Simon Stevens’ first appearance in front of the Health Select Committee has produced some interesting changes in tone.
He is less inclined to see competition as a barrier to change than his predecessor, hinting at a more pragmatic approach to how it is used.
He struck a note of realism about how far we can expect the Better Care Fund to reduce emergency admissions. And he seems to have a more nuanced view about hospital reconfiguration than we have heard so far.
He also signalled in a number of areas that local resolution of issues is going to be required rather than centrally developed ‘cookie cutter’ solutions
Mental health, community services and spending beyond the NHS to improve health all got more of a mention than they might under previous management.
Perhaps the most important was his signalling about localism. In Stevens’ view the centralised commissioning of specialised services, like chemotherapy and cystic fibrosis care, represents an over extension of the concept because it took in too many other services too quickly.
This is undoubtedly true as NHS England appears to have spectacularly overspent the budget – something that Simon Stevens himself acknowledged.
He also signalled in a number of areas that local resolution of issues is going to be required rather than centrally developed ‘cookie cutter’ solutions – particularly the application of urban models to rural areas.
Of most significance was a strong message about a shift in responsibility for primary care to clinical commissioning groups (CCGs). As well as potentially increasing the engagement of GPs with the CCG, it rectifies a very important defect with the current arrangements: the fragmentation of commissioning where responsibility for primary care sits with NHS England, while responsibility for secondary care rests with GPs.
The old style of planning primary care is through big centrally developed plans. A few area teams are considering this approach and I wonder how these will fare against more organic bottom up approaches in which local GPs work out their own way to develop new services.
In general, while messier and less elegant, my bet would be on the organic local approach.
The challenge in the NHS England planning guidance was to create primary care at scale. Increased scale will allow some economies to be made in back office services but the real benefits are more likely to come from being able to develop more professional approaches to management, from developing specialisms and other efficiency improvements.
But above all it allows practices to create a platform that can be used to develop new approaches to delivering community services, mental health, social care and consultant-provided services and diagnostics.
This can also be used to bring in voluntary sector and other non-health services. This type of model is already being talked about and is beginning to emerge. It has the potential to be positively disruptive.
It will however, develop unevenly and at different speeds. It will sometimes fail or cause problems.
We will be working with the leaders in this area over the next couple of years in a research project we are undertaking led by Dr Judith Smith. The challenge for Simon is whether his sensible and pragmatic view will withstand a top down culture in which Secretaries of State give the ‘hairdryer treatment’ directly to hospital chief executives through regular phone calls.
Edwards N (2014) ‘Primary care: will Stevens drop the 'cookie cutter'?’. Nuffield Trust comment, 30 April 2014. https://www.nuffieldtrust.org.uk/news-item/primary-care-will-stevens-drop-the-cookie-cutter