The NHS Modernisation Bill: a view from the NHS

A growing disconnect in NHS policy

Macro health policy and NHS policy directives are increasingly detached from the priorities and actions of people within the NHS, and the key pressures they face. The combination of volatility, poor communication and absence of robust planning is producing a delivery dichotomy. This has been building with the absence of road maps, definition, and detailed action plan directives, creating a credibility problem. This situation is dangerous as people and organisations respond with inaction as they know/ assume/ hope that policy will change, and there are few sanctions for failing to progress or meet deadlines.

It doesn’t help when the King’s Speech focuses on a few health issues that are generally marginal rather than of central concern within the NHS. It is good to see commitment to rejuvenated mental health legislation, given that the last Act was in 1983, but, here again, how often has that been heralded and not delivered?

A single care record is arguably the pivotal NHS piece for improving patient care. It would be the manifestation of an integrated system of care and entirely in line with a refreshed one team NHS. But, where is the robust plan for how we move from where we are now to where we need to be? The current ways of working are a fragmented mess, and there is little evidence of the big nettles being grasped around single NHS suppliers, mandated interoperability, or poor staff data/digital competency.

The abolition of local Healthwatch bodies will sadly pass with little attention, as they failed to thrive and were left with poor funding, no real mandate and a reliance upon the commitment of volunteers. The public is rightly confused about who to complain to and who to consult given poor awareness of the CQC, Health and Wellbeing Boards and Healthwatch.

Healthwatch functions will be absorbed by ICBs struggling through reorganisation that is proving to be far more distracting and unsettling than predicted, while at the same time now facing increased responsibility around vaccines, screening and specialised services. The position in many ICBs is chaotic; experienced individuals are leaving, key roles are disappearing and new ways of working are unclear. Last week’s speech also suggests further ICB boundary changes may come, which is both predictable and concerning.

The space between policy and delivery on the ground

The overwhelming sense is one of fatalism; an acceptance that we live in volatile and disconnected times where the operational NHS gets its head down and looks after patients the best way it can, whilst trying not to take too much notice of what is being postulated as policy.

The fundamental policy dichotomy isn’t helped by the absence of definition. We need consistent, clear communication on the raft of new concepts. The new NHS is to be built on strategic commissioning, Neighbourhoods, frailty, advanced FTs and a raft of new acronyms – IHOs, SNPs and MNPs. These all remain conceptual, varied in local interpretation and susceptible to the fatalistic inaction so frequently described in NHS meetings as “let’s see if that ever happens”.

I work in an area of England that is one of the most advanced in its development of the new systems, but last week saw us confronted by the absence of clarity. How do we advance our part of the proposed Integrated Healthcare Organisation by setting up Single Neighbourhood Providers and a Multi Neighbourhood Provider when there is no detail on any aspect? In fact, we have no current assurance that the concepts will actually become tangible. We are at the stage where legal status, governance structures and operational consequences need to be worked through, but how do we do that? Too many others are saying “why bother” until the definition is confirmed.

In the meantime, the known unknowns remain. Most of the neologisms in the last paragraph are dependent upon overdue consultation on a new GP Contract. More immediate concern is with increasing operational pressure, most notably in mental health, and uncertainty around practical issues that exist now. For example, the continued odd position around the ARRS workforce, where 26,000 people are involved via PCNs in a complex mix of local arrangements largely separate from mainstream NHS employment.

Uncertainty is prevalent regardless of the sector. We are seven weeks into the NHS business year, but the internal financial transaction systems for hospitals are unclear, as are the activity recording systems. We do not have the mandated consistency of the original Payment by Results system, but instead, a variety of local approaches to tariffs, block payments and financial incentives.

It is dangerous to shrug and wait for clarity whether that is on the single national formulary, GP contract, the future of PbR or anything else. Things may not be visible, but they may still be happening, at least somewhere, and clarity can come suddenly and in odd ways.

This week, we saw impactful policy disseminated once more in line with the recent pattern. Specialised services are the highest cost activities that support the most ill patients and they provide the most significant funding of our most prominent hospitals. We have had five years of poorly communicated policy oscillations that have led to consistent misinterpretation within the NHS and those companies working with specialist drugs and devices. The first cohort of lead ICBs for each NHS Region that will host the new OPICs (Office of Pan ICB Commissioning) has been announced via a media report. For many companies, these will be the determinant of their business, but this has been announced through a media leak that many in the NHS and industry will miss.

What does this mean for partners looking to engage with the NHS?

The fundamental phenomenon that companies need to recognise is the dichotomy of definition. Companies should not assume that what they read or hear is the reality or the true local position in a key geography. That is the case at the point of clinical and operational delivery, but also at ICB level. There is high variation in local interpretation, progress and ways of working. This is a time that demands authentic insight, war-gamed scenario planning and flexible plans that can be adjusted for policy emergence and variation of implementation.

As ever, there is a need to understand the NHS from the inside out so organisations need to be close to those trying to achieve progress in putting policy into practice. That isn’t easy of course, but a necessary first step is to examine paradigms and objectively test their current suitability. The temptation otherwise is to default to some kind of market access standard recipe, and I frequently see the consequences of that in the field with well-meant but anachronistic value propositions.

Too many companies appear to have taken an understandable but unwise approach to the continued volatility and uncertainty. They have carried on as before and will wait for clarity to emerge. I would suggest there is far more to be gained by mirroring the more progressive elements of the NHS and working with them to design the new ways of working, as many of these will be developed locally and “bottom up” through practical interpretation of broad national policy. The key is getting close to those who will make positive things happen. They are out there.