refloated in its STP proposals.

Also, from South London, where a lot of journalists live close to the Epsom and St Helier hospitals that have been under ‘threat’ for years and are now up for review again as part of an STP plan that says it can afford only three or four of its five hospital sites.

Good in parts; if not enough parts

Whether this kind of coverage really informs the public about what is happening and what is at stake is another question. Because the STPs are about a lot more than ‘cuts’. All of those published so far certainly make heroic assumptions about the level of ‘efficiency’ their local services can come up with in the next four years.

But they also propose to focus on prevention, so fewer people get sick in the first place, and on focusing support on the elderly and those with long-term conditions, so they need fewer trips to hospital.

Some talk about introducing long-overdue digital services to take pressure off GPs and reduce pointless trips to outpatients, and some certainly want to create specialist centres for maternity, A&E or cancer, on the grounds that these will do a better job than the local DGH can manage to do.

At the same time, the growing furore may encourage some trusts to resist their local STP plans. An awful lot are still behaving like there is going to be a hospital bailout – although why is anybody’s guess, since the government has said repeatedly that there won’t be, and it has bigger global issues on its plate.

It will make it harder for those managers that do want to be bold to execute change. And, finally, it will distract aattention from the multi-billion pound question. Will implementing the STPs, if it can be done [my blog post], save the kind of money that the NHS needs to save? And what on earth will happen if not?

The NHS: in an awful place

It was a shock to switch on Parliament TV the other week to watch Simon Stevens at the public accounts committee, and to see him sporting a substantial beard.

The Health Service Journal says the chief executive of NHS England has been on holiday to the Arctic. If so, it’s tempting to think he’s channelling Captain Scott: “My god, this is an awful place!”

Hard sledding

 NHS finances are certainly in an awful state. As detailed in blog posts below, the health service in England has known that it is facing a growing gap between funding and demand since 2008.

It has been asked to tackle via Sir David Nicholson’s ‘quality, innovation, productivity and prevention’ agenda and, more recently, Stevens’ ‘Five Year Forward View’. This called for more effort on public health and the introduction of new ways of working to help bridge a funding gap now projected to reach £30 billion by 2020-21.

Unfortunately, acute finances went over a cliff last year, with the sector finishing 2015-16 some £2.4 billion in deficit, and the NHS as a whole only making it through in balance by the skin of its teeth (and, ahem, forgetting to mention that it was going to get £750 million than it expected out of National Insurance).

In a financial ‘reset’ in July, trusts were asked to accept ‘control targets’ to try and get the acute deficit down to £250 million this year; but some are holding out, and there’s widespread scepticism about whether the rest can deliver.

Meantime, the ‘Sustainability and Transformation Plans’ that are supposed to help local organisations deliver £15 billion of savings over the next five years are yet to emerge from central vetting.

(The rest of the £30 billion is being closed by £8 billion from the government, most of which will arrive towards the end of this Parliament, and £7 million from cuts to the budgets of the various bodies that oversee and regulate healthcare).

Unhelpful questions

 Unsurprisingly, reputable think-tanks are starting to post blogs asking whether the STP agenda can deliver, and if not whether the NHS is financially ‘sustainable.’ Stevens probably finds these unhelpful.

He certainly didn’t react well to a succession of PAC members asking what would happen if the STPs didn’t deliver, or whether he had a Plan B for that. After all, he won’t want trusts thinking there is an alternative (like a bail out) on the way; because they won’t get into the change agenda if they do.

And he doesn’t want policy makers or the public thinking seriously about failure ; because the local results will be awful, and the national results could include a new ‘debate’ about the future of the NHS as a taxpayer-funded, universal service.

Cancel Christmas

 So, no failure and no plan B. This message was backed up by the NHS ‘to do’ list that Stevens told the PAC would be out some three months earlier than normal, on 22 September, rather than Christmas Eve.

This document, officially the ‘NHS operational planning and contracting guidance 2017-19’ says commissioners and trusts will be expected to get into balance and hit key targets, and that if they miss in the next financial year they will simply have to catch up the year after that.

