Editorial Friday 4 December 2015: Interview with Rob Webster and Stephen Dorrell, NHS Confederation

Stephen Dorrell and Rob Webster are the chair and chief executive of the NHS Confederation. This is part one of a two-part interview.

HPI: Now we have the clarity of the 2015 Comprehensive Spending Review, what are the three main priorities for the system?

Rob Webster: The Spending Review doesn't make our task any easier; just clearer. Nothing’s changed in the degree of difficulty of the improvements we need to make. But it seems that we do have political will and a financial context.

So we've got to use the next two years of growth and this point in the Parliamentary political cycle immediately, to do the really difficult things. This is an opportunity we can't waste: to focus on how services must change to meet people's service needs now. We think there'll be some good news on service change and support in the forthcoming planning guidance for the next couple of years.

So we have to grasp this opportunity and make change happen, to ensure that people identify how place matters to them in thinking about having sustainable health and care services.

We need to develop shared ambitions that people can live with in delivering sustainable services that deliver maximum value for patients. This probably means that commissioning has to work at greater scale, and that some organisations will have to give up sovereignty or disappear.

The prize for doing this - having a sustainable NHS delivering an improved service - is one well worth having.

Stephen Dorrell: Quite reasonably, the NHS response has been to focus on the bits marked 'NHS' in the CSR. But every thoughtful person knows that we are just one part of the wider health and care sector, and the CSR was significantly less comforting in the local government and social care sectors.

Unless we succeed in taking forward service change, failures in social care will soon make the traditional model of NHS provision even less sustainable (if social care continues as it is now). Because it already can't cope with low resources and high demand.

In the run-up to the CSR, Simon Stevens was very clear with his five tests about the NHS pitch, and his ask for £8 billion front-loaded was conditional on social care being sufficiently funded to deliver the current pattern of care. That condition has not been fulfilled.

RW: When I talk about the importance of considering place and service, this has to be about serious prevention, well-functioning social care NHS and addressing the wider determinants of health.

So: we know that where you live defines how long and well you live. See any director of public health's report to stare this fact in the face.

And if we don't stand with public health and with renovation of housing stock, education and employment, then any medium-term gain from improving place-based services will be lost.

And if there's no focus on making social care sustainable in the next eight months, the short-term opportunity to prevent big problems will be lost. The NHS Confederation are going to keep on pushing on this agenda.

SD: The opportunity for NHS service change is very welcome, but this is broader than that: it's not just about an internal NHS process.

HPI: As it’s funded now, can the NHS continue to provide the range of services it currently provides?

RW: I want to start the question in a slightly different place, of asking whether we’re clear on the value we deliver in the services we provide.

Talking to Andrew Dillon of NICE recently, he mentioned their list of about 900 treatments and interventions that we should not do or only rarely do, and he was saying that the service doesn't really access that information to make decommissioning decisions.

And I was reminded of our work with the Academy Of Medical Royal Colleges about delivering value, which found that there is some work we should stop doing which could save about £1bn very fast.

The question is 'are we clear about the efficacy of the intervention that we're now doing'? How can we stop wasting the assets of patients and staff, and harness them to help us deliver the full range? Do we think we need to deliver care in the same way we do today? With maybe a breathing space of two years?

I think that patients want a different kind of service especially if they have long-term conditions: we have to act as guests in their lives.

The game is up. Patients today shouldn’t have to kow-tow to how organisations are used to providing care. In the next two years, can we redefine services to add value where people live and define this change?

If so, the commitment to healthcare free at the point of delivery can be maintained.

SD: The question links back to what we discussed at the start; this sector need to get more comfortable with internalising change. I don’t want to see delivery of the same old pattern.

RW: I’ve worked as a chief executive in the NHS and worked in Whitehall, and having seen both ends of the telescope, you get a distorted view from both ends.

After the 2012 Act, we saw a degree, or a period of time, where the national system was still working out its roles and staffing up to do them, the effect of which was giving local systems space to get on with some necessary things.

So people just got on in many parts of the country, and decided what they wanted to change. Now we can see results of that in the integration pioneers, the devolution agenda and vanguards. People see that change is required.

But there are two big areas where we’re not moving as fast as we can. Firstly, sheer daily operational pressure on organisations crowds out any thinking about the medium term.

I’m clear from my visits that many organisations are very highly stressed. Secondly, there’s no change model or capacity / capability for change to be aligned to the task ahead.

