Houston we need a solution: time to stop describing the problem

There is too little public discussion about the solutions to the financial challenges facing social care and the NHS, says Nigel Edwards.

Blog post

Published: 03/04/2014

My start at the Nuffield Trust coincides with the anniversary of the new system and Simon Stevens’ first week in charge of NHS England.

I’ve been spending time on international work for the last two years and have been somewhat concerned by the nature of the debate on health and social care recently.

The first reason is that there is too little public discussion about the solutions to the financial challenges facing social care and the NHS.

There is a shared view that 2015/16 is going to be tough. We also know after the Budget that 2014/15 is also looking like one of the toughest years the service has faced.

Working in other countries I have noticed a tendency that there comes a point where the scale of the problem means that it becomes difficult to think about or discuss solutions.

In truth, we will need much more imaginative models of care delivery if we’re going to meet the financial and other challenges we face

Some of the solutions that have been proposed to-date don’t seem very convincing, either in terms of the size of savings they can produce or the time required.

The repeated claims for savings in procurement are insufficient and have been repeated too many times over the last 20 years to be credible.

Reconfiguration of acute services is often proposed but the evidence for this producing large savings quickly enough is poor.

Today’s Barker Commission interim report is therefore a much-needed run through of the various options for meeting the funding challenge and is long overdue but we need creative thinking on cost reduction, as well as the funding challenge.

Some very positive stories are starting to emerge from projects to create more integrated care and people from different organisations are finding ways to work constructively together.

It is, however, becoming clear that this is rather more of a long term project than was originally thought. Nuffield Trust research also suggests that it may be difficult to get quick gains in terms of reduced admissions in the way that the Better Care Fund seems to assume. Experience from the USA seems to confirm this, there are reasons to be hopeful but it would be best to be very patient.

The latest planning guidance exhorts clinical commissioning groups to consider a range of very bold steps to change the shape of the delivery system. These include centralising elective surgery, creating scale in primary care, centralising elective services, and pushing forward other changes in care.

But none of these have received much mention, at least not at the Nuffield Trust’s recent Health Policy Summit 2014 where it seemed these ideas had not caught the attention or imagination of many in the room.

My third concern relates to the current structure. It clearly doesn’t work well, with competing parts that aren’t aligned as they should be. The absence of an obvious system leadership is beginning to matter, especially where major change is required.

In some cases local leaders are creating their own approaches but these are difficult to make work. A particular hazard here is that optimising the goals of one part of a complex system may cause significant problems for the whole.

A particularly common example is the assumption that a commissioner saving – for example from reducing admissions – can be realised as a saving for the whole system. Provider costs are very sticky and pretty fixed. This is known but not really discussed.

But it’s not all doom and gloom. For example, there is much we can do to improve efficiency by getting some of the basic processes right and using the estate more effectively.

Reducing hospital stays and bringing health and social care teams and budgets together offer the prospect of better care at lower cost. These can buy time for more significant change.

In truth, we will need much more imaginative models of care delivery if we’re going to meet the financial and other challenges we face.

What we do know from experience is that these things need political space and take time and almost always they require parallel investment. So the creation of a change fund, as outgoing NHS England chief executive Sir David Nicholson recently suggested in his swansong, makes sense and looks a good idea. It would have been useful earlier.

There is a lot of talk about transformation but without a huge crisis this does not generally happen in one large step.

There is now – after 15 years punctuated by ‘once in a life time’ reforms and change ‘visible from space’ – growing evidence that successful transformation is much more likely to be the result of a very different process.

One that is more bottom up, evolutionary, based on experiment and learning, has widespread engagement and which is consistent over a long period. Simon Stevens’ speech seems to recognise this and ready to challenge some of the current ways of thinking and to harness the energy of patients, staff and communities.

I will be working with colleagues at the Nuffield Trust to be supportive and helpful to those at the front line and in policy-making roles. My big interest has always been about finding out what the people on the ground are doing that is appearing to work and how we can bring that back to the policy-makers and make them think differently, as well as helping the people at the front line make sense of some of the things that policy-makers decide to do.

I look forward to working with you in the months and years to come.

Suggested citation

Edwards N (2014) ‘Houston we need a solution: time to stop describing the problem’. Nuffield Trust comment, 3 April 2014. https://www.nuffieldtrust.org.uk/news-item/houston-we-need-a-solution-time-to-stop-describing-the-problem