Oh yes, and there’s to be no moaning about contracting being difficult. And if there is, or if healthcare communities miss their targets, or if they fail to sign up in the first place, they won’t get any of the very small carrot that NHS England has available in the form of a £1.8 billion ‘Sustainability and Transformation Fund’.

Cancel the internal market?

There are lots of interesting aspects to the guidance. It tries to tell trusts that they won’t be able to play off one central body (NHS England, with its control targets) against another (NHS Improvement/Monitor with its operational requirements, or NICE and the CQC, with their expensive treatment and staffing rules).

All these bodies are united, it says, in “supporting” the NHS to deliver the STPs. This is sensible, but suggests the NHS in England is no longer trying to operate anything like the internal market introduced during the Thatcher era.

In its latest incarnation, trusts (regulated by NHS Improvement/Monitor) are supposed to compete for business from clinical commissioning groups and patients (acting on CQC information).

But the guidance not only says these bodies will work to bring some central rigour to the situation, but that in future less attention will be to commissioners and trusts than to STPs. These are starting to emerge as administrative areas and ones in which “co-operation” rather than competition is the order of the day.

To support this, the guidance says that STP areas will be given their own control targets. Subsequently, Stevens said that he would not be adverse to them applying to suspend ‘payment by results’ in order to meet them.

The end of PbR would definitely mean the end of the attempt to get money to ‘follow the patient’ that was at the heart of the internal market. This will cheer many, including the BMA, which has been arguing for some years that the NHS can simply not afford the plethora of organisations required to run it, or the transaction costs.

But the STP areas would be very convenient vehicles for the kind of ‘accountable care organisations’ that some left-wing commentators believe that Stevens, who spent a chunk of his career in the US, wants to introduce to England, in order to “privatise” the NHS.

There is no alternative (well there is…)

It’s worth saying that even if the NHS did move towards and ACO model, it would not have to be operated by insurers. It could be run by the NHS itself, to reward the kind of integrated and preventative care that the STPs are being told to develop.

A shift to insurance would be a political decision, and not one it’s easy to see health secretary Jeremy Hunt signing up for.

Just in case, though, the NHS should really try and make it back to base camp. On which front, Stevens’ message is that the sled dogs are not on the way with more provisions. And there ain’t no map out there except the Forward View.

Analysis: I have been writing analysis pieces on financial and policy issues for the research arm of Digital Health Intelligence (picking up the implications for the healthcare technology market). There’s more on the reset here and the planning guidance here.

Stealth plans to steal records: is care.data back?

 

 

You can tell when a story is really ‘hot’; lots of media outlets rush to claim it as their own.

Last week, the NHS managers’ magazine, the Health Service Journal, claimed a big ‘exclusive’ on a story that a programme very like care.data was heading for Treasury approval, a few days after the political website, Politico, ran a story about a “stealth plan” to “sell UK patient health data.”

Any moment now, one of the papers will run something similar – keep an eye on The Guardian. Even so, this story was definitely broken by the website I work for, digitalhealth.net; which featured it in its Thursday newsletter on 4 August.

What was care.data?

The story is explosive because care.data was explosive. This was a plan, drawn up by NHS England’s gung-ho national director of patients and information, Tim Kelsey, to expand a dataset known as the Hospital Episode Statistics, and to add more information from other healthcare providers.

All this data was to be ported into a little known body called the Health and Care Information Centre, which would hang onto identifiable patient information, but also prepare it for publication.

The HSCIC was to remove identifiers (such as a patient’s name), from some information and then make this ‘pseudonymised’ data available to researchers and others. Completely anonymised information would be published.

The project went awry when GPs realised they were first up to start supplying identifiable patient information to the new service; and started asking how patients would know this was happening.

In theory, patients can opt-out from having their identifiable data used for anything except ‘direct patient care’, but it was not clear what arrangements would be made for them to opt-out of the new GP dataset.

Then, privacy advocates pointed out that it is possible to reverse the de-identification process; so it might be possible to identify patients from their pseudonymised data, especially if they lived in a remote area, or suffered from a rare condition.

Kelsey and Prime Minister David Cameron made things worse, by suggesting that the pseudonymised data sets might be used by insurers, to adjust premiums, and big pharma to make “every patient a research patient” and boost the UK economy in the process [BBC].

