Time to be radical? | Niall Dickson

Niall Dickson

While the virus embers continue to burn and the service struggles to get on its feet, in England an existential debate has begun about the future of our NHS and its link to wider care services, writes NHS Confederation chief executive Niall Dickson.
It comes at a time of great opportunity but also of unprecedented challenge. It comes as social care is on its knees and when, for now at least, there is no sign of government producing short or long term solutions to that thorniest of problems.
This is an administration that does not appear to have a strong ideological backbone. That is helpful in that it is open to practical proposals and lacks an instinctive answer to every policy question.
However, it also means it is susceptible to short term pressures and to whichever way the political and media winds may be blowing.
To make the most obvious of points, it is also completely distracted by the here and now, and rightly so by the health of the economy and the nation. The arcane world of health service and social care reform may look to many like a second order issue.  

Time to step forward?

 But it does matter, and the absence of an obvious party line means there is a chance for the service to influence the debate.
For the first time since 2012 there is talk of significant legislative reform. Under the May government with its tiny majority, there was a willingness to consider tweaks to the 2012 Act provided that the NHS was united in its support. The Confederation (and all its parts) came in behind a set of proposals designed to make integrated working easier and remove some of the barriers created by the current framework. It was above all intended not to offend anyone, especially the then Opposition, though it was always a moot point whether Labour would have agreed to support it anyway.
But the world has moved on. The government has a significant majority, social care's plight is more desperate, there is tension between NHSEI and DHSC, and the pandemic has further exposed major weaknesses in how health and care services are funded and organised. Less visible though no less important, views have changed in government and within the service.
The first change is growing support for more radical reform. To be clear this is by no means universal, nor is there a unanimity of view about what changes are required, but there is now greater acceptance that we need a new set of relationships and powers if we are to create the right environment for integrated services to thrive. There remains a real fear that a top-down reorganisation (or even the retention of national contracting) will suppress local innovation and initiative and waste time and effort, and there is a healthy scepticism that structural change on its own will not be a panacea.
At the same time, at least among system leaders, there is a growing view that loose gangs of autonomous bodies choosing to proceed at whatever pace they think they are capable, is not an acceptable way forward. As part of our NHS Reset campaign, we will be publishing a report this week on the future of ‘system by default’ and it reveals the extent to which views among ICS and STP leaders have developed in recent months. It appears to be a seismic shift.
We now need to devise a structure with levers, incentives and relationships that will help us deliver a very different health and care experience for patients and users based on the ambitions in the NHS Long Term Plan and whatever equivalent will emerge in terms of social care long-term.

Time for a new purpose?

The purpose needs to be clear. There has been a welcome focus on health inequalities, and the related but distinct failure to provide services equitably. We all know a one-size-fits-all service that is free at the point of use is not sufficient because often it will not be suitable for or accessible to the most disadvantaged.
Of course, the NHS and social care need to be there for everyone – if they are services for the poor, they will be poor services and they need to support everyone not just those who are socially disadvantaged.
But the focus on population health must mean a greater focus on the important (if partial) role health and care services and organisations can play in promoting wellbeing and tackling avoidable morbidity and premature death among deprived communities.
The second difficult change within that purpose will be a much greater effort towards preventing and managing morbidity. The penny has long since dropped that the acute care we rely on when we are very ill or very injured can only be sustained if it is supported by a range of effective and efficient services which are relentlessly focused on keeping us as healthy and as independent as possible.
And if the last few months have taught us anything it is how interdependent not just our healthcare services are on one another but how the range of local players cannot function without each other.
We have a commitment for the first time in the history of the NHS to divert more of the additional investment into the community and into mental health than the acute sector. Given the current backlog of routine care, there may be a temptation to forego this – it should be resisted.

Time for health and care?

So what reforms are needed to help realise such a shared purpose? One thing is clear, this is not just about the NHS. There is still a failure to understand this at various levels within the system, including at the centre. It is not so much a purposeful rejection of need for joined up services, it is a cultural mindset that cannot escape the NHS paradigm. You see it in presentations where the authors just ‘forget’ to mention social care or local government or the community and voluntary sectors, or at best they are thrown-in after-thoughts.
In part, this is because the current accountability models support that view of the world. So whatever new structure or arrangements are put in place, they need to embrace and bring together local resources into a common endeavour. In practice, there now seems to be a lot of support for joint funding for health and social care at system level.    
But if you give a statutory underpinning to this, how would that work in practice? Some will advocate permissive legislation allowing areas where health and local government can agree a way forward to come together, others point out that those areas most in need of reform may be least likely to embrace it.
There is a lot of nervousness about the prospect of a top-down solution. Indeed, it is probably fair to say each part of the system is concerned that the bit above it will start to dictate and interfere even more than in the past. NHSEI is concerned at a departmental landgrab, ICSs are worried about NHSEI and their regional outposts imposing more performance targets and regulation, some NHS
Trusts fear loss of autonomy and Primary Care Networks can see themselves being ignored and excluded as the larger players establish the rules of the game. And there is suspicion in local government where they recall how responsibility for education was siphoned away from them.
The answer must lie in subsidiarity, with responsibility and decision-making being vested as close to the frontline as possible, starting with primary care and others on the front line being given the freedom and autonomy to innovate.
It will require carefully defined powers and responsibilities at each level which will need to include responsibilities to collaborate and deliver wider goals. 

Time to make accountability work?

 And then there is the related question of accountability. The current arrangements are at best a muddle - invisible to the public and organisation-focused, with even local authority accountability having more to do with potholes and national politics than social care.
For now, there are more questions than answers. Mostly we know where we want to go, but there is uncertainty about how to get there. It must mean bringing health and care together as never before, reconciling local and national accountability, giving local systems the powers to lead while freeing up providers of all kinds to innovate and come together in new ways – and all this without the imposition of stifling procurement and bureaucratic regulation.
There is a window of opportunity here. Over the coming weeks we will be working with our members and with local government, NHSEI, DHSC and others in government to try and shape a new health and care system. I hope you and your Boards and teams will have a chance to reflect on this and please do let us have your views.

Niall Dickson is chief executive of the NHS Confederation. Follow him on Twitter at @NHSC_Niall

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