SD: If you're very hard-pressed, the greatest danger is that the urgent squeezes out the important.

The Confed is a relatively small organisation, but if we can provide a framework of context, support, justification and simple clarity of view on the nature of change and help people see the 'why', then that's a necessary, important part of the value we add.

HPI: Rob, you talked there about the game being up: do you think people and organisations have been resisting changes, and if so, why?

RW: Do I think places are holding back on change? There’s more than one kind of game … (joking) decathlon, pentathlon ... but really, we’ve got to think about the NHS’s confidence with the Treasury. The standard Treasury joke is that the NHS invests to spend, rather than investing to save.

We have as a system to get the Treasury confident that the NHS is making the changes required.

So there’s a game with the public, of describing a compelling vision of the future showing how services will be better. Our research shows that 75% of the public would support change - if we can describe it better, using clinicians and not politicians.

And there’s a game with the staff, and my biggest worry is about finding ways of keeping our staff with us and getting them to take the journey into new service patterns which will affect the way they work every day.

And if we can’t sort the staff game out, we’ll have lost.

HPI: The public have heard '£10 billion more for the NHS'; analysis reveals that the truth is not quite that. How should system leaders deal with this?

RW: Let’s start simply: do most people understand the difference between £1 million and £1 billion? No, of course not.

SD: It just sounds like a lot of big numbers!

RW: I think back to our work last year with the public, talking about change. We found they were willing (more so than politicians and indeed NHS leaders) to see that change could happen and accept it, but they told us that they needed help to better understand changes in outcomes and service. When asked what they needed to know, only 40% said that they understood enough about the service to get engaged with the debate.

So a sum of millions or billions won’t necessarily mean anything in the abstract: people want to know ‘what does this mean for me and my services? How is this adhering to NHS values?’

SD: We must avoid any tendency to sound patronising. People are not stupid: they know that a service (of sorts) is delivered from a physical building they can see. That’s the NHS that they know now.

Then experts tell them ‘in future, you’ll rely on a system’, and people’s past experiences of a joined-up health and social care system vary between mediocre and downright bad.

So people feel they’re being invited to transfer their trust from a building they can see, to a system whose joined-up nature (for more families that not) has failed them at least once. That’s not an easy ask.

So I’m unapologetic for my view that the way we deliver care has to change to deliver equally equitable access to high-quality channels of care - but we must demonstrate that we can do it consistently and safely before we ask the lay public to trust us to do it at scale.

RW: If we focus on place as our currency of planning and delivery for joined-up service in real lives, then it needs a consolidated view of commissioning, with patients and public in at the heart  of service delivery, design and assessment.

And we can build a compelling vision of commissioning as being about that.

My challenge for Simon Stevens and NHS England is to mobilise that, so that we can mobilise staff, GPs and patients. With NHS Improvement and Jim Mackey, we’ll see how we go about harnessing the tens and hundreds of thousands of people who want to be members and governors of NHS bodies.

This is something we can only do locally: it can’t be done nationally. NHS Confederation say we need to create a national framework which empowers local leaders to deliver.

SD: It’s also a challenge for many NHS career managers. The organisations that became the NHS in 1948 started out as ones that were strongly locally rooted, which became the nationalised NHS.

One consequence was a gradual de-localisation, which cut off the NHS’s roots in local communities and political processes.

NHS managers may often feel that local political processes and communities are part of their problems. But with our current change problem, local politics have to be part of the solution.

This can’t work if we don’t engage with users, and elected representatives, but most importantly with local people: they’re the ones who can improve our understanding of the local health and care sector; of what's required and facilities change process.

Health and care have to be done with the local population; not to them.

RW: This is tough stuff to do, changing the behaviours and minds of millions of staff: one million in social care; one and a half million in the NHS and there's the voluntary and charity and for-profit sectors.

The soft stuff is really hard to deliver.

HPI: What is your position on the wisdom of making cuts to public health and education/training budgets?

RW: Those are two different debates / arguments. The NHS is made of people, not buildings, kit or drugs. We spend money on people: people are at the heart of care, which is always given by a person. And we need to show care in how we put together carers’ jobs.

We’ve got to support our workforce to change how they work daily, so adequate training arrangements are clearly needed. The jury’s out whether local education and training boards (LETBs) connections to Health Education England have impact, although the underlying principles are good and sound.

