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?