It was a good week for the chief executive of NHS England, Simon Stevens. His Five Year Forward View dominated the media, sent the health commentariat into a swoon and cornered politicians of all hues into vaguely pledging to find more money for the NHS. In a mere 40 pages he set a sense of direction around better prevention, new models of coordinated and personalised support and an apparent green light for localities to decide for themselves how best to make progress. The disastrous Lansley reforms almost seemed a distant memory.
This is encouraging stuff but we shouldn’t get too carried away. There are four potential deficits in the Stevens review: an implementation deficit; a democratic deficit; an ideological deficit; and a funding deficit.
The implementation model is avowedly bottom-up – localities are to select from a range of new care models and their leaders are urged to focus upon whole healthcare economies rather than their own individual organisations. This is easier said than done. The Lansley reforms have pitched local organisations into a competitive and sometimes confrontational relationship with each other. Putting aside organisational self-interest will take more than exhortation, it will need strong central direction – the very opposite of Stevens’ local discretion model. Interestingly the review threatens a “whole-system, geographically-based intervention regime” for laggards. There will be limits to the concept of local organic change.
This implementation deficit is linked to the democratic deficit. Stevens wants to see the development of new multi-agency models of care and support, and this will inevitably mean big changes to existing service patterns. Where in this model is there any accountability to and engagement with local populations? The review talks of the need to engage with citizens and communities in new ways but comes up with little more than a consumerist shopping list – better information, enhanced self-management, more choice and “integrated personal commissioning”. The current ragbag of foundation trust governors, lay members of CCGs and patient participation groups is inadequate and Stevens really should be requiring a better game on citizen engagement.
This penchant for consumerist rather than citizen engagement may well be a reflection of a wider factor – the ideological deficit. Stevens likes to refer to the NHS as a social movement not just a healthcare service, but his long tenure at the US private healthcare company, United Health, has aroused some suspicions. The defining feature of the Lansley reforms have been the embedding of competition law into the NHS, yet bizarrely the Stevens review makes no reference to this whatsoever. His call for ever more ambitious coordination between commissioners and providers is at odds with the capacity of private companies to invoke legal challenges to such arrangements, and this worry will not have been helped by his evasiveness on the issue during his media rounds last week. It may well be that he does not see competition as central to his vision, in which case it would have been helpful – albeit politically difficult – to say so.
Finally – and most importantly – there is the funding deficit. Stevens has a formidable shopping list with no specific prices attached – a public health revolution, a new deal for primary care, new support for carers, an information revolution and a modern workforce that is properly valued and rewarded. The £8bn figure (above inflation) that Stevens seems to be asking of politicians does not even appear in his review, but thus far no political party has pledged to meet it. This is the first funding deficit.
The second funding deficit is the assumption in the review that somehow the remainder of the estimated £30bn funding gap can be filled by efficiency savings from the key proposals in the review, notably on public health and new integrated models of care. The biggest single saving since 2010 has been on NHS staff salaries and Stevens admits this cannot continue, so where will the required £22bn be found? The review outlines three different efficiency scenarios, dubbed tartly by one critic as “unlikely, unfeasible and incredible”.
There is little evidence to support the view that health and social care integration will save much money, or that community-based services will be any cheaper than hospital-based services. Indeed for all his talk of the need for a system outlook, Stevens makes heroic assumptions about the contribution of social care, failing to acknowledge or appreciate how harshly local government has been financially punished since 2010. Birmingham, for example, is praised for its local GP hubs with links to social care, but there is no mention of the fact that the city council is required to make cuts amounting to 60% of its controllable budget by 2018.
Stevens is right to say it is no longer credible to “muddle through the next few years” and he is right to call for “a sustainable strategy”. It is not entirely clear that his review has provided us with the answers.
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