Can the NHS do two very important, very big, things at once?

The crucial question for the next five years.

In my concluding post before the Easter break. I’d like to reflect on some of the reactions I’ve received to my posts since Christmas.

The rhythm of explaining the 6 different Hows for each What of change, was an important discipline. Too often, many of us who want to argue for change in the NHS jump from one policy change to another without thinking through how it will happen. For example, sticking to a single issue like skill mix and burrowing much more deeply into how to help make that happen, taught me a lot about both the techniques and necessary arguments for change to happen.

It led me to say – and to believe much more strongly – in the feebleness of policy on its own. Writing what you want to change and calling it ‘policy’ has, since the publication of the Five Year Forward View in 2014, had little impact on change in the NHS.

As a practitioner involved in trying to create new models of care 2014-2018, I don’t find that paragraph easy to write. But over those years we didn’t pay sufficient attention to the how of spreading change rather than the what of a new model of care.

Some reactions, from clever and insightful people, to the arguments put forward in my posts have been similar to mine. Many of them noted and agree with me when I said that it’s really important, over the next five years, that the NHS brings down the very long waits that now seem for ever embedded in patient experience.

The current public anxiety about their NHS is based upon their very real experience about its seeming inability to deliver timely service to millions of people.

Others felt that it’s very important, over the next period of time, that we start the process of developing and implementing a new model of care for the NHS. They correctly argue that if we carry on with the present one, an aging, sickly population will present so much illness to the NHS that the model will collapse. So, they argue that it’s vital, right now, to begin to change it.

I strongly agree with both of these arguments – and that’s where I seem to part company with many others. Most people argue back to me that it will be possible to ‘steer the NHS super tanker’ in a different direction. That we could, for example, return to the competency of the early noughties and, over the next 5 years, drive waiting times down.

But that, alongside the development and implementation of a new model of care, is beyond the NHS. People often then divide between arguing for the one or the other.

This really is important because whilst most people agree that the NHS needs to do both, very few feel that it can.

And let me be brutally honest about my own history. When I was Alan Milburn’s special adviser between 2001-3, I was pretty one-eyed in my determination that the NHS could and should concentrate on what seemed at the time to be the very hard task of reducing long waits. As I’ve said many times previously, from July 2001 to the autumn of 2002 it took a huge effort to persuade the NHS that long waits were not only a problem but were one that it could solve. And if, once the NHS had taken this problem on board, anyone had said “actually, on top of reducing long waits, you need to start to change the whole model of NHS care”, I would have been somewhat sceptical of its ability to do both.

In 2002 when Gordon Brown asked Derek Wanless to review the way the National Health Service was funded, he went beyond his remit and not only commented on the method of funding but made some important recommendations about the way in which the NHS worked with the population. He developed three different expenditure models for the NHS. And the differentiation was whether the public were engaged with their health and their health service. Unsurprisingly a disengaged public would need much greater public expenditure than a fully engaged public. Nowadays I would describe what he was proposing as a ‘new model of care’.

In 2002 these ideas not only came as a surprise but we ourselves were still “fully engaged” with how the NHS might deal with the problem of long waits. It didn’t seem possible to me and others, that the NHS could concentrate on both the reduction of long waits and the development of a new model of care.

Looking back of course I was wrong. We should have begun the long march to creating a new care model then. At that time the NHS was once again growing in self-belief, and we could have trusted in that growing ability to work for patients in different ways at the same time.

If the NHS had started to believe in 2002 that it could engage much more fully with the public and patients, the new model of care we need today would be part of a much smoother transition.

What strikes me today about the ‘either-or ism’ of either improving the present model of care or creating a new one, is that this impacts on how people feel about the levers of reform. Most people would recognise that the NHS needs to improve its productivity and many of them would agree that this would involve changes in NHS payment mechanisms.

A few weeks ago, I posted about the NHS Confed publishing an outline of how ICSs could use new systems of financial flows to boost the allocative efficiency for the NHS. Allocative efficiency would improve productivity as ICSs could ensure that less expensive interventions were, for example, improving the health of the frail elderly. Allocating less expensive resources to improve patients’ health would help develop a new model of care. New financial flows would improve health care.

Similarly, I frequently post about how a consistent payment by results funding mechanism would incentivise more work to reduce long waits for elective care. This would improve the technical efficiency of the current NHS model of care.

Many people believe that within the current system there are very considerable improvements in productivity to be made by getting the current system to work harder. And they are right. The 20% additional nurses and the 19% additional doctors between 2019 and 2023 should lead to productivity improvements between 2024 and 2027. Of course they are right.  To improve patient’s experience we have to reduce what everyone calls ‘the stock’ of the waiting lists.

At the same time a different group of reformers argue that changing the model of NHS care would prevent numbers of people going onto waiting lists unnecessarily. Of course they are right. To improve patient’s experience we have to deal with what everyone calls ‘the flow’ of people onto the waiting lists.

I have had many discussions with some really good people about these two interventions and am struck by the fact that most people arguing for one do not believe that the other can be done at the same time.

My response to this is that the NHS is now a service with over £160 billion a year flowing through it.

I think the nation needs it to be able to do two things at once.

And over the next decade it will.

Have a good break!

I’ll be back in the week beginning April 15.