The bold proposals to transfer responsibility for Greater Manchester’s health and social care needs to accountable bodies in the region were the talk of our annual Health Policy Summit.
This reflected two very contrasting themes that were evident at the Summit. At one end of the spectrum, there was a focus on micro-level improvements that have the potential to add up to major change. At the other end, were discussions of big structural changes needed within the NHS.
Micro-focus, major impact
One change approach discussed was the redesign of care models with a focus on higher quality, more integration and the better involvement of patients and communities. This emphasised the organic nature of the changes, the need for time for people to learn new ways of working together and the need to work through change, pathway by pathway.
This route to change is messy and slower than we might wish, but it is potentially transformational.
We heard about the long journey of Intermountain HealthCare , progress of Accountable Care Organisations (ACOs) in the US , and the work to build new models of care in the Netherlands and across the NHS.
This part of the discussion had relatively little to say about structures, incentives, regulation or commissioning – the issues that so dominate policy-makers’ thinking.
Large scale, high level change
Almost at the other end of the spectrum, there was much discussion of larger structural changes, including Labour’s proposals on commissioning and ‘Devo Manc’.
For bold structural proposals, such as ‘Devo Manc’, to work, among other things, it will require:
- A strong leadership and a governance model that will not fall apart if there are changes in local political leadership or when difficult decisions need to be made – particularly where these affect individual hospitals or local services. This will be an issue in Manchester where many think there are too many hospitals.
- The ability to move money between budget headings.
- Getting a waiver on aspects of regulation, in particular competition and procurement rules.
- Working out a modus operandi with Monitor, Trust Development Authority, Health Education England, NHS England and other national bodies.
- The freedom to change the provider landscape without external interference or challenges to the legitimacy of this process locally.
- Creating space to make changes when all of the existing national commitments and targets must still be met.
- More freedom, potentially, to depart from some nationally set requirements, such as waiting time targets.
Considerations for Manchester
Although they look very different, these two approaches share some common features. And there are reasons for both optimism and caution
Those leading change in Manchester may want to bear the following in mind – much of which is based on learning from evaluations of over 30 different community-based interventions we at the Nuffield Trust have conducted in recent years:
- Joining up services and strategy might create opportunities for significant savings, but this is still only a hypothesis. It does seem a likely one, but we may find out that integration is a necessary but not sufficient part of the mix. More important may be changes in: how care is designed and delivered, the mind sets of the professionals and how they work together. Both approaches risk a fatal disconnection between the top of organisations and the front line. The last 30 years contain plenty of examples of great agreement at board level between organisations being torpedoed by problems at the front line or middle managers defending their patch.
- Structures and governance are only part of the story. The quality of the relationships in the system and the existence of a strong shared purpose are very important and have tended to be underplayed. In particular, this means being very clear how disagreements and conflict will be dealt with and how the leadership group will respond to adverse events – for example, how will a significant overspend or performance lapse be dealt with? There is also the danger of too much governance, and we have also observed projects choked by an epidemic of meetings, PRINCE methodology and self-imposed bureaucracy.
- The time required to address these issues has tended to be significantly under-estimated. Some of the changes in mind-sets and relationships cannot be accelerated. Both the micro and macro approaches run the risk of not being able to deliver results in the timescales set by the financial position of the NHS and local government. Simon Steven’s comments at the Summit recognised this and suggested that the early years of the Five Year Forward View would be marked more by the standard type of efficiency savings than results from new models of care.
- Many attempts to make both micro- and macro-level changes have suffered from an under-investment in leadership. However great the leaders, they are of little use without competent managers with the time and skills to make things happen. This is often a deficit in many systems. As our recent Fact or Fiction blog argued, the NHS does not employ an unjustifiably huge number of full-time managers.
- Even if all goes well, it may still be difficult to release savings from new models of care. The ambition of many of the US ACOs has been bending the cost curve, not making it go negative. Strategies for reducing fixed costs will also be required – this means making some difficult and locally painful decisions. This is where it becomes difficult to keep stakeholders on board – especially the hospitals.
- Obstacles to data linkage must be overcome , otherwise contractual obstacles and other system rules will slow progress.
- Many of the attempts to develop new models have not paid enough attention to how primary care needs to change to work with the new system. The Manchester Memorandum of Understanding does not have a lot to say about this.
The importance of real-time evaluation
The emphasis on evaluation – using real time feedback – was an important part of the discussion and a critical issue we raised in our report: Evaluating integrated and community-based care: how do we know what works? Speaking at the Summit, NHS England’s Sam Jones reiterated the importance placed on this in the Forward View , so there are some important lessons here too:
- Being clear about what success is and how it will be measured. There may be too much emphasis on reducing hospital admission and not enough on population health measures.
- The links between the outcomes that are expected, the actions being taken and the design of the system need to be clearly set out.
- Linking evaluation to organisational development and systems for sharing knowledge.
- Making change on a scale large enough to be detected.
One to watch
All of this means that very careful thought and planning will be required, but also that there will need to be a parallel and huge effort to create savings and headroom to allow these new approaches the time and space to develop.
Manchester’s proposals are bold and potentially transformative, but they carry risks – especially at a time when the public finances are in a perilous state. We will be watching with interest.
Edwards N (2015) ‘Devo Manc’: Small steps, great leaps’. Nuffield Trust comment,5 March 2015. https://www.nuffieldtrust.org.uk/news-item/devo-manc-small-steps-great-leaps