As a media campaign finally got going about the proposal [feature by me], the HSCIC embarked on a cack-handed patient information programme that consisted of a junk-mail leaflet that failed to mention the programme by name or include an opt-out form.

Eventually, the outcry became so much that it was forced to stop the programme. Four ‘pathfinder’ areas were lined up to try out new publicity ideas, but these were halted when health secretary Jeremy Hunt announced that National Data Guardian Dame Fiona Caldicott was going to conduct a review of data security and patient consent.

What has happened now?

Care.data finally seemed to have been killed off when Dame Fiona put out her report. After all, the then-life sciences minister George Freeman announced that the programme would be “closed”.

Digitalhealth.net reported this [news story by me], and so did the limited number of other news organisations that covered Caldicott 3 (most being busy with the final report of the Chilcot Inquiry into the Iraq war that was issued on the same day). However, when we got around to digging a bit deeper, it became obvious that things were less clear-cut.

For a start, we established that the collection of the GP dataset will go ahead. Then, we worked out that the HSCIC, which has since renamed itself NHS Digital, wants to set up something called the Data Services Platform to collect information, hold it securely, de-identify and anonymise it, and release or publish it.

That all sounded very much like care.data [feature by digitalhealth.net]. Admittedly, FAQs on the NHS Digital website talk about the DSP collecting and issuing information for ‘commissioning’ (the planning and purchasing of NHS services, undertaken by NHS management bodies) rather than for researchers or pharma companies.

But there seems nothing to stop the recipients of de-identified data being extended in the future. And there’s another wrinkle.

One of the oddest things about the care.data row was that it managed to make the deeply dull Hospital Episode Statistics controversial; and (because more than a million people did register strong objections to their data being shared for anything other direct care) less complete than they used to be.

In the course of her review, Dame Fiona appears to have been persuaded that this is a bad thing; so bad that data destined for the NHS Digital ‘safe haven’ should not be subject to patient opt-out.

So, if everything goes ahead, people won’t be able to object to their information being included; even though the most eye-catching feature of Dame Fiona’s report was a/two new patient ‘opt-out/s’ from data being used to regulate health services and/or for research.

Are medical records going to be sold by stealth?

When people read headlines about ‘records’ or ‘patient health data’ being sprayed around by the government, they probably imagine that the stories underneath deal with the kind of intimate information held in the ‘Lloyd George’ envelopes of their youth.

That is not, and has never been, what care.data or the DSP have been about. Both are dealing with ‘data items’ or pieces of information extracted from such a record, that can be used to answer questions such as: ‘what kind of person goes to A&E on Saturday’ or ‘is treatment x in hospital more or less effective than treatment y by a GP for people with condition z’.

The ‘pseudonymised’ data to be pushed out of NHS Digital would look even less like a medical record. The idea that this information is going to be ‘sold’ is also over-selling.

The proponents of care.data talked about recovering the costs of data processing; there’s no suggestion that NHS Digital will charge commissioners for the information processed by the DSP.

Even so, it’s a basic principle of data protection that data should only be used for the reason it is collected. Where that data is put to other uses, people should know what those uses are, and have the chance to opt-out if they want.

The NHS seems to think it should be different; it’s not entirely clear why. At the same time, the establishment of the DSP looks set to kill off attempts to de-identify data at source (or to remove patient identifiers before the information destined for the DSP leaves the GP surgery).

This is a shame; as the concerns about the recipients of data being able to reverse engineer it to identify individuals haven’t gone away; even if the government looks set to legislate to increase the current penalties for doing it.

And even if data is not ‘sold’ this does not mean it won’t end up in the hands of private companies. Commissioners already use commercial ‘business intelligence’ services; so it will go to the providers of those services, even if usage is not widened beyond commissioners in future.

So: medical records, no. Sold, not exactly, But stealth, definitely. When digitalhealth.net called NHS Digital about HSJ’s story last week, its press office tried to claim the magazine was confused, that care.data has not been revived and that, indeed, nothing new is happening.

No new data has been collected, it said. NHS Digital already processes information for commissioning. There’s a consultation underway on Dame Fiona’s proposals.

