Local leaders unleashed? What to expect from Simon Stevens’ reign

The response to NHS England Chief Executive Simon Stevens’ first interview says as much about the challenges facing the NHS as the content of the interviews themselves.

Mr Stevens’ message – to be pragmatic, to decide what’s right locally, to be bold, and to look beyond current bricks-and-mortar configurations – quickly transmuted under the media spotlight into one of harking back to a bygone age of cottage hospitals.

The fact that this happened, and that it was such a predictable outcome, shows the scale of the task facing NHS leaders attempting to implement necessary change.

Previous attempts at a national policy level to encourage local solutions to what often feel like intractable local problems have had mixed results. Some providers have used foundation trust status to good effect, but the model and its freedoms appear increasingly underpowered.

Patients, service users and members of the public will justifiably expect that plans should explain clearly why changes will make services better

Some commissioning organisations have created plans that have transformed aspects of care, but attempts by primary care trusts and successor clinical commissioning groups to marshal convincing arguments in favour of locally led change have not gained traction.

Despite more than a decade of these policies, the postcode lottery is still a live issue, and the provider landscape remains largely unchanged in much of the country. Under a system that has historically emphasised “top down” direction, attempts to adopt new ways of doing things locally have not always been welcomed.

Where innovative approaches have been deployed, these have sometimes been thwarted as an unintended consequence of other reforms, or simply left to wither away.

So what is different this time? Mr Stevens’ message that managers should look beyond regulatory and policy-based barriers to change is a significant cultural shift. In his first interview with HSJ, Mr Stevens said commissioners and providers should not be hidebound by current regulatory or policy designs.

He advocated pragmatism on competition and the commissioner provider split, and suggested NHS leaders could consider community wide alternative solutions rather than simply focusing on hospitals.

In a subsequent speech to the NHS Confederation’s annual conference on Wednesday he went on to outline options for a radical shake-up of links between GP services, community, hospital and social care, “ending many of the historical demarcations that have existed since the creation of the NHS in 1948”, and encouraging local experimentation.

This is good news for local areas with plans for big changes that are rooted in reality, but that might have fallen foul of a more compliance-based approach. Local leaders who have come up with proposals that are robust but require open-minded and imaginative consideration by regulators and policy makers should therefore expect a fair hearing.

They will expect NHS England to support this by applying Mr Stevens’ logic, nationally in its engagement with the regulators, and closer to home through the behaviour of local and regional teams.

Mr Stevens’ strategic shift should help leaders with strong proposals negotiate a route through current regulatory and legislative processes, but despite NHS England’s new approach, local leaders’ plans will still face scrutiny from a public that can sometimes be suspicious and change-averse.

Patients, service users and members of the public will justifiably expect that plans should explain clearly why changes will make services better, and show how they will demonstrate that promised improvements have been achieved.

Part of the answer to this will be to embed effective evaluation of changes in proposals, thus generating an evidence base for changes. The NHS has relied too heavily on small, fragmented and one-off pilots, and Mr Stevens’ call in his NHS Confederation speech for a systematic approach to evaluating new models of care is to be warmly welcomed.

Local leaders will need to work harder than ever to win backing from the medical professions, local government partners, patients, service users, the media and the public, as failure to convince these groups has often been the death knell for proposals.

They must be able to articulate their vision sufficiently clearly and plausibly to a lay audience to counter the kind of inherent nervousness about change that can make harking back to a model of provision that actually pre-dates the NHS sound like a good idea. Otherwise they may find that despite the more encouraging national policy context, their own message gets lost in translation.