Editorial Friday 23 September 2016: The Two-Year Forward View - STPs, the exam question and playing 'Chicken'

HPI readers with elephantine memories will remember that there was a time before NHS England's boss was Sun King Simon Stevens.

It seems improbable, but it's true. In the BS Era (Before Stevens), the NHS Commissioning Board's previous Comrade-In-Chief Sir David Nicholson asked the sector to deliver their three-year plans. It was called 'A Call To Action'.

The 'Call To Action' was intended to lead to CCGs developing "three-to-five year commissioning plans, setting out commitments to patients about how services will be improved. This information will also be used by NHS England to shape its direct commissioning responsibilities in primary care and specialised commissioning.

"Information gathered in this way will drive real future decision-making. This will be evident in the business plans submitted for both 2014/15 and 2015/16. These plans will signal service transformation intentions at both local and national level".

The Call To Action had as its aim getting the NHS' own views on how it could achieve the projected £30 billion post-global financial crisis funding gap 2015-20.

You'll remember the publication of those Call To Action commissioning and change plans?

Ah, you don't?

Not surprising. The plans went back and forwards a few times, before being quietly euthanised.

The problem was that even after added optimism, the plans submitted couldn't answer the exam question of how the system could change to save £30 billion.

So we had to change the exam question. Hence the Five-Year Forward View.

Now we have a Two-Year Forward View: the planning guidance for 17-18 and 18-19. Christmas has come early, twice.

The new exam questions
This guidance is very clear that Stabilisiation and Transformation Plan footprints, or health economies, are the new unit of action, and that two-year contracting (with variability by agreement) is the new normal.

Without any legislative basis, "each STP becomes the route map for how the local NHS and its partners make a reality of the Five-Year Forward View, within the Spending Review envelope. It provides the basis for operational planning and contracting".

Mmmm. If not mmmmmmm.

When I assessed the Five-Year Forward View, amid a broadly positive take I suggested that "it’s reassuring to read that 'there is also value in a forum where they key NHS oversight bodies can come together regionally and nationally to share intelligence, agree action and monitor overall assurance on quality'.

"Perhaps this could be some form of regional authorities of health, overseen by an NHS executive?

"The FYFV is opaque about the operational details of how we will do the twin track of winning hearts and minds to deliver this change, and of the strategic means of making the changes happen".

Boom: STP footprints are the "operational details of how" - the answer to my questions.

STP footprints are the new regional health authorities. (They're not the new SHAs at all: they have system-wide budgetary duties in exactly the way that SHAs didn't.)

Albeit RHAs had the staff to do their jobs, much in the same way that STP footprints don't.


My take on the FYFV opened with Proverbs 29:18 ‘where there is no vision, the people perish: but he that keepeth the law, happy is he’. This Two-Year Forward View is unambiguous that if people are unco-operative, happiness will elude them.

The TYFV is also very smart in its presentation of NHS England and NHS Improvement as utterly united. This is the Simon-And-Jim Show. Eliminating any potential for squeeze-averse commissioners or providers to hope to play NHSE off against NHSI is not just smart system polities: it encapsulates what the TYFV is asking the system to do.

Mainly, though, the TYFV tells the system what the new exam question is.

Yes, of course, the NHS has to carry on doing everything -the mandate, Old Uncle Tom Cobbley And All (and of course nine 'must-dos' ... none of which is  seven-day services) - but the real exam question is financial balance in 16-17.

That is the gig, ladies and gentlemen. Break even, or get broken.

Welcome back, grip. Have we missed you, command and control.

The politics come in here.

Everybody knows that 17-18 finances are unlikely, but 18-19 and 19-20 are pure comedy. So there is going to need to be a Stevens Ask.

And the Ask will be made of a government led by people who: don't know Simon; didn't appoint him; are keen on rupture with the Cameron crowd; and might be listening to a Treasury which has some decidedly odd ideas about the NHS being over-staffed with full-time staff.

This puts financial balance in 16-17 in the spotlight, down-stage centre.

No pressure, then.

Now you might be thinking 'grip, command and control' does't sound very Simon-And-Jim.

(Although you probably haven't worked in NHS England if you do think that ...)

The point is this: funding decisions are made by the government of the day. It's quite sweet watching the politically naive saying 'but Simon didn't ask for enough' but it's wildly impertinent, in the literal and metaphorical senses of the word.

Simon Stevens may be good, but he doesn't have statutory tax-raising powers. Yet.

Playing 'Chicken'
I don't know whether HPI readers were seriously self-destructive when young, but if you were, you might have come across a bracing game called 'Chicken'. You get into your cheap, shit car in a field, and drive straight towards another self-destructive young person in their cheap, shit car, who is driving towards you.

The 'Chicken' - the loser - is the person who swerves out of the way first.

Simon Stevens is having to play political 'Chicken' with the government. He's sent out the word that he's not panicked by deficits or ordinary poor performance (although Jim has to rattle some cages).

He's saying to providers 'there's no more money - sort it out. But don't think you'll get away with the old trick of getting sacked and then appointed somewhere else. This time, we expect providers to at least be co-operative players - and sometimes leaders'.

The STP thing is the real game.

Fuss in the media about NHS funding? Grist to the mill. Helpful mood music from providers, royal colleges and think-tanks sets the scene. BBC (and glory be, 38 Degrees) lurid headlines are essential.

And we have a new Prime Minister, and a new Chancellor.

The dialogue might go along these lines:

No. 10 to Simon Stevens: "WTF?"

Simon Stevens: "Sorry, not sure how that got out there. Simple answer is, this is the first time the NHS has faced up to the changes that have to happen.

"If you back me, the additional funding the NHS needs is £x (where x = a number higher than £9 billion, but not massively so).

"If you don't back me, you're in for £35 billion - or endless stories about evil Tories cutting the NHS ... which might even lose you an election against Corbyn.

"And you wouldn't want that, would you?"