That’s true; but also weaselling. George Freeman claimed care.data was being closed and yet all of its elements are to go ahead; this time without an opt-out for patients. That consultation was launched on the day that Chilcot reported and closes on 7 September, just as the schools go back.

You’d be hard pushed to read it and know what is at stake. Even so, as I argued in our editorial at the start of August, the government was trying to pull a fast one, and it’s been caught out. Which is stupid; because it was a lack of clarity and honesty that got it into so much trouble the last time.

 

 

The perils of the pioneers: or, more reasons to worry as the NHS financial climate gets colder

 

William Hahn – Going Home (Pioneers Braving a Storm)

So, it’s official. As audit bodies and think-tanks have been predicting for months, hospitals in England have run up a £2.45 billion deficit; the biggest overspend in their history.

And that’s after they sucked up an additional £1 billion of money meant for capital spending, and resorted to what the IPPR think-tank described as “crisis driven” “accounting tricks” to stop the figure going any higher.

It remains to be confirmed whether the Department of Health bust its budget as a whole last year. A recent House of Commons health committee hearing was told that it might have done; but there’s a chance it has managed to squeeze enough money out of central and commissioning bodies to get in under the wire.

In a way, it doesn’t matter. The acute sector has gone over a cliff, with horrible implications for the NHS’ big plans to sort out its finances by doing things in new ways.

Ever more heroic plans  

As set out in several blog posts below, these plans were set out in the ‘Five Year Forward View’ in October 2014.

This called for investment in public health (to try and reduce demand), an efficiency drive, and new ways of working (to make the NHS more efficient at dealing with the demand coming towards it, as the result of an ageing population, more chronic disease, and new treatments).

Together, these were supposed to generate £22 billion of savings; with the government chipping in £8 billion to close a funding gap that might otherwise reach £30 billion by 2020-21.

A briefing for the health committee hearing added some useful detail to these headline figures. It said the Treasury spending review settlement assumed that £7 billion of the £22 billion will be “delivered nationally”; presumably by cutting the budget for the DH and organisations such as NHS England.

That leaves £15 billion to be “delivered locally”, of which £9 billion is supposed to come from “conventional provider productivity”; or from hospitals becoming more ‘efficient’ by squeezing wages, maintenance and supplies and generally “doing more with less.”

To reach this figure, hospitals would have to become 2% more efficient every year. The health committee’s note says the NHS regulator, Monitor [now NHS Improvement] believes this is “stretching but achievable.”

However, as also noted below, most watchdogs and think-tanks believe it is “heroic” at best and la-la land at worst; if only because hospitals have been trying to make these kinds of savings since 2008, when the former chief executive of the NHS, Sir David Nicholson, first sounded the finance alarm.

The fact that hospitals overspent by £2.45 billion in the 12 months running up to the first year of the Forward View suggests that the latter view may be more realistic.

Perils of the pioneers

Meanwhile, after a lot of semi-public haggling with NHS chief executive Simon Stevens, the Treasury agreed to front-load a chunk of its £8 billion to create a ‘Transformation Fund’ to pump-prime the bigger reform ideas.

One of the consequences of the hospital overspend is that almost all of the money in the fund for this year will now go on bailing out the acute sector. Another think-tank, the Nuffield Trust, has estimated that all but £339 million of a £1.8 billion pot will vanish this way.

So there isn’t going to be much cash about to try out all the new ideas that the plethora of ‘vanguards’ and ‘test beds’ are supposed to be setting up. This would be worrying if they were guaranteed to work. But they’re not.

As newspapers and broadcasters focused on the hospital deficit figures, they largely ignored a report that slipped out from the London School of Tropical Medicine’s policy innovation research unit on the ‘integrated care and support pioneers programme.’

The integrated care pioneers were set up by the Lib Dem social care minister, Norman Lamb, in the last Parliament, to test out one of the big ideas in the Forward View.

Specifically, they are testing out the idea that creating health and social care organisations that actually talk to each other and try to provide more ‘seamless’ care for patients will save a lot of money; not least by keeping them out of expensive hospitals by treating them at home or even keeping them well.

Some 14 pioneers were announced in November 2013 and another 11 in January 2015; and the PIU asked them how they were getting along in spring 2014 and summer 2015. Not all that well, was the short answer.

