Cowper’s Cut 372: Status symbols
There is a live debate around the NHS Ten-Year Plan, which centres on Tom Kibasi’s advocacy of rewiring the English healthcare system so that it offers new and differentiated forms of access based on an individual’s health status.
On hearing this idea, a cynical person might reply, ‘congratulations, Tom: you’ve just invented good-quality primary care at scale’.
Happily, as all ‘Cut’ readers know, I am in no way whatsoever cynical.
One revolutionary element of the thinking behind this is to change and upend the English health system as it always has been: one in which hospitals are hugely dominant citadels and seats of power.
‘This time it’s different’
This ‘Kibasification’ approach is an interesting idea: one worth considering seriously. The first, most obvious question about upending the traditional acute-dominated NHS provision system in the ‘left shift’ towards provider innovation and patient prevention is ‘what will be different this time?’
To answer this, we need to think about why past efforts did not succeed.
In relatively recent policy times, the 2008 Darzi Review went long on this.
2014’s Five-Year Forward View proposed seven new models of care (acute care collaborations; urgent and emergency care networks; primary and acute care systems; multispecialty community providers; specialised care; modern maternity services; enhanced health in care homes; and Ringo).
And 2019’s NHS Long-Term Plan pledged doing things differently; preventing illness and tackling health inequalities; backing our workforce; making better use of data and digital technology; and getting the most out of taxpayers’ investment in the NHS.
Despite all these policy plans, the operating model of the NHS in 2025 would remain highly recognisable to somebody who had just arrived from 2005.
There are valid reasons why these changes did not happen. The austerity decade from 2010 to 2019 saw the lowest GPD per capita funding growth in the NHS’s history. During this time, pay restraint sowed the seeds of major industrial unrest and loss of goodwill that have subsequently been reaped. Capital-to-revenue financial transfers, pursued to mask the real state of NHS finances, caused major dilapidation and neglect of the physical estate.
There was also the matter of a global pandemic hitting an overstressed and under-resilient system, with unsurprising consequences.
Indeed the only major national policy initiative not to pursue this shift was the Lansley reforms which brought us the 2012 Health And Social Care Act. The Lansley reforms were provision-agnostic, instead putting their faith in choice, competition and clinical commissioning, whose absence of effect we saw in action.
One obvious conclusion would be to say that the provider system didn’t change because it didn’t need to. You may attribute this to a failure to successfully incentivise the change, financially and reputationally. You might argue that the provider system didn’t need to change (what’s regular ain’t stupid), but it did need adequate resourcing. And you’d certainly mention that during this period, there has been no visible and successful national driver of change, playing the role once occupied by NHS IMAS, the Modernisation Agency and other national programmes.
This recent piece for the NHS Confederation is quite a good summary of some of what would need to change.
But what we lack clarity about is the differences in the English NHS ecosystem and economy that are going to reliably support this change over a long period.
The challenges to this idea are numerous.
Policy Unicorn alert
One problem is that this quest for the Holy Grail of segmentation (or value-based care for the Porterites) is evidently hard. It may even be quixotic.
The English NHS has an absence of population health management data infrastructure, and management capacity and capability to make a need-stratified, variable-entry-point system work effectively. This is particularly true at a time when local NHS managerial structures in ICBs face a 50% cost cut (on top of last year’s 30% cost cut).
Such a system would probably also need financial incentives to drive behaviour change, getting patients to comply with its methods: it’s very hard to see this coming in a tax-funded single-payer system.
There is also the obvious point that more ‘front doors’ for access means more complexity for both providers and users. It would be hard to argue that our current access arrangements are uncomplicated: they are certainly often inadequate.
There is a significant risk that the pursuit of stratification will collapse under the weight of complexity and measurement.
Another of the most meaningful objections is about implementation. The hard, patient work of getting the ‘push’ and ‘pull’ factors right; the challenge of making the case for something new to both providers and users: these are not nothing. Do we have evidence that the current national leadership is good at them?
Everybody needs good neighbours
Then there is the question of how this will fit with the political enthusiasm for a neighbourhood health system.
Nick TriggleHealth correspondentnicktriggle
The door-to-door system being given considerable airtime recently is an interesting model, but despite its preventative potential, it seems quite full of holes.
Firstly, it will be effective in urban communities, with housing close enough together to make it practical. That is where a fair amount of health need is located, but not all.
Secondly, if it is to be an in-hours service, then it’s going to miss the working poor. These people do the jobs that cannot be done from home.
Thirdly, if it is effective, it will find a lot of un-met need and medicalise that need. Are we confident in the system’s ability to cope with that?
An un-done deal
As many readers may know, this is a live debate, and not at all a done deal.
But there is an evident demand from Health But Social Care Secretary Wes Streeting for ‘radicalism’ in the Plan.
So we risk the Politician’s Syllogism coming into play: something radical must be done; Kibasification is something radical; therefore Kibasification must be done.
There exists an appreciation of political risk: specifically, of the opposition’s opportunity to present such a change as being ‘an end to the universal NHS’. However, that presupposes an opposition smarter than the party led by Kemi Badenoch and one less utterly indifferent to public policy than the party led by Nigel Farage.
The political reality is that the English NHS currently exists between two rails: the Treasury’s utter unwillingness to countenance further-increased NHS funding on the basis of its recent delivery track record; and the Labour manifesto pledge to have restored 18 week RTT performance by 2029.
Those, and those alone, are the facts of English NHS life.
The Alan comeuppance
Andrew Bridgen vs. Matt Hancock: it’s on for a full trial.
Invest now in popcorn-manufacturers.
Recommended and required reading
Shaun’s Sunday Times piece on concerns about malpractice and possible fraud in the private cataracts market.
“What I care about is ends, not means. I want to give people the freedom to design and deliver their services and I’ll hold them to account on the ends, the outcomes.” Very dull Wes Streeting interview in The Spectator.