Legacy thinking won't bridge the health policy disconnect

We are seeing a significant disconnection between policy based on legacy thinking and the future direction of health policy. 

There are three interlinked themes of this disconnection.

FT model flaws

First, the design of the provider delivery model. 

The foundation trust model is over a decade old. Like its previous NHS trust model, it has moved from exclusivity to mainstream.

The expectation is that all trusts will reach foundation status. This is a flawed assumption. Some will not be financially viable in their current form or system configuration, and some will not find the effective leadership to run an entrepreneurial public sector business.

Financial and leadership issues are emerging with an increasing number of FTs.  The “freedoms” of FT status are either largely illusionary or aspirational for the majority of FTs. 

The freedoms around access to capital, developing services and investment of surpluses, all depend, like any business, on the preparedness of buyers to buy the services offered. 

The expectation that all trusts will reach foundation status is a flawed assumption’

As clinical commissioning groups grow in maturity, they are learning to shape more effectively what they want to buy. This will significantly constrain FT freedoms.

Hospitals, as the bedrock of NHS provision, are under considerable scrutiny. 

Sir David Dalton is reviewing their effectiveness, with initial headlines pointing towards the need to spread best practice (“buddying”) and avoid hero leadership. 

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Systems transcend local needs

NHS England chief executive Simon Stevens has also questioned the “big is beautiful” mantra, giving succour to smaller district general hospitals and community hospitals. This opens up prospects for alternative delivery models that may not fit with the FT framework.

For aspiring FTs there is also the support of the NHS Trust Development Authority. Its remit is what it says on the box, and there is no doubt that many trusts benefit from development. 

However, issues of viability have as much to do with the system in which trusts operate, as they do with their operational effectiveness. Rather than the TDA, we should have the System Development Authority (SDA).

‘With a local focus, opportunities for effective primary care provision could be more fully realised’

The second theme is therefore about the local system. Systems go beyond “local health economies” to embrace social care and the factors that determine health. 

Demand on acute hospitals, and their accident and emergency services in particular, stem from the demands of patients with long term conditions, the design of their care pathways, and the disconnection among service providers. 

Add to this the inability to discharge effectively, and hospitals really are stuck between a rock and a hard place.  

Eleven systems have been identified as “failing” and targeted for intervention. Many other systems also need targeted support. Hence, the role of the re-scoped SDA. 

The better care fund has been beneficial in prompting conversations about the transfer of resources out of institutions and into the community, and these discussions have brought to the fore the role of primary care. 

With a focus on local systems, the opportunities for really effective primary care provision could be more fully realised.

Under new management

The tariff does not help. It inclines towards perverse incentives to win lose contract arrangements, rather than risk sharing. What is needed is flexibility in costs and income along the full length of the care pathway, not maximising individual parts.

Which gets us onto the third theme: “under new management”. 

The future proofing for the NHS presented by Mr Stevens at the NHS Confederation conference seemed to have been lost on many in the audience. Trust board agendas can now be shaped around his three themes: commissioning, providing and transformation.

Competition is here to stay and boards would do well to consider the observations of organisational writer Karl Weick: “The environment that the organisation worries about is put there by the organisation.”

Shaping the future

Which moves us on to what might be the shape of the future environment.

It is built around the local system in which the NHS operates. 

There are a number of features of this system. 

First, there is the role of the health and wellbeing board to set the vision and prioritise action on the determinants of health.

‘The future is built around the local system in which the NHS operates’

Second, the better care fund can enable this change - short and long term - supported by flexibility in contracting. 

Third, the system players should work towards what Michael Porter identifies as value for patients: the best outcome at the lowest cost. This implies redesigned care pathways and an integrated approach to provision.

Fourth, the role of the hospital takes on a different complexion in its local system. This will both change what it does and enhance viability long term. 

Fifth, the demarcations of labour - health and social care - will be challenged through new job design. 

Finally, the way to make this system work is to have conversations: mature ones about what is in the best interest of the patient, rather than the organisation.

John Deffenbaugh is a director of Frontline