The researchers found their staff really wanted to bring about change, but that they were battling to overcome organisational intertia, IT problems, and the bigger financial situation, which gives hospitals an incentive to suck in patients, because they get paid for treating them.

Indeed, it found a lot of pioneers had already scaled back their ambitions, and were focusing on a much more limited agenda of ‘risk managing’ populations (to try and find the elderly, chronically sick patients who are constantly admitted to A&E because other services are so chaotic) and to ‘case manage’ them (to try and make services a bit more coherent, by putting one person in charge of co-ordinating them).

In a bind, with no easy way out

Taken together, these threads suggest the NHS is in a bind. The acute deficit figures suggest it is just not making the kind of “conventional provider productivity” savings it needs to stay in budget, never mind generate efficiencies of 2% a year.

And the integrated care pioneer report suggests that it’s not managing to change the way it does things in order to make more fundamental savings; even when it’s trying pretty hard to do that (although Norman Lamb thinks the pioneers have been left to wither since the Lib Dems left the coalition).

So where next? The response of most commentators is to say the NHS just needs more money. The amount being spent on the service, as a proportion of GDP, is falling; and it needs to rise again.

Faced with similar deficits, in tattier hospitals, ground down by years of cash releasing efficiency savings, governments have cracked and found more money in the past. So the acute sector may tacitly be assuming that this will happen again.

But with a Conservative government in power that appears to have public support for its austerity agenda, it doesn’t feel wise to bet on it. The Treasury and the DH are certainly sticking to the line that the government has agreed to fund “the NHS’ own plan” and that’s that.

A less common response is to say that the NHS’ traditional attempt to first stabilise the acute sector and then get into the reform agenda is wrong.

Things are so bad that the NHS just needs to get on with the kind of shifts that other service sectors have made (introducing IT to streamline operations, finding cheaper ways to deliver activity, and passing work off to new providers or to users where possible) and to pay for this from real – if very painful – personnel and cash shifts.

The experience of the pioneers is not promising; but it’s possible to argue that if they weren’t separately funded they wouldn’t be able to segue into another form of activity, as the rest of the system desperately tries to prop itself up around them.

All eyes will be on the vanguards, to see if they can manage to pull of this kind of trick. Because the third response put forward by commentators is to give up/introduce insurance/privatise it; and we don’t want to get there.

The NHS and the five year plan(s)

Let’s deliver the five year plan in four years!

If plans can save the NHS, then it should be just fine over the next five years. NHS England, acting on behalf of all of the health service’s many central management and regulatory bodies, issued its annual “must do” list this week.

The “must dos” come down to two big items that are always on the list and one that’s new. The two perennials are stay in budget – or, this year, sort out the horrible mess that is hospital finance – and to keep on top of the targets the public know about – like waiting times.

The new one is to try to work out how to implement the ‘Five Year Forward View’ that NHS England put out in October 2014.

The Forward View is chief executive Simon Stevens’ big plan to close a gap between the funds available to the NHS, its rising costs, and the even more rapidly rising demand being put on it by an ageing population and the growing burden of chronic disease (such as obesity).

This gap is due to reach £30 billion by 2020-21. The Conservatives promised to find £8 billion of this during last May’s general election campaign, and the Treasury duly dug up £8.4 billion in the spending review last November.

So there’s £22 billion to go, and the NHS is supposed to find it by damping down demand through health promotion and bringing in new, more efficient ways of working.

The first is a non-starter, given decades of failure in this area, the present government’s manifest reluctance to act, and public hostility.

(This week, it was revealed that 4 million people are now living with diabetes, and Public Health England’s response was an app to encourage parents to find out how many sugar cube-equivalents there are in the processed junk of their choice.)

(After which quite baffling levels of ‘nanny state’ criticism and btl outrage were tipped over the chief medical officer’s attempts to update guidance on alcohol consumption by suggesting that people should try to drink rather less than they apparently do.)

So that leaves new ways of working; which means trying to keep people out of expensive hospitals, ‘integrated’ health and social care to try and cut out the waste that occurs when they fall between the gaps between the two systems, and financial incentives for this to happen that are being trialled by ‘vanguard’ projects.

