Getting to the point of health systems

by Mike Farrar and Andy Cowper

The NHS in England’s annual budget is £161 billion. Yet across the sector, from the still-growing backlog (the longest waits are dropping, but median waits rising) to the workforce (strikes over pay and early retirements aplenty, despite increasing international recruitment and more training) to the state of the estate (over £10 billion in backlog maintenance, despite the 40 New (If Fictional) Hospitals Programme), and primary care facing relentless demand.

It doesn’t feel great.

These are extraordinary challenges, but so were many others faced by the NHS throughout its nearly-75-year history. So why does all of this feel so difficult and daunting now?

Some factors are obvious: the pandemic was draining and traumatic for many who worked on the front line at high personal risk throughout. It isn't clear that sufficient recognition and mitigation of this has followed as a priority.

NHS resources and capacity not matching demand is not something new. Indeed, the aim to move to population health on a geographical basis through the new integrated care systems seems sensible and hopeful, and much more evidence-based than the misguided Lansley reforms.

But for busy health and care leaders, the idea of major system reform over and above operational pressures is at risk of being perceived as a distraction from, rather than a solution to the current challenges

So, what’s to be done?

Politics, policy and prevention

Prevention is always easier to aspire to than to deliver.

The next general election is eighteen months away (more probably fifteen), and so the issue of politics comes into sharp focus. Recent policy announcements from the opposition promise greater focus on prevention and more care closer to home.

These may be the right priorities, but they were also promised in the Department of Health's 2006's Our Health, Our Care, Our Say, which made many of the self-same promises on prevention.

The then-Health Secretary Patricia Hewitt's introduction to that document has gained a retrospective poignancy: "year on year, as health and social care budgets continue to rise, we will see more resources invested in prevention and community health and social care than in secondary care.

"Previous governments have aspired to parts of this vision. But we are the first government to lay out both a comprehensive and compelling vision of preventative and empowering health and social care services and an effective programme for making this vision a reality. This White Paper truly represents the beginnings of a profound change: a commitment to real health and well-being for all."

The context for why this didn't happen is significant: the global financial crisis hit the UK economy in 2008. The impact on future health spending was obvious: 2010-19 saw the slowest funding rise in the history of the NHS, in terms of GDP per capita. The abolition of primary care trusts in 2013 saw the end of the promising ‘Spearhead PCTs’, which had been making significant efforts in preventative and public health.

There have been good examples of where resource shift into prevention and community have been shown to make a difference. But most have lacked scalability and sustainability.

As a consequence, mainstream NHS leadership in hard-pressed provider organisations lacks lived experience or faith that such approaches will manage demand to any significant overall level. Even when they do believe, they struggle to find an operating model that allows resources to be reallocated from their existing cost base.

Even in the potential of the better-functioning landscape of ICSs, there is evidence that leaders appear to be struggling to bring local government (and their locus on the wider determinants of health) fully into the centre of their resourcing policy and strategy.

The current Government’s policy and advice remains important. April saw the arrival of The Hewitt Review: Norfolk And Waveney NHS Integrated Care Board chair and former New Labour Health Secretary (2005-7) Patricia Hewitt’s independent review for the Government of the emerging integrated care systems that have been rolled out across England.

The main impression that this report left? It means well.

But arguably it ducks this conundrum of how we manage the immediate issues of the day whilst designing a more sustainable system for tomorrow.

The hardy perennial of a call for greater emphasis on prevention (accompanied by a 1% shift of resources) would of course be a good thing, but it has to be accompanied by a realistic approach to managing the consequence of resource shift for those currently in receipt of it.

System working and pivoting to prevention - how to shift resources

The question of resource shift is important. Prevention is often seen as the ‘enemy’ of cure, perceived to be taking resources away from acute care, when acute providers are already struggling to meet their own cost pressures.

This needs to be challenged - shifting resource to population health management (targeting more resource on those with greatest need); earlier diagnosis; and secondary prevention can all be linked directly to reducing the demand from patients currently in hospital, but for whom that admission could have been avoided.

If we are to be successful in moving the NHS in this direction, then we need a clear focus on secondary prevention; as opposed to purely focusing on primary prevention and lifestyle. If we can do this, the result is likely to be the relocation of services, rather than necessarily budgets, out of hospital.

