The health and care system is awash with change. NHS England (NHSE) is being subsumed into the Department for Health and Social Care (DHSC), Integrated Care Boards (ICBs) are being cut and rebranded as ‘strategic commissioners’, with changes to other layers of the health and care system’s complex governance structure yet to be confirmed. What’s clear is that the rule book has been ripped apart, giving way to major structural reorganisation. Such large-scale change creates a huge amount of noise, uncertainty and anxiety – all things that threaten to undermine the change management of an incredibly complex system like the NHS.
At the same time, there is renewed pressure on the system to address significant operational and financial challenges in line with the government’s Plan for Change, and its NHS 10-year health plan is due imminently.
A lot is riding on the 10-year health plan to create an NHS ‘fit for the future’, improve population health outcomes and bolster the economy. How the plan lands will help to further shape the public and NHS’ staff view as to whether this government can be trusted with the NHS. And while no one expects outcomes to improve overnight, people need to believe that the vision is achievable.
The main thing health and care leaders need in order to deliver these momentous changes is a degree of clarity – something so far that is marked by its absence. The plan needs to include a clear and aligned set of policies that convince those charged with delivering this change that the disruption, long days and sleepless nights will be worth it.
At its most the plan could set out a bold path to a more preventative and empowering model of care. This is the only way to put the NHS on a more sustainable footing and arrest an ever-growing share of scarce national resources going to healthcare.
It should also take a broad approach to health, forging a new relationship between citizens and public services through a neighbourhood model and align with wider public sector reforms including in local government to improve national prosperity. Boosting productivity and supporting the workforce will be key, and recovery and reform must be treated as two sides of the same coin.
But it cannot simply describe policy changes; it must give an indication of how delivering this change will be possible.
Providing clarity: a new operating model for health and care
Arguably not as eye-catching or politically salient as other changes proposed in the plan but without the clarity of a comprehensive system operating model it will fail at the first hurdle. Each part of the system needs to be clear on its purpose, what it is accountable for, and to whom, something that does not currently exist. Instead, historic structures are layered on top of one another like a coral reef.
NHSE has attempted to bring some clarity with the Model ICB Blueprint. The appointment of Richard Barker – a well-respected ex regional director – to lead of the NHSE and DHSC ‘transition programme’ is a positive sign that the future of NHSE’s regional teams is being thoughtfully considered. However, many questions remain unanswered, including the future role of neighbourhood teams, place-based partnerships, primary care at scale, trusts, and integrated care partnerships (ICPs).
The NHS operating model is best described as a collection of parts rather than a coherent whole. But NHS leaders – some of whom are being asked to make 50% cuts to running and programme costs at breakneck speed already need answers.
The NHS Confederation has been engaging with our members across the health and care system to suggest what a new system operating model that they support should resemble. Our recent publication based on engagement with leaders across the health and care system, articulates our vision for that future model. It maps the role and functions of bodies operating at the health and care system’s different geographical scales – from neighborhoods to the centre – and how they could work together to achieve a more integrated and devolved healthcare model that delivers the government’s three shifts.
We believe change should be guided by three key principles:
- Devolution and subsidiarity – the operating model must devolve decision-making to local leaders to drive change, while holding them accountable for outcomes.
- Change-led improvement – this will empower the public with greater choice and local leaders with greater autonomy over how the changes are delivered.
- Clarity and accountability – the system must both reduce acute demand and redistribute resource out of hospital. The decision about who leads this change should be agreed locally.
In the words of Lord Darzi from his report on the NHS, ‘it is notable that the biggest rises [in hospital spending] occurred when the NHS’s commissioning structure was at its most distracted: from the publication of the Liberating the NHS white paper in 2010 and the passing of the Health and Social Care Act of 2012.’
Faced with similar circumstances, the government must ensure its 10-year health plan can deliver its vision by creating and giving the health and care system a clear path to delivery, with local flexibility. Providing a simple and effective system operating model will be crucial.