This is where the plans come in. The guidance tells the NHS’ planning and purchasing bodies, clinical commissioning groups, to come up with one year plans to tackle immediate issues and five year ‘Sustainability and Transformation Plans’ to tackle the longer-term stuff.

So, everybody is supposed to draw up one year plans that will make a start on five year plans that will eventually deliver on THE five year plan.

Heroic amounts of management effort are going to go into this Soviet-sounding regime. So is it likely to deliver the tractors? The National Audit Office, for one, gives reasons for doubt.

Just before Christmas, it put out a report noting that overspending by hospital and mental health trusts is now so bad that it is not going to be cancelled out by underspending in commissioning; pushing the NHS as a whole nearer to the point of going into the red.

Also, that this is because hospitals have run out of short-term savings, are failing to find long-term, recurring ones, and that attempts by regulators to ginger them up month on month is just disrupting any do plans they have in place.

Also, that there is “no coherent plan that shows how the gap between sources and patient needs will be closed by all parts of the NHS” and that those big, Five Year Forward View projects to change working structures and practices have yet to be tested.

Also, that past experience suggests there are reasons to think that they won’t work; and won’t save much money if they do.

The NAO ended up by calling for a “holistic and coherent” approach that would show a “clear pathway for trusts to get back to financial stability” while explaining what contribution each bit of the service would make to delivering on the Forward View.

It’s not clear that the planning guidance delivers this. There are 209 CCGs in England. If they all come up with a one year plan and a five year plan then we’ll have a lot of plans. But it doesn’t follow that we’ll have a plan that amounts to a coherent plan to deliver THAT plan.

This is why so many financial experts are worried; even as the Conservative Party continues to insist that it has stumped up the money for “the NHS’ own plan” (which, to be fair, it sort of has) and will soon be spending more on the health service than has ever been spent before (which, to be fair it is; but that’s hardly the point).

It’s also why three former health ministers came out this week to say that a cross-party commission is needed to review the future of both health and social care; with everything from the Forward View to payments for some services and tax rises on the table.

“The reality is that we either see the system effectively crash or we confront the existential crisis now,” said one of those ex-minsters, Lib Dem Norman Lamb. “This transcends party politics.” The first bit sounds right.

The Conservatives ‘won’ the general election – what does that mean for the NHS?

“The NHS belongs to the people” (discuss)

The Conservatives are back in power. With no Liberal Democrats to provide any check on their policies, and Labour in the throes of a leadership contest that looks set to distract if not consume it for some time.

What is that likely to mean for the NHS? It’s hard to think anything good, not least because the party’s manifesto has relatively little to say on the subject, so a lot is going to depend on how reforms already in train are allowed to play out in practice.

The manifesto: The Conservative Party manifesto says the NHS was “founded on the principle that no-one should ever have to worry about their ability to pay for their healthcare [and that it remains] a profound expression of our values as a nation.”

That sounds fine, but it’s an odd way of putting the health service’s founding principles. These are usually given as “a comprehensive service, available to all on the basis of clinical need, and free at the point of delivery.”

So this line was either written sloppily, or it implies that the party wants some wriggle-room when it comes to providing a comprehensive service – that is one that is (or that aspires to be) the same everywhere and to meet the needs of everybody – and to providing a tax-funded service that is free to users.

The first is likely to be more significant in the short term, because new service models are already being developed that will leave the NHS (and the social care services delivered by councils) looking very different from city to city.

The second could be more significant in the longer term, if there is pressure to find new ways of funding those new service models – some “small” charges here, a bit of means testing there… an insurance model that would still “provide reassurance to hard working families when they need it most.”

The Conservative Party manifesto; pledges (and silences)

That £8 billion: Specifically, the manifesto says the Conservatives will “spend at least an additional £8 billion by 2020 over inflation to fund and support the NHS’ own action plan for the next five years.”

Much of the election campaign debate about the NHS focused on this £8 billion pledge, since Labour refused to match it, saying instead that it would set up a £2.5 billion ‘better care’ fund, paid for via a mansion tax.

