The ‘year of Francis’ ends in confusion, conflict and hope

2013 was meant to be the year Robert Francis’s final report into care failures at Mid Staffordshire Foundation Trust led to profound changes in the NHS. “Francis” did indeed turn out to be hugely influential − but that influence had little to do with the interminable report’s 290 recommendations.

‘Policy has been driven by Hunt’s appetite to reconfigure the relationship between government, the public and the NHS’

The biggest impact of the Francis report was to enable Simon Stevens’ return to the NHS. Persuading Mr Stevens to take the top job at NHS England had been the ambition of many senior government players since the election. Mr Francis did not kill Sir David Nicholson’s career personally, but his report’s publication handed the axe to the Daily Mail which then effectively created the vacancy for Mr Stevens to fill.

“Francis” also had a significant effect on the power balance operating on many trust boards. Medical and nursing directors were empowered, while finance directors and their ambitious cost improvement plans were weakened. Whether that was a good or a bad thing depended on the quality and urgency of those plans; but its main impact was to shift financial problems down the road.

The final − related − outcome of Francis was a power shift between regulators. Last year’s HSJ100 ranking of the most influential people in health saw Monitor riding high, with the Care Quality Commission beginning its rebuilding.

CQC on the rise

This year’s HSJ100 reveals a CQC taking centre stage as its army of inspectors begins to roam the land; while the role − and even the independence − of Monitor is undermined by an interventionist health secretary.

The new policy we have seen this year has − as HSJ predicted in its final editorial of 2012 − been driven by Mr Hunt’s appetite to reconfigure the relationship between government, the public and the NHS along the lines found in education.

‘GP commissioners have a day job to go back to and are therefore less likely to accept unhappy compromises’

As Michael White has remarked, the Lansley vision of a commissioner-led, market-stimulated NHS with limited day to day government input now seems to belong to a different era.

But it would be wrong to suggest we are rushing back to 2002 (minus the money, of course). The confusion of the last few years has created the space for some significant new ideas to emerge through the cracks.

While commissioning was the dog that (continued) to fail to bark in 2013; it is at least beginning to growl.

Happier new year

Battles between commissioners and providers in Oxfordshire and elsewhere will continue to grow in number and influence − GP commissioners have a day job to go back to after all and are therefore less likely to accept unhappy compromises. NHS England chair Sir Malcolm Grant remains firmly on the fence over specific cases of commissioner/provider tension − but seems broadly in favour of capitated outcome contracts.

‘The mantra for many NHS leaders in 2014 appears to be, “Let’s not waste a good crisis”’

Providers too have seen their impatience about the pace of service change boil over. HSJ reports that two of the country’s biggest hospital trusts are planning to drive service integration by taking over GP practices. HSJ expects the acute sector’s cross cutting ambitions will not stop there.

There also appears to be an outbreak of healthy pragmatism; whether it be amendments to the Health Act to facilitate commissioners working together across regions; likely changes to CCG involvement in primary care commissioning or reining in the role of the competition authorities in service reconfigurations.

HSJ would hope − and expect − 2014 might bring similar sensible changes in the marginal tariff that is pouring oil on to the NHS’s smouldering emergency care problem; as well as a way for successful NHS hospital trusts to provide support to struggling counterparts without endangering their own fortune and reputation.

The mantra for many NHS leaders in 2014 appears to be, “Let’s not waste a good crisis.”