Building a compelling case for change

Tackling access problems and adopting prevention as a central strategy are not (or don’t have to be) incompatible, especially if the health and care system can focus on secondary prevention, targeting our resources on those with greatest need (interestingly also, the only way the NHS will ever get to grips with reducing health inequalities); rather than just seeing primary prevention as the goal.

Achieving this will require a systematically-applied, data-driven approach: one with a vision aligned fully with financial flows, incentives, governance and regulatory oversight. This is currently lacking.

Political rhetoric and policy papers alone are insufficient. We have also yet to see an explicit statement by either Government or Opposition that in the current economic and workforce environment, supply-side growth is not a realistic option on its own.

As Hewitt herself writes, there is “real concern that the transformational work of ICSs and specifically the opportunity to focus on prevention, population health and health inequalities might be treated as a ‘nice to have’ that must wait until the immediate pressures upon the NHS had been addressed and NHS performance recovers. That is what has always happened before, and must not happen this time".

In the absence of a convincing explanation of why what’s always happened in the past will not happen again this time, this is just rhetoric.

To be fair, perhaps no report for the Government (however independent) could ‘tell it as it is’ about the parlous present state of health and care. But without this level of honesty, there is a mountain to climb in gaining public and professional support for the case for change.

The need for real honesty in addressing the task ahead and a detailed appraisal of what it will take to fix things is surely behind the exceptionally muted reaction to Hewitt’s report in many quarters - including from the Department Of Health And Social Care itself, which is responding to the Hewitt Report in a ‘grouped’ reply with that to the Health Select Committee’s report on ICSs.

Towards less top-down-ism

A second theme of the current policy discussion is the balance between national and local priority-setting and decision-making.

The Hewitt Review calls for fewer targets: this looks sensible. And the report’s 'six principles' of "collaboration within and between systems and national bodies; a limited number of shared priorities; allowing local leaders the space and time to lead; the right support, balancing freedom with accountability and enabling access to timely, transparent and high-quality data" sound very reasonable.

Evidence from successful examples of integrated care and prevention have a strong local flavour. Canterbury, Alzira and Jönköping all demonstrate this at the heart of their approach. Successful community engagement and the community assets approach, as famously seen in The Wigan Deal, require a highly localised set of priorities.

So they are hard to square with the policy direction of travel of recent years, which has seen the Secretary Of State For Health And Social Care explicitly taking back control in the 2022 Health And Social Care Act.

More recently, the Prime Minister’s health advisor put great emphasis on actual physical co-location of the NHS England senior leadership team into the Department Of Health And Social Care’s offices, so they are under the Health Secretary’s watchful eye. How likely is this kind of national system leadership to do such hands-off things?

So when we read the words of the Hewitt report that "we should encourage and deliver subsidiarity at place, system, regional and national levels. We are currently one of the most centralised health systems in the world, and ICSs give us an opportunity to rebalance this", we may feel encouraged.

Yet it’s not clear that this is born of an understanding of why past efforts at decentralisation failed; nor is it obvious how it will be different this time. But the Review’s intentions are clearly sound.

Being clear about what an ICS is for

The revealed preference from NHS England over the 2023-24 budget-setting has been to treat ICSs and ICBs as systems ‘inspectors’ and regulators. Those with long memories may reflect that most versions of intermediate tier organisations throughout the NHS’s history have done similar things.

If that is all these new organisations are allowed to be, then their potential to mature into something genuinely transformational will be killed at birth.

The potential for taking a systems approach is all about these systems taking responsibility by themselves and for themselves. Those places starting to do this well assume the transfer of responsibility for the available resources to provide the best services they can. Their power and uniqueness is not as lobbying organisations, working to highlight inadequacies of resourcing services: it is about using the power of system oversight to convene and share goals, and to oversee a transition of priority alongside a safe shift of resource.

There is also a risk here: that ICSs become large, crude commissioning bodies which do very, very little to enable and encourage providers to take responsibility for improving outcomes within a finite pot of resources, through innovation; productivity improvement; tackling unwarranted clinical variability; and seeking system ‘allocative’ efficiencies, rather than unrealistic organisational cost-cutting (as seen through this year’s level of CIPs).

