The new chief executive of NHS England speaks to Victoria Vaughan about his bold vision for the NHS
The new chief executive of NHS England speaks to Victoria Vaughan about his bold vision for the NHS
NHS England chief executive Simon Stevens had only been in the captain's chair for six months when, in October 2014, he published his bold vision for the health service – the Five Year Forward View – to general critical acclaim. It succeeded, in part, by deftly weaving a path between the two prevailing – and conflicting – public policy narratives. On the one hand, it propagated the current health service reform programme by, according to NHS Clinical Commissioners, giving "a very clear steer that local clinical commissioners are at the heart of the future NHS”. On the other, it addressed the one unifying, underlying claim of those that oppose the reforms by clearly stating that the NHS will continue to remain free at the point of access.
But it wasn't just good politics. The document also set out a number of new care models that, by integrating primary, secondary and social care, received the backing of managers on the front line. More than 260 health organisations rushed to sign up to his vision by volunteering to become vanguards of which 29 have been selected for the first wave, announced in March. And many of these projects are being headed-up by clinical commissioning groups (CCGs). Mansfield and Ashfield and Newark and Sherwood CCGs, Hampshire and Farnham CCG and Harrogate and Rural District CCG are all setting up integrated primary and acute care systems (PACs) – joining up GP, hospital, community and mental health services. While NHS Sunderland CCG and NHS Dudley CCG are working on creating multispecialty community providers (MCPs) – moving specialist care out of hospitals into the community.
Stevens says NHS England works to link areas that have similar circumstances rather than working along geographic locations as has traditionally happened. “We have often thought that if it is something that needs to take place at a bigger scale than your immediate town or locality then go find three next door neighbours to do it together. However, actually it turns out that, and we have seen this with the vanguards, what they wanted to do in Harrogate and what they wanted to do in Yeovil has got more in common than Harrogate versus what they wanted to do in Stockport.”
Stevens confirmed that the vanguards will be matched in this way, with areas that have similar priorities working together regardless of location, and that NHS England is in talks with Monitor, the Trust Development Authority (TDA) and the Care Quality Commission (CQC) on how it could work.
Critics argued the vanguards are just another NHS fad, destined to go nowhere. But Stevens gives four reasons why this time it’ll be different. “This was not a bid for money. We will make some investment using some of the £200 million funding we have got available for next year in these vanguards. However, we deliberately did not include a box saying, ‘And tell us what share of the £200 million you think you need’. Secondly, the reality now is that, frankly, in many places people can see they do not really have a choice. The availability of more and more money to fund increasing volumes on the old model is under challenge in many parts of the country. The third reason is that it does genuinely go with the grain of what front-line clinicians want to do. It is not managerially deposed… The fourth thing is that it is not just the usual suspects. Actually, Morecambe Bay is one of the 29 vanguards, so some places are parts of the country with long-standing and deep-seated issues that they have got to confront.”
The ultimate aim is that, if Stevens’ plans are successful, in five to 10 years time healthcare currently delivered in outpatients departments will be available in the community through MCPs. Those forming the first MCPs envisage they will take funding responsibility for the population that they are there to serve, using the GP registered list as the basis for that.
Another new care model outlined in the Forward View is the PACs, where hospitals employ GPs, something that will set alarm bells ringing for those CCGs struggling to manage spending in secondary care. The Forward View mentions “safeguards” to stop costs spiraling out of control. Stevens elaborates: “Hospitals that are in a partnership of equals with their GPs are coming together to form integrated health systems, they will have to take on responsibility for the fair shares population funding for the people that they are responsible for. For the people of Harrogate, the Harrogate PACs will have to take responsibility for managing health service resources within that total [budget].”
The much-criticised payment by results (PbR) method of funding hospital care will also be limited to areas where it’s of benefit. PbR was designed to do several things, one of which was to radically slash NHS waiting times, which has been successful. But the current challenge is about meeting the needs of people with multiple chronic conditions. Stevens is looking to the vanguards and places that want to redesign their urgent emergency care systems to test new funding models that overcome some of the issues. Stevens took on his role following a fairly tumultuous time for the NHS with its total structural reorganisation. Stevens sensibly distances himself from the Health and Social Care Act 2012 responsible for that shake-up. While many will say it has bought clinicians together, many more will say that the resulting fragmentation and organisational upheaval at a time of constrained budgets was damaging. “I was not involved in the Health Act so I cannot speak to the precise judgments and trade-offs that were made at the time,” he says.
Stevens does say that it was a good idea to shield nascent CCGs from the responsibilities now conferred to them through co-commissioning. But he would not be drawn on whether it was always the plan for CCGs to take on commissioning of primary care. “I cannot speak to that. All I can say is that it is certainly my plan to give them that option because I do think that it makes sense wherever possible to try and combine integrated place-based judgments made as close to local communities and front-line professionals as possible,” he says.
But when variation is widely considered a bad thing, surely 211 CCGs with varying levels of co-commissioning will result in increased complexity? Stevens agrees it will for NHS England but not for CCGs. “It is simplifying [things] locally. It means NHS England has got to be fleet of foot in terms of working with the different options that people have made.” He makes the point that the NHS cannot sit and wait until everyone is ready to innovate. “It is a great mistake to assume that nobody in the NHS can get going on something better until everybody would be ready to do it. That is a very poor basis on which to back improvement across the country,” he says.
And leading the charge is Greater Manchester where “Devo Manc” sees the 10 councils, 12 CCGs, 15 NHS Trusts and Foundation Trusts come together to work out how best to spend the £6 billion health and social care funding . Stevens says that “the reason I so enthusiastically supported” the plans was simply because they asked: “Give us the tools and we will do the job.” He was quick to highlight that it is “not the end of the NHS in Greater Manchester, or the end of difficult decisions – just hopefully a better way of taking them – and ‘not’ necessarily a model for how the rest of the country will or will not evolve any time soon. We are open to conversations but we are not necessarily envisaging that this is what the endgame looks like in every part of the country.”
This interview took place in early March.