You can mount intellectual arguments why changes to nurse funding are OK. But the delivery will be key, and so we want to work closely with NHS England and Health Education England so that the right supply of people with the right values are going into nursing.

SD: The headlines on nurse training are that we have a shortage and ending bursaries does mean that the cap on training numbers is lifted. Insofar as it goes, this is the right policy response to problems.

We must now ensure new funding mechanism is unlimited bureaucratically.

HPI: Although that’ll depend slightly on the attitudes of lenders …

SD: It’s about making certain arrangements work to deliver access. Yes, that’s partly about lenders, but also about employers making the jobs sound attractive, and about not wasting those nurses we’ve already trained, as they’re the cheapest! It’s not a success that the NHS too often recruits idealists at 20 and turn them into cynics by 40 (if not sooner!).

By engaging with those we do employ, by being genuine good motivational employers, people will want to come through and be motivated to deliver as a new workforce of value.

RW: At the heart of that, I think we’ve broken the social contract with many of out staff, who no longer feel supported. They say they’re in love with the job, but hate coming to work.

Getting the implementation wrong could disaffect people, so we need to open the gates to as many as possible and be a model employer, so we can end up in better place.

SD: Although we need to be careful about the language, because the NHS is not an employer, but a group of such. We’ve developed a degree of competition by example in the health and care system, as the NHS is not the only employer of nurses.

RW: We know from research that the majority of staff are values-driven and see it as a vocation as much as a job.
But the public health issue is pretty hard to swallow, seeing a budget cut.

There are two strands policymakers have got to understand: firstly, public health funding relates to care delivery on substance misuse, smoking cessation, child and adolescent mental health services, sexual health.

Local government are having to make tough choices. Read Jim McManus on how he’s got to choose between smokers, drinkers, druggies, kids. Public health is hidden in plain sight.

Secondly, it’s unclear what the argument for not protecting public health  is: if we believe that housing, education, employment and environment are determinants of health, and so we think that public health interventions can accelerate improvementin environments as well, then if we’re cutting budgets and significantly downgrading local government resources, where does the impact come from?

If the role of local government in this area shrinks to just being about social care and child services, other services shrink. Lots to say on this, clearly.

The optimist in me says difficult conversations must be possible to get the central-local balance right; the pessimist in me fears this many not be possible.

SD: After spending 36 years in elected politics, I recognise both of those analyses. And we have to come down as optimists, because, frankly, this just has to happen.

Go back to the point on service change. If an acute provider can see that changes in public health provision for drug and alcohol abuse mean significant increases in demand that they can’t meet sensibly (and could even with x4 or x5 the available cost of interventions), either we say 'the sodding politicians have messed up' or we engage with people who have the solutions.

Without prejudice to expressing the view, we’ve just got to get on with it.

HPI: Are NHS capital-to-revenue transfers a good idea?

RW: No. It’s a sticking-plaster solution, and we have to rip it off and get something sustainable. I've been around long enough to recall the state of 1980s and 1990s NHS infrastructure.

I think we all understand that we can't bust the financial vote, and that we need to reassure the Treasury they can have confidence that we can manage resources. Capital-to-revenue switches are an obvious problem for maintenance, and for transformation, which we need - and there's a deadline.

SD: The health service largely has only one source of revenue funding, but there’s more than one source for capital, which we’ve learned to tap.

Shifting more public resource from capital budgets into revenue suggests that we have to shift more to find alternative sources of  capital.

RW: And some of our members are already working in partnership with capital providers: Greater Manchester West are working with Priory Group on mental health services: Priory bankrolled four ward developments, allowing repatriation of patients, so they can deliver better care and secure the resources they need.

Another acute provider is saying they’re about to develop a new hospital as part of an academic park with their university, and then there are housing associations, and the not-for-profit and for-profit sectors.

Again, it’s about service change. This funding settlement does not allow to go on responding to demand with the current care model, and we shouldn’t want to anyway. We need to unlock the funding levers of change.

It poses the question whether we have the capacity and skills to do this. NHS history is littered with good and poor examples. You tend to find that money’s always available out there for capital projects, although we’ve tended to pay too much for it.

SD: And there’s a role for the Confed in facilitating that learning, not as a provider of services but in drawing attention to learning, be it from past failures or successes.

RW: And there have been lots of successes.

SD: But occasional failures, from whose errors we can learn a lot.

Part two of the interview will appear shortly