National policies, local outcomes
Reform roundtable on how local NHS organisations are responding to national initiatives and tighter budgets held on 27 June. Introduced by Alastair McLellan, Editor, Health Service Journal
The passage of the Health and Social Care Bill has brought the NHS to the national headlines. However beneath the surface the key issue facing the NHS is the need to achieve £20 billion of savings by 2015. Whether it will be possible to redesign local services to meet the “Nicholson Challenge” by the next election will be one of key public policy issues of this Parliament. To explore these issues Reform convened a roundtable seminar led by Alastair McLellan, Editor of the Health Service Journal, who presented the findings from HSJ Local, which tracks local changes in the NHS. These were the headline points:
Despite Health Ministers’ resistance to suggestions of hospital closures, hospital reconfiguration is the only game in town. There is now a wide recognition that reforming the structure of clinical services can reduce costs and improve quality. Successful initiatives, such as the reconfiguration of stroke services in London, have helped to change the terms of the debate. Engaging the patient voice and focusing on what model of care is needed for new healthcare needs would also strengthen the case for change. However, while there is an in principle agreement among policy makers and NHS leaders, there are still local difficulties in agreeing to significant changes to services. Tensions between providers and commissioners continue, while local clinicians have resisted moving care into different settings in some areas. In rural areas there is also uncertainty whether the specialisation and centralisation of clinical services that worked in London are appropriate.
The newest Foundation Trusts (FTs) and those providers that have still to be authorised as FTs are facing the greatest pressure. Non Foundation Trusts also face the challenge of having to engage with commissioners plans for service redesign and also meet Monitor’s requirements for authorisation. In this environment mergers are high on the agenda, often with smaller Trusts preferring to merge with equals rather than be absorbed by a larger organisation. To overcome local resistance over hospital closures mergers could allow a more discreet consolidation of services. However, there is some doubt that the mergers currently proposed will allow the reconfiguration of services needed to deliver significant savings. Other options would be to “re-profile” existing hospitals, i.e. keeping the NHS sign over the door but changing what services are actually offered.
There has been debate on whether the provisions in the Health and Social Care Act will help or hinder the transformation of clinical services. While some Clinical Commissioning Groups are proving very innovative in planning the redesign of local services, many still lack the capacity to take these decisions. The Health and Wellbeing Boards and Personal Health Budgets are still only having a slight impact, while the Any Qualified Provider framework is only slowly evolving, with more traditional procurement remaining the key vehicle to bring new providers into the system. Some providers are also anxious that they will fall foul of the new regulatory regime led by Monitor and many in the NHS await further strucutral changes following the Francis Inquiry. There is a sense that while the reforms could create a better health system, there is danger that advances in clinical commissioning and designing a more transparent and rules based failure regime would be undone by the pressure of the Nicholson Challenge.
The overriding concern was that many of the necessary reorganisations of local services were taking place too slowly. Some aim to implement these changes in the “golden period” in the middle of the Parliament, yet too will wait for approval until 2014 – very close to the general election. While local leaders are being attentive and cautious in making Plan A work, there remains no Plan B. If the new commissioning structures and failure regime cannot see through the transformation of clinical care in time there are three options: Services will be cut, the NHS will be bailed out or a top down solution to save money will have to be found.