For the NHS, better means not “more” but “different”

13 July 2017

Moving on from the “end of austerity”, this blog will return to the NHS and exactly what needs to happen now to improve a system under great financial strain. It will draw on ideas raised at yesterday’s Reform roundtable which looked at the next phase of NHS reform (under the Chatham House Rule), following the latest plan set out by NHS England before the Election.

The first thought is that the reform direction of travel remains absolutely right. Taking the example of cancer, a joined-up service which enables early diagnosis is precisely the way to improve patient care. Survival rates for patients with stage 1 colorectal cancer are ten times better than those with the more advanced stages of the disease. The cost of care for a stage 1 patient is ten times less. Shifting the balance of NHS activity towards primary care, self care and prevention remains exactly the right thing to do.

The second is that the NHS still feels paralysed by its funding arrangements. Forward-thinking NHS leaders would love to put more resources into primary care and prevention. They feel stymied by the payment-by-results framework that directs those resources to hospitals according to their activity. Different parts of the country (including Hull) are finding ways to look beyond the PBR arrangement.  Their experience needs to be turbo-boosted and spread. It feels to me like a core role for the central authorities i.e. NHS England and Improvement. There are great ideas on this in Reform’s recent STP paper.

The third is that the future depends on decentralisation and, with it, a bonfire of NHS red tap. To the great credit of NHS England, it is seeking to do exactly that in the eight areas that are developing “accountable care systems”. It really does want those regions to be responsible for healthcare in their areas, with all that entails. It remains to be seen whether the regions have true freedom to make necessary changes, and how they will be held accountable. Reform’s forthcoming second paper on commissioning will address these issues.

Even more importantly, what will happen in the 36 areas that are not deemed to be able to work together in the new model? As it stands, those are clearly the great majority of the NHS.

Fourth, the NHS needs to make a difficult argument on workforce. In the short term, there are vacancies in the traditional model of working, particularly for GPs, which are undermining patient care. The real task, however, is to find a completely new workforce for the new era. The distinctions between primary and secondary care start to erode if, for example, areas start to organise themselves around the care needs of specific segments of the population. The NHS will see traditional job descriptions “put in the blender”, as one attendee put it. Certainly the NHS should also do much more to harness self care and informal care. Again, a Reform paper on this is forthcoming.

In general there are real examples of reform success up and down the country. My own feeling is that the Department of Health needs to do much more to tell these stories, to help the NHS and everyone else understand the direction of travel. The NHS is forever poised between two arguments: better means “more” (money, staff) and better means “different”. The authorities are trying to make the second of those, rightly in my view. They need to make it at a much, much higher volume.

Andrew Haldenby, Director, Reform

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