Can the NHS still deliver major service change?

“We cannot run a health service just bottom-up, it is an absurdity. Getting clinical involvement is essential, but the idea that [all] 6,000 London GPs will agree is nonsense; and the idea that [all] consultants would agree is even further nonsense.” So declares a senior clinician in the detailed analysis of Healthcare for London, the most ambitous, wide-ranging and controversial reconfiguration initiative of recent times.

‘The Healthcare for London review was produced by an organisation that no longer needs to soft soap its message’

The review of Lord Darzi’s 2007 brainchild was released by NHS London after its demise on 31 March. No longer having a website to publish the study, the leadership of the abolished body asked HSJ to step into the breach. You can read our analysis of the document and study the entire 160-page document on hsj.co.uk.

The review is the strategic health authority’s own take on where Healthcare for London succeeded and failed, so it needs to be read with the appropriate pinch of salt. But the programme is generally viewed to have got some very difficult things right, as well as making some high-profile mistakes. It is therefore likely to influence future system leaders.

Refreshing directness

One of the strengths of the Healthcare for London review is that it was produced by an organisation that no longer needs to soft soap its message: it even suggests the use of management consultants for their modelling and other skills was “an important factor in success”.

The review also stresses the importance of clinical and public consultation and the appropriateness of letting local agencies take the lead where relevant. With refreshing directness it confesses to how badly NHS London failed to engage GPs over the polyclinics proposals.

‘The study records distress over the loss of staff in “the middle tier” who could help “make the system work”’

However, the most striking message is the one reflected in the opening quote of this article. That much significant and sustainable change requires the ability to act at pace across health economies, to provide an “end-to-end story [which looks] at the whole system” and to commit resources specifically to that task. This is striking because the report suggests the NHS’s capacity to do this has been undermined by the reforms. As one “senior NHS executive” says: “You can’t expect people to make a major change happen on top of their day job. It needs focused resource and dedicated leadership”.

The study records distress over the loss of staff in “the middle tier” who could help “make the system work”, raising questions over whether clinical commissioning groups have the leadership capacity to deliver alone.

NHS England’s ambition

The review states bluntly: “The challenge for the new system is whether there is the vision, appetite and determination to align multiple organisation leadership behind a common purpose.”

Its conclusion calls for the “potential of the reforms to fragment” the NHS to be mitigated by a partnership of agencies ranging from the London mayor to academic health science centres. It is a laudable goal, but one in which few will place much faith. As outgoing NHS London boss Dame Ruth Carnall told HSJ last month: “Networks are weak organisations, [they are] great when everybody agrees. It’s difficult when they don’t because no one is in charge.”

The recognition of the need for system leadership appears to burn bright in the approach being adopted by NHS England. This week its director of strategy Bill McCarthy declared the organisation would be “more ambitious and radical in the way we look at service change” and will seek to place a “frame” around local plans to ensure consistent outcomes.

Quite how CCGs will react to being “framed” will depend on how successful NHS England is in delivering what the Healthcare for London report calls a “careful, nuanced and, possibly, varying balance between central direction and local engagement and decision-making.”