However, it’s surprisingly ambiguous. Again, it could just be sloppy wording, but it’s not quite clear whether the Conservatives are planning to spend an extra £8 billion a year by 2020-21, or an extra £8 billion between now and 2020-21.

The difference is a huge amount of money. But in either case, what the manifesto doesn’t spell out is that “the NHS’ own action plan” requires the NHS itself to find another £22 billion of efficiency savings over the same period.

This is because the plan – the ‘Five Year Forward View’ issued by NHS England chief executive Simon Stevens in October – is designed to close the gap between rising demand and likely funding that could reach £30 billion without action.

Now, most policy experts don’t think the NHS has much chance of doing this. It has managed to make significant efficiency savings over the past five years, but mainly by holding down wages and the prices paid to hospitals for treatment.

The result, as NHS Providers keeps pointing out, is that hospitals are looking at a £2.5 billion deficit in the coming year. Meanwhile, the Conservative’s much-vaunted cuts to council budgets mean there’s something like another £4 billion of pressure on the health service coming from social care.

Vanguards – of what? Whatever the £8 billion pledge amounts to, therefore, the NHS is going to have to find some big ways to find even bigger savings over the next five years.

It has already started. Just before the official general election campaign got underway, NHS England issued a list of 29 ‘vanguard’ sites to test out two ideas.

These are letting acute trusts expand to take on some community and primary care work; and letting GP practices expand to provide more services, including some now provided by smaller hospitals.

In both cases, the idea is that removing the boundaries and gaps between different services will both provide a smoother “patient journey” and save money. But the implications for the way the NHS does things are huge.

At least two of the ‘integrated primary and acute care systems’ vanguards (Salford and Yeovil) are being allowed to effectively dismantle the ‘internal market’ that has operated in the health service for the past 25 years, by creating new vehicles (an integrated care organisation and a joint venture) to both commission – that is plan for and buy – care for its local population and deliver that care.

Up front, this looks like a move to overcome one of the big problems with recent attempts to ‘join up’ healthcare; namely that when a new service is set up to keep people out of hospital, the hospital loses the money it would have got for treating them – adding to its deficit.

If the organisation that runs the hospital holds the local health service budget, it has more incentive to cut its costs by setting up a service for which it will still be paid.

In principle – and in practice, for the moment – this can happen within a system in which all the organisations involved are NHS organisations, spending money raised from tax. However, there is also plenty of scope for the vanguards to let in the charity and private sector; both of which can trim costs by casualising their staff.

After all, the last round of Tory-led commissioning reforms, which led to the creation of GP-led clinical commissioning groups, pushed a surprising number of community and mental health staff into ‘community interest companies’, and handed chunks of primary care and out-of-hours services straight to private companies, such as Virgin Care.

There is also scope for these new models to evolve into something like the ‘accountable care organisations’ that have been set up in the US to run everything from primary to acute care services for patients referred to them by insurers.

Indeed, as Stevens spent ten years of his career in the US, at the giant United Health, there is plenty of suspicion that this is where the vanguard policy is heading. It’s safe to say that Labour and the Liberal Democrats would have been less happy with this – and more likely to resist it – than the Conservatives.

It’s also safe to say that some of the names being bandied about to take over from health secretary Jeremy Hunt might be positively enthusiastic about pushing the policy in that direction.

Jeremy Hunt is likely to leave his health secretary post: who is going to take over at Richmond House?

Fripperies: The Conservative manifesto doesn’t mention the vanguard programme, although it does express support for another initiative, the ‘Better Care Fund’ to bring together health and social care.

Instead, it focuses on more specific promises, such as better access to cancer drugs, more health visitors for new mothers, and improved access to GP services.

The manifesto promises a seven day a week NHS by 2020, which will surely only be possible if a good chunk of the NHS is delivered through online advice sites, call-centre triage, and phone or video consultations.

This is probably not what elderly, Tory voters in the shires had in mind. But local paper rows about whether a call to a doctor at NHS 111 constitutes a 24/7 GP service will be nothing in comparison to the potential upset that could be caused by a move to hospital-lite, accountable care organisations.

Of course, the NHS could yet avoid going in that direction. It’s just that the general election result makes it significantly more likely that it will.