After Brexit, three National Health Services?

3 April 2017

Last week was an exceptional one, with the Government giving two full days to Brexit (first Article 50, second the great repeal bill). Under the cover of Brexit, however, major events took place in various aspects of the domestic policy agenda.

Three National Health Services

On Friday, Simon Stevens made the most important announcement on the NHS of this Parliament. The “Next Steps” update on the Five Year Forward View explained how his thinking had developed over the last two-and-a-half years, and what the Service would now do for the rest of this Parliament.

There are 80 pages in which every paragraph matters, and inevitably it will take time to digest (and also to read between the lines).  Some initial reactions would be:

  • On the one hand, “Next Steps” sees the NHS as one national service. It makes national commitments to improve mental health, cancer care and so on. It is presented as a national delivery plan, quite unlike the original Forward View which had four thematic chapters (why change?, empowered patients and citizens, new models of care, themes of implementation).
  • On the other, the NHS is to localise, at least to some extent. The Manchester NHS remains under local democratic control. Eight other areas will form powerful local organisations (accountable care organisations, ACOs), without the purchaser-provider split. The remaining 35 local areas will also work more closely together, under the Sustainability and Transformation Plan umbrella.  So there is a big tension between the national and the local, and generally the national will win out when there is such uncertainty.
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  • The idea of commissioning takes a real whacking, dropped as it is from the accountable care organisation areas. The question remains, however, how will the ACOs be accountable? Without clear accountability of the right kind, these local areas will either do very little to change or will actually put change into reverse (by putting resources in the big hospital providers). “Next Steps” does still believe in competition to some extent, since it supports patient choice of provider and the use of personal budgets.
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    What do Ministers want? There are now three kinds of NHS: Manchester (answerable to Mancunians), ACOs (answerable to ?), the rest of the Service (as you were). Is the Government’s policy, ‘anything goes’? In which case, are they going to evaluate performance in the different zones? Or does it see an evolution at work, in which Manchester represents the pinnacle to which the rest of the Service should aspire?

    Digital transformation, criminal justice and the role of the National Audit Office and the Public Accounts Committee

    On Thursday, the National Audit Office warned that the Government Digital Service had yet to find its ideal role. Having been established as a disrupter of existing ways of government working, it was now struggling to establish itself in a Whitehall in which the government departments are becoming more and more capable.

    There was perhaps a hint of this at Reform’s criminal justice conference, also on Thursday. I found the progress towards digital transformation described at the conference genuinely inspiring. Hundreds of thousands of cases per year are being settled online rather than in the courts (such as speeding fines). Katy Bourne, the Sussex Police and Crime Commissioner, is organising four police forces to put video communication in their stations, to allow officers to give evidence much, much more efficiently. No doubt there is much more to do, but the progress and commitment is real.

    I wonder then if the NAO and indeed the Public Accounts Committee need a slightly broader role? At present they have to report to Parliament as to the progress of Government initiatives in their own terms. Should they complement that by writing about the kind of changes to which Government should aspire? In other words, should they write about the potential of digital transformation per se, rather than the success of GDS?

    Equally the PAC issued another report last week saying that the Department for Education was not well prepared to make the forthcoming cuts in school pupil funding. That may be true, but the real question is whether value for money can be found in schools’ budgets. That research would be just as valuable for Parliament, if not more so.

    Andrew Haldenby, Director, Reform

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