The context for this year’s Health Policy Summit was – and remains – undeniably bleak. The funding plans announced in the 2015 spending review were assumed to have some scope for flexibility later in the parliament. They were not premised on Brexit, nor were they expected to be handed over to a Government that believes the NHS can be dealt with in the same way as other public services.
Midway through the Five Year Forward View, the road ahead could not be tougher. Yet all is not lost, and it’s unhelpful to ignore those that are making progress in spite of the challenges. With a critical look at the evidence, this year’s Summit aimed to inject some positivity into proceedings by sharing ideas on what does work, what doesn’t, and how to make change happen.
I have attended all nine of the Nuffield Trust’s summits and, as time has passed, so the nature of debate and conversation at the event has evolved. This is mirrored in the discourse of policy elsewhere.
This year, the focus shifted away from big policy ideas, levers, incentives and other national-level interventions. This is a reflection of two things. First, as I have argued before, the notion that there is a policy instrument for every problem in the NHS has been thoroughly tested and found wanting. Second, with no new money available and the direction of travel very much set by the Forward View and financial constraints, the potential for policy-makers to influence change is limited.
With that conclusion in mind, the Summit highlighted some of the ways people are effecting practical, on-the-ground change. This was reflected in a number of presentations that explored how transformation was being developed through experimental small steps – borrowing from some of the techniques of quality improvement (with both the advantages and disadvantages of this). A number of these were explored in detail in a tour de force by Mary Dixon-Woods, RAND Professor at Cambridge University. We also heard about the hard work involved in developing primary care at a larger scale from Modality and in the USA.
The Summit also reminded delegates to look beyond some of our usual frames of reference. Sir Harry Burns poignantly demonstrated the case for generating health rather than just treating sickness, armed with a large body of evidence about how poverty, poor education and the environment compound serial failures of many services to address the real problems people face. This acts as further evidence that too much of what is currently done within the NHS deals with (or passes on) the immediate, superficial problem but fails to get to grips with the source of the issue. The deep cultural roots of this are not easy to fix and again may be out of the reach of traditional policy tools.
At the Trust, we have long been interested in how policy-makers – both locally and nationally – tend to latch on to solutions that appear attractive, but should be treated with caution and can even be misleading. The notion that moving care into the community will cut costs is one of these premises, and Summit delegates heard the findings from Candace Imison’s evidence review on this subject. In her presentation she showed how a number of models that are assumed to produce cost improvements by introducing new models do not have the desired effect. Some of the schemes and models to reduce demand or shift work do not appear to work well, while others demonstrate mere promise, at best. Those that do work are not easy to implement and many of them raise questions about how savings can be realised – particularly for Sustainability and Transformation Plans.
Nonetheless, the mood at the Summit was positive in spite of the tremendous pressures. The task ahead is vast, but there was a feeling from speakers and delegates that it could be dealt with, and indeed it must. The question that remains is whether there is sufficient time, expertise and spare money to get there.
Edwards N (2017) 'Leaders are signed up for change - will that be enough??'. Nuffield Trust comment, 15 March 2017. https://www.nuffieldtrust.org.uk/news-item/leaders-are-signed-up-for-change-will-that-be-enough