Editorial Wednesday 4 June 2014: Thoughts on NHS Confederation conference, day one

Some quick reactions to the first day of the conference.

Rob Webster gave a human, personal and well-judged speech in his first conference as Confed CE, warning that the time has come for burning ambition to replace burning platforms. Praising colleagues' success in the achievements of sustaining care quality over years of flat funding,

Webster called for ambition, determination and realism among the political leaders in the lengthy trundle to the next general election.

This isn't just a crap speech; it's an ex-M&S boss crap speech
M&S ex-boss and reviewer for the government Sir Stuart Rose, by contrast, delivered a litany of cliches. Technology exists, apparently, and is changing things. Who knew?

Leadership is not the same as management, Rose also told delegates. Indeed it isn't. It's not the same thing as an avocado, either. Leadership requires and open mind and a can-do culture. Yes, it was that bad.

Simon Stevens
Fresh from his walk along the turbulent surface of the Mersey, Simon Stevens delivered an impressive, detailed, realistic and thoughtful call for local, evidence-based action to deliver change.

Powerfully clear about the redundancy of one-size-fits-all national plans (calling for "not a five-year plan, but a five-year forward view"), Stevens acknowledged that the balance between local innovation and national standards will challenge health economies. He was equally clear that different models of care will be appropriate in different places: "rather than uncritically adopting the merge and centralise as our overriding ‘meme’, let’s go with ‘horses for courses’. In some places mergers and traditional reconfigurations will – after careful stress-testing – clearly be needed, and they will have NHS England’s full support.

"But let’s also allow complementary models to emerge, be tested, and adapt over time, in different communities, reflecting their different legacy care patterns and the heterogeneity of their patients".

A farewell to pass-the-deficit-parcel-bomb
Deficit-fanciers were comprehensively warned that overspends will not result in money being robbed from services such as metal health to net off the overspenders. And there was a hearty hint to the TDA and Monitor that Simon was "confident" of consensus on the need for "an NHS that is more flexible, more adaptable, where national and local thinking converges to create different clinically and financially sustainable paths for particular communities." .

Specialised commissioning is in focus: "as we take a hard look at NHS England’s £14 billion portfolio of specialised commissioning, on grounds of quality or efficiency for some tertiary conditions we are going to choose to work with a smaller number of leading hospitals. Our selection of these long-term partners will also be influenced by the maturity of the relationships these hospitals exhibit, both in terms of win/win contractual behaviours over the next 12-24 months, and their shared understanding of the medium-term financial context within which the whole NHS is having to operate.

Although 175 service lines across 280 providers are now defined as ‘specialised’, just 76 providers account for 80% of the spending. So we need a more realistic categorisation".

Cue bigger acutes looking very, very intently at both their five year plans and their behaviours with commissioners. The lack of signed-off specialised commissioning contracts with some major acutes did not get a mention.

There was also clarity that "I am definitely not suggesting a wholesale reorganisation of medical training and staffing across England. What I am arguing is that medical training and staffing should not drive the wholesale reorganisation of district general hospitals across England. The tail should not be wagging the dog".

Stevens highlighted the need for payment systems reform, and for much greater activation of patients as experts and carers: "change in the NHS is not merely a techno-rationalist activity, it’s health as a social movement, working with communities and civil society organisations and local government and faith groups and patients groups and many others". And he usefully outlined the plans for the NHS to adapt to and plan for the advent of genetic medicine.

His conclusions were empowering: "our problems are soluble, but they won't solve themselves ... we should be open-minded and pragmatic about how we move forward. Of course resourcing will matter. But let’s also think more creatively about our options – disentangling means from ends, and discarding false dichotomies".

But ...
There are some risks to Simon's vision, and none are of his own making.

The first is that there will be people at senior positions in the system who have by tradition been maladapted for liberation and self-determination. The potential consequence will be a risk that the cage of top-down command-and-control to a national blueprint is thrown open and ... nothing happens. It's called Stockholm Syndrome, and it's a very real risk.

As I have previously written, the NHS needs a chief anthropologist much more than it needs any chief inspector.

Another risk is of confirmation bias. This was a major, detailed and thoughtful speech, and for seasoned Stevens-students, contained few surprises. The danger might be of the bien-pensant policy community looking into it and seeing reflected what they want to see. Guarding against this risk, Simon Stevens likes to be intellectually challenged, and is up for debates. They will at times be needed, and they'll feature evidence and evaluation heavily. Well and good.

The third is a capacity and capability risk. The Lansley reforms reduced the NHS management overhead to 45% of the 2008-9 level. Money isn't everything, but as skill-sets go, the analytical capacity and capability to do the kind of detailed data modelling (understanding two standard deviation points' value, regression to the mean, outliers, Old Uncle Tom Cobbley and all), verification and mapping the data onto implementation is in huge demand. Running a data-driven NHS is going to need these skills.

It was a grown-up speech from a credible leader, nuanced, realistic and unflinching. It offered no false hopes that things will be easy.

It's a bloody good start. Well done, Simon. The NHS is lucky to have you back.