This Friday marks the first year anniversary of NHS England’s Five Year Forward View. Its launch came during the pre-election period in which the future of the NHS was at the top of the public’s priority list. Simon Stevens and his colleagues expertly won over most of the service’s leaders, and the Government, to a consensus about the way forward. But one year on and the outlook looks increasingly bleak.
With winter approaching, the NHS is facing a financial black hole with NHS hospitals heading for an unprecedented end-of-year deficit of £2 billion – raising the spectre of a likely emergency bailout from the Treasury. On the back of the first quarter's financial figures, financial regulator Monitor felt compelled to label this as the “worst” financial position facing providers for a generation.
Combined with rising waiting times, low staff morale, a damaging ongoing spat between the government and medical profession over seven-day services and a recent high profile report from the quality regulator, the CQC, raising concern about safety in hospitals, it is clear that the NHS in England is at a critical juncture. The service will find it near impossible to balance the books while maintaining standards of care.
So what can leaders do to fix this?
Faced with this situation, the policy ’levers’ beloved of generations of civil servants and politicians look increasingly ineffectual. The traditional model of securing change or improvement in the NHS, whether using market incentives or the blunter tools of command and control, has been about putting pressure to change onto the tier of management or providers below.
The results are monitored through more or less well-designed targets, standards and reporting. And if it doesn’t work, the answer is more pressure – to the point of firing or forcing out those who are not delivering. The evidence for the failure of this approach lies in the number of experienced leaders leaving hospitals, and the problems the NHS routinely has in replacing them.
This limited model requires the people at the top to know exactly what is supposed to be delivered. Yet the Forward View makes quite clear that the process of remodelling the NHS into a better integrated set of services will need local leaders to work out bespoke solutions and experiment with them. That means we need managers and clinicians to pull forward in directions only they can identify, rather than being pushed by Whitehall. Resorting to exhortation and tough words may make political leaders feel better, but it won’t turn the NHS into the self-improving organisation we all want it to be.
The traditional model also assumes that the underlying problem is one of people not trying hard enough, or not having their priorities right. But it is clear that the NHS faces hard limits in time and resources: problems that are systemic, not down to individuals. There simply may not be enough nurses to meet staffing guidance within the current budget (our workforce planning strategy is a separate matter of significant concern that requires fixing). We may need to fundamentally reconsider the trend of rising expectations about what the NHS can deliver.
There is no credible plan to deal with these problems and get back to a sustainable financial position. The leisurely approach to the issue being adopted throughout the NHS is deeply concerning.
So, what can an organisation like the Nuffield Trust do to help at a time like this? Today we publish our strategy for how we will play our part. We will be more grounded in the practical implications of policy-making, working closely with NHS staff and policy-makers to identify solutions to the challenges facing the NHS. We want to work with, and support, those leading change during this critical period. The future of the NHS depends on what local leaders can achieve in the face of immense challenges: we need to think about how we can support them.
There are five areas where I think we can add real value: quality of care; new models of health care delivery; workforce; older people and complex care; and providing independent scrutiny of government policies and the performance of the system. Our work in each area is outlined in more detail in our new strategy. In each area we will:
Improve the evidence base that leads to better care for people in the UK through our research and analysis
Use the position afforded by our independence to provide expert commentary, analysis and scrutiny of policy and practice
Bring policy-makers and NHS staff together to raise issues and identify solutions – we now run learning networks and have assembled a panel of 100 clinicians, managers and other staff that we regularly survey to ensure their views inform the work of policy-makers.
These are pressing times for everybody who works in and around health and social care, and the service is clearly at a crossroads. We want to contribute to these debates and discussions, not just stand on the side-lines. My overriding priority for the next five years is to make that contribution happen, by supporting the staff, the policymakers and the ideas which will make the real difference.
Edwards N (2015) ‘The NHS: no more levers left to pull?’. Nuffield Trust comment, 21 October 2015. https://www.nuffieldtrust.org.uk/news-item/the-nhs-no-more-levers-left-to-pull