Facing up to Simon Stevens' 5 year look forward

So now we have Simon Stevens' five year forward plan setting out what he says is a consensus among NHS leaders about what is needed if we are to continue with an NHS which meets a national commitment to universal healthcare, irrespective of age, health, race, social status or ability to pay; to high quality care for all. He believes his proposals are a viable way to secure a comprehensive tax-funded health care service. It is a readable document 5yfv-web.pdf and the fact that it is neither a gung-ho Lansley/Letwin proclamation of the benefits of competition nor a move towards more healthcare charges appears to have seduced guarded approval from many different quarters.

Stevens is adamant that the NHS needs to change in order to meet new demands, new expectations, higher standards and new technology and suggests that these changes need to be locally designed (within a choice of nationally approved models) and locally led. "England is too diverse for a ‘one size fits all’ care model ... Different local health communities will instead be supported by the NHS’ national leadership to choose from amongst a small number of radical new care delivery options, and then given the resources and support to implement them where that makes sense."

Stevens is reasonably frank about the money needed to finance the NHS (which secures him internal support) and he also makes a perfectly justifiable case that the NHS cannot survive if it is expected to pick up an infinite bill for lifestyle related ill health. He does not present competition as the key dynamic of change, indeed does not explicitly mention it at all, thus enabling Burnham to claim he is on their side and Hunt to mock Burnham for raising false fears.

But behind these bold strokes lie a multitude of problems.

The first question to ask is 'Is this a new version of the Tory "No top down reorganisation" pledge of 2010?' The paper rubbishes frequent changes of direction by politicians wanting to reform the NHS and Stevens insists that he is about changing the front-line, not the back-room. The problem is that this leaves the existing backroom (with its market oriented structure) in place with CCGs having an expanded role. The about to be marketed Commissioning Support Units, which have a big influence of CCGS and may go into the hands of privateers are not mentioned. Councils and elected mayors are seen more as a source of public health support than joint commissioners - Stevens is at best luke warm about Health and Wellbeing Boards - which reflects a general and long-standing hostility within the NHS to being under any sort of direct local political control. Meanwhile we hear that GP-led CCGs will be given more collective responsibility to develop primary care. There are clear and major conflicts of interest here - which have already surfaced in discussions about whether CCGs and NHS England can co-commission local GP contracts. There is little detail about how exactly changes will be brought about but either the existing structure will produce a bias towards the market, or there will be further backroom reorganisation because the current structure is 'not fit for purpose'.

Secondly it is perfectly possible that the front line reorganisations planned will actually, under the disguise of integration, create a number of new local services which CCGs may either want to put out to tender, prompted by the CSUs, if current laws and regulations stay in force, or which will be much more bite-sized enterprises for future privatisation, just as in social care.

Thirdly Stevens tries to give the impression that he recognises the need to carry staff with him especially as the new models will require major adaptation by staff, and he continually speaks the language of incentives, whether for producing better services, or for improving their own health. However if these are on the lines of the arguable unethical offer of payment to GPs to diagnose dementia, they will cause chaos. Yes he says that pay freezes cannot last indefinitely but that's not much reassurance when he talks about ensuring pay is in line with the private sector (which generally means high salaries for the top managers and low wages / zero hour contracts for the rest).

Fourthly there is quite a lot of faith in the benefits of technology - diagnostic, assistive, informational etc. We all fantasise that this might be so, but efficacy and patient benefit are not yet adequately evidenced on a broader scale.

Fifthly we don't yet know what integrated care will actually mean in practice - though there will be a chance to understand it in Sheffield as local proposals for the largest Better Care Fund in England take shape over the next few months. Again the benefits to patients need to be clearly evidenced, and not just be aspirational.

Fifthly the politicians have already run away from the financial analysis. OK it's early days but they don't want this commitment even based on Stevens' optimistic predictions of efficiency gains. Already the NHS is saying that most of the easy efficiency gains have been made. Future efficiency gains will mean job losses and quite possibly more low cost outsourcing. Stevens observes about work-place health that mental health problems have overtaken MSK as sick leave issues. Well, quite. In the NHS, as elsewhere, we all know that this is partly related to squeezing the staff harder as part of efficiency measures. Nothing is said about dismantling the expensive structures for administering a market in healthcare. Nor, as Clive Peedell has pointed out for the NHAP, has Stevens said anything about how the cost of the new investments he proposes will actually be met.

Stevens' financial predictions are also based on more effective prevention services. Well these may or may not happen / be effective, but they certainly won't under this government which has caved in to commercial pressures from the alcohol, tobacco and fast food industries, undermined public provision of all sorts and, through its attacks on benefits, women and disabled people has increased the ill health of the very people whom the NHS identifies as having the most needs.

There's a lot to analyse and debate in Stevens' proposals - and there are plenty of interesting and positive ideas to work with. It is not however any sort of yellow brick road for NHS survival. Indeed a senior lawyer at Price Waterhouse Cooper has commented to HSJ: “There will be a number of challenges including leadership, culture, how money flows in the system, and allowing time for improvement. But the most difficult challenge will be political. The radical agenda will require political leaders to pick up the gauntlet thrown down by NHS leaders. Politicians will need to embrace the reform challenges as well as the resource challenges. Change of this scale will not be pain free. Each political party ahead of the next election will need to set out how it plans to champion changes to local health services including hospitals.”

So pressure needs to be kept on the parties - particularly Labour - to set out how in more detail what their proposals may be: both for finance and for structure. Here are a few possible key points.

The NHS needs a minimum 4% annual real terms increase, and all parties should recognise that NHS funding can't be seen in isolation from what is happening to public services in general.

Even given the need to keep reorganisation to a minimum, the competition regulations must be removed, the market-oriented structure replaced and injurious PFI contracts renegotiated or abolished.

National and local decision making must be democratically accountable and transparent.
NHS staff must be valued with reward not just words and positively enabled to increase their ability to adapt to changing needs.

Rushes into outsourcing must be prevented especially in the likely to be vulnerable community services.

The assumptions of austerity budgeting and a low tax economy need to be challenged