Simon Stevens interview - Making sense of the NHS reforms?
Simon Stevens is President, Global Health, at UnitedHealth Group and a trustee of the Kings Fund. He’s best-known in the NHS for his seven year stint at 10 Downing Street and the Department of Health, where he co-authored The NHS Plan and much of the subsequent reform agenda.
More recently he’s been particularly involved in the debate about strengthening the NHS commissioning function.
He discussed the current NHS reforms with Health Policy Insight editor Andy Cowper.
Health Policy Insight: What do you make of the current debate on the Coalition Government’s Health Bill?
Simon Stevens: I’d say it’s silly to downplay the fact that on just about any measure, the NHS has in recent times probably been performing better than at any time in its history. That’s a tribute to a decade’s worth of funding and modernisation effort on the part of many, many people.
But second, that doesn’t mean the NHS will be able to continue to perform at that level if it simply carries on as it is. Aging, chronic disease, and the continuing decline in paternalism mean that’s not true over the medium term.
’History suggests that four years of funding squeeze means the NHS is pretty much guaranteed a ‘hard landing’ - unless something dramatic changes.‘
And the enormous budget crunch the NHS now faces means it’s certainly not true in the short term. History suggests that four years of funding squeeze means the NHS is pretty much guaranteed a ‘hard landing’ - unless something dramatic changes.
So the only relevant test is: which parts of the new reforms are genuinely likely to help ‘future proof’ the NHS? On that, the devil is in the detail - and the trade-offs and judgment-calls are all shades of grey.
Unfortunately in the current hyper-partisan atmosphere, the means and the ends have become hopelessly politicised and confused.
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HPI: So is there a defensible rationale for any of the proposed health reforms?
SS: Well let’s take them in parts.
The rationale for moving all NHS hospitals to foundation trust status is the same as it was when the last government said it should happen by 2008. It was right then, so 2014 isn’t exactly rushing it. But obviously doing so is going to require some tough decisions that it’d be better to face up to honestly, transparently and soon.
’The need to continue transitioning to incentive-driven rather than target-driven health care improvement will be as obvious from the upcoming Mid Staffs Inquiry as was the need for national quality standards arising from the Bristol Children’s Heart Inquiry ‘
More generally, the need to continue transitioning to incentive-driven rather than target-driven health care improvement will be as obvious from the upcoming Mid Staffs Inquiry as was the need for national quality standards arising from the Bristol Children’s Heart Inquiry.
That said, just about everybody seems to want more clarity about how the new competition regime is supposed to work. This so-called legislative ‘pause’ needs to deliver that, while distinguishing legitimate practical concerns from simple ideological opposition.
As for commissioning, as I remember it, both the BMA and the Kings Fund came out in favour of a national NHS board some years ago. They argued it would put some needed daylight between day-to-day politics and the strategic planning and commissioning of NHS care. That’s still true.
’The rationale for engaging GPs in commissioning is over two decades old, and has been supported by both Conservatives and Labour.‘
And of course the rationale for engaging GPs in commissioning is over two decades old, and has been supported by both Conservatives and Labour. (Lib Dems have tended to prefer local politicians in the driving seat).
In practice GP commissioners are likely to be most impactful in reshaping health services at the community-hospital interface, which should better respond to the needs of patients with chronic conditions. John Reid, Patricia Hewitt and Ara Darzi all produced blueprints for this, but nothing much happened.
If it’s true that “one GP with a budget is worth ten on a committee”, the hope is that new GP consortia will be able to accelerate that.
HPI: Can GP commissioning consortia get GPs to behave more collegially? What will it take to improve the quality of primary care provision?
SS: Peer group effects can have a powerful impact on professional performance. Historically, those have been stronger in hospital medicine than in general practice. The NHS Atlas of Variation, and concerns about the limited impact of the current QOF, show that needs to change.
If consortia don’t get serious about this agenda, presumably some combination of greater performance transparency, easier patent choice, and action by the CQC or NCB will be needed.
But it’ll be interesting to see whether the NCB gets more interventionist about quality or not. PCTs struggled with that given the inherent conflict between spending Monday to Wednesday trying to enthuse GPs about World-Class Commissioning and then on Thursday and Friday trying to police primary care provision. Doing both at once is an incredibly culturally and managerially sophisticated task.
HPI: So is it realistic to expect GP commissioning consortia everywhere to lead needed change across the NHS?
SS: Your question neatly underlines one of the ways these reforms have been mis-communicated. That’s because the national commissioning board (and no doubt some sort of regional tier) means GPs aren’t being expected to do all the heavy lifting.
As I understand it, David Nicholson says he’ll be making pragmatic judgments about the speed and extent of budget delegation to individual GP consortia. So in practice there’s going to be a more staged transition than the initial ‘big bang’ rhetoric implied.
For that more phased approach to work, however, it’ll be important to eliminate the conflict facing PCT managers over the past four or five years: “help your GPs take on commissioning so that you can then be fired”.
In addition, the largest single contribution to the £20 billion efficiency gap is expected to come from hospital tariff reductions (i.e. cutting the reimbursement per treatment), as against the difficult work of targeted prevention, patient engagement, tackling clinical variation, and fundamentally redesigning the mix of services.
So these hospital tariff savings will – or won’t - happen largely independently of GP commissioners.
That means much of the financial risk from the NHS budget crunch will be parked direct with hospitals. If hospitals succeed in making these productivity gains, their staff will experience some combination of a jobs and/or pay squeeze.
If hospitals fail to make these productivity improvements, they’ll end up with large deficits and their patients will experience longer waits and worse quality care. (Nor, by the way, should the reality of those pressures be a point of party-political dispute, given that Labour went into the last election campaigning to spend less on the NHS than the Conservatives.)
HPI: The reform legislation is currently ‘paused’ to allow more public consultation. How would you like to see the current proposals on GP commissioning evolve?
’If the aim is genuinely to see clinically-led commissioning, the international experience suggests that’s best achieved through coalitions-of-the-willing, not conscription.‘
SS: If the aim is to go for a one-size-fits-all GP commissioning model, arguably that could have been achieved just by changing PCTs’ governance and beefing up their PECs.
But if the aim is genuinely to see clinically-led commissioning, the international experience suggests that’s best achieved through coalitions-of-the-willing, not conscription. In which case, it would be worth also testing at least some models in which more than one group of voluntary consortia are allowed to form and operate within a geographical area.
And if GP consortia are going to succeed, then they ought to be able to decide on the infrastructure they need to do it. It seems odd to say that consortia can decide how to spend £60 billion, but not how many epidemiologists or support staff they can employ to help them do so.
’Given the slow pace of NHS commissioning development over the past twenty years, it’s understandable why policy makers want to give it a shove.‘
I also like idea of testing new integrated models on the provider side of primary and community care, including what in some countries are called multispecialty clinical groups. These bring together GPs, consultants in some key medical specialties, nurse practitoners and therapists who are able to decide where the make / buy boundary lies as between what they do themselves versus what they refer to hospitals.
And there are lots of other ideas out there too.
’Rather than looking – again - for a structural answer that will work the same way everywhere right across the country, maybe it’s time for more emergent models, more experimentation, and more diversity.’
The bottom line? Given the slow pace of NHS commissioning development over the past twenty years, it’s understandable why policy makers want to give it a shove.
But rather than looking – again - for a structural answer that will work the same way everywhere right across the country, maybe it’s time for more emergent models, more experimentation, and more diversity.