Despite evidence that some ICSs are falling into this trap, there is hope through the emergence of provider collaboratives that providers are willing and able to take on these responsibilities, albeit this is still patchy across England.

If they are to succeed, ICSs must become systems convenors and transformers, and not simply system regulators and inspectors.

This is not only about their role, but also about their leadership capability and orientation. It is not surprising that the early ‘leading’ ICS appear to have at their heart the concepts of transformation, distributed leadership, a strong partnership ethos (especially with local government) and inclusive leadership.

Culture change and mindsets shifts take effort and time to deliver

Whilst the focus of much thinking is on resourcing, policy and strategy, anyone involved in leading within the NHS and care system is acutely aware that culture and behaviours have to shift and align with a new direction of travel.

A shift towards prevention and demand management; a move from competition to collaboration; a move to greater empowerment of clinical and care professional leaders; an equality of input and voice from VCSE, primary care, social and mental health alongside the powerhouse of acute physical care; a move from short-term to longer-term thinking are all examples of how culture and behaviours will need to shift. Once again, these are underestimated and underinvested in the national policy rhetoric and debate

Resourcing change

Whatever the future direction of travel and evolution of the ICS model, the weight of evidence is that change management requires some resource. Yet ICBs have little sooner been created in law than they are being required to cut their management / workforce spending by 30%.

Oh, and their projected overspend in 2023-4 initially looked to be somewhere about the £6 billion mark (yes, of course this number was brought down through top-down pressure from NHS England).

Integrated care sounds intuitively sensible. It may prove to be the right approach. But its chances of success will be severely restricted if there is no resource or time for leaders to organise and implement reforms - or crucially, to convince their front-line staff of their benefits.

Alignment, alignment, alignment …

The key to ICSs’ success as vehicles to deliver local and national priorities will also be found in the fundamental alignment of their role and function with the operating model (planning, financial flow, incentives, regulatory requirements), which is usually set out nationally.

This is currently not evident.

If ICBs mirror the best global examples of place-based working, then they need aligned policies and operating rules to support them. Sadly, we see continued ambiguity and fragmentation in these, which hamper their ability to deliver on their statutory triple aim.

When the Labour Government in 2000 set out its NHS Plan to reduce waiting times for care, they had a strong alignment of policy levers with the task at hand. They may not have been universally popular (and arguably should have been reformed in 2008, when the high-water-mark standard of 18 weeks was achieved), but policies such as foundation trusts, national tariff, Independent Sector Treatment Centres, growth in medical and clinical staffing numbers and the Quality and Outcomes Framework in the GMS contract all aligned to deliver the overarching policy objective.

This is not the case today. ICSs, built potentially for longer-term transformation and a pivot to prevention, are now being expected to deliver short-term, narrow access standards. Built for one purpose but being asked to do something different. It’s no wonder that many are questioning where their levers of power are in the new system, and asking for tools to do the job.

Unfortunately, what is in prospect looks like moving ICSs further towards the pyrrhic victory of becoming system managers rather than system transformers.

So today, a new vision is urgently needed: one to allow ICSs to work inclusively and equally across the NHS and local government, and to empower their providers and populations to enable transformation that can achieve progress on access standards in the short term, but in parallel with (rather than at the expense of) demand management and prevention strategies.

ICBs and ISCs should be the right platforms to deliver these changes. But they have to be enabled to do so, by aligning policy, resource, and the operating principles.

System working, in theory, and arguably in reality, is the only way to deliver the triple aim. Simply asking acute providers to deliver ever more activity within an unreformed system is unlikely to be effective in meeting financial or service delivery standards on a sustainable basis. As we all know, even on the Government’s top priority to reduce waiting, the NHS can't deal with elective recovery if it thinks the problem is about just the stock (the ‘order book’ of patients waiting and the available staff and capacity) – it has to deal with both ‘stock and flow’.

The challenge now is to be bold enough to call out these issues, and encourage the current and future Government to learn these lessons quickly.

Mike Farrar was an NHS strategic health authority chief executive, and is now an independent management consultant

Andy Cowper is the editor of Health Policy Insight