‘System by default’ – how to make a good idea a reality | Nick Ville

Nick Ville

Implementing the new ‘system by default’ approach to running and organising the NHS must be delivered through incremental change that identifies what is needed and what will work, not through central diktat, writes Nick Ville, director of membership and policy at the NHS Confederation.

This article was first published by the HSJ.

The recent planning guidance told us a lot about the ways in which NHS England and NHS Improvement hopes integrated care will develop over the next 18 months. One thing is absolutely clear – ‘system by default’ and devolving more influence and authority to integrated care systems is very much the direction of travel.

Reports over the weekend suggest that there may be a Whitehall ‘power grab’ from NHSE amid speculation that No 10 is impatient for results.

This makes the development of a mature relationship with local systems even more important as HSJ’s Dave West explored in an editorial this week. We agree that the delivery of the NHS long-term plan depends on establishing strong partnerships between local systems and NHSE/I, underpinned by a shared view of what needs to be achieved and by when.

There is widespread support among health leaders for shifting resourcing away from the centre, and towards local partnerships who can make decisions as close as possible to the communities they serve. So, it is welcome to see that NHSE/I is also considering how it needs to change to deliver this.

In what is a considered and thoughtful piece of organisational development, NHSE/I is asking how key processes, principles and ways of interacting with systems need to develop if it is to make ‘system by default’ a reality.

Simply, what needs to change within the organisation to facilitate better communication and more productive relationships between national programmes, regional offices and systems themselves?

As part of the NHS Confederation’s work to support systems, we are bringing together a ‘network of networks’ – for example a network for system leads, for chairs and for programme directors – with the core aim of spreading learning and articulating the needs of partnerships.

From across these networks, we have already heard a range of suggestions that may start to form the basis of a different relationship between systems and NHSE/I.

Many of these suggestions relate to the experience that system leads and programme directors have had with the national programmes. This is one area where evidently there is potential for relationships and ways of working to be improved.

One reason for this is that systems want to see greater ‘process discipline’ in regards to issues like funding and reporting.

This means, for instance, that there should be simple, straightforward arrangements for allocating targeted funding from national programmes. Not the complex and unnecessary new service-level agreements or memorandums that systems currently have to grapple with.

One leader said:

“It’s like whack a mole; there are so many national programmes that someone will always want to make a name for themselves by issuing a new piece of funding. Someone needs to get messaging back to national teams for greater process discipline and for better fair share alignment.”

On reporting, meanwhile, we have heard from systems who have been asked by national programmes for data or information with very little notice. Timescales can be arbitrarily set, with little notice or negotiation.

This, in turn, puts pressure on staff working within systems and can detract from transformation work. A new ‘system by default’ approach should address this.

Another reason for wanting to improve systems’ relationships with national programmes stems from the ongoing dynamic of national versus local. While there is strong support for the delivery of the national priorities articulated in the NHS long-term plan, they will vary in how relevant they are to different systems’ demographics.

For example, prevalence of mental health conditions and the priorities for service improvement in one system may differ significantly to that of another system. Some system leaders believe this needs to be better reflected at a national level, both in terms of narrative and process.

Ultimately, systems want to have more open conversations with national programme teams prior to the implementation of new initiatives. They would like to be more closely involved in identifying what is needed and what will work, as opposed to having projects imposed on them from above.

It is time for brave changes. While NHS Confederation members have limited appetite for another Whitehall-led reorganisation of the health service, there is broad support for re-working the relationships between local and national.

Of course, ‘system by default’ must not become a licence to ignore national commitments, but it’s great to see the openness with which NHSE/I is approaching this rebalancing of power.
It should be reassuring to systems that there seems to be a genuine willingness to challenge old ways of working and reflect on what needs to change to make ‘system by default’ work for everyone

Nick Ville is director of membership and policy at the NHS Confederation.


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