David Oliver: Binary truths don’t help health policy debateBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4518 (Published 24 October 2017) Cite this as: BMJ 2017;359:j4518
All rapid responses
I find myself agreeing with a great deal of what Dr Puntis says.
Strategic Transformation Partnerships (STPs) were pushed through in undue haste. They were in effect told to promise "savings" and reductions in urgent activity or hospital bed use that were unevidenced and beyond any credibility and to stay within financial "control totals". It's doubtful that even those writing them really believed what they were promising was deliverable.
They manifestly (in their first iterations) did not involve local clinicians with relevant expertise or a stake in service transformation nor did they involve the local public. And as virtual entities they have no basis in statute. They have been criticised for all these reasons in reports by the King's Fund, and the Royal College of Physicians and by many commentators - very much including me. And folllowing the first iteration of STPs, NHS Chief Executive Simon Stevens himself had to make it clear that there should be no promised secondary care bed closures without viable alternatives in place.
For all this, the discussion on STPs and New Models of Care and the Five Year Forward View illustrates quite neatly the point of my article. There is another side to the coin and another set of interpretations, in essence:
1. Simon Stevens on taking over as NHS Chief Executive inherited a situation not of his making in which the disastrous Lansley Care Act had stripped the NHS of experienced managers, of clear lines of accountability through Strategic Health Authorities, had left Clinical Commissioning Groups (often too small or not with the right skills) to commission services from providers.
2. Stevens also inherited an NHS facing a huge hole in its budget following deliberate austerity policies and he has been repeatedly vocal and critical of government about the finances and workforce gaps, including while giving evidence in parliamentary committees. It was pretty clear back in 2012 that the NHS faced at least a £30bn funding shortfall just to maintain current levels of activity. Throw in cuts since 2010 of around 25% in social care and public health funding and we have a perfect storm. Realising there was no way that the Treasury would provide the £30bn, he probably asked for £15bn, was promised £8bn and the NHS probably only received about half of that.
3. In the midst of all this we had Brexit and general elections leading to more uncertainty about the economy and future NHS funding and workforce.
Within that context it could reasonably be argued (especially when we know that services are often disjointed, fragmented, poorly co-ordinated, that organisations often retreat to their own sectional interests preventing effective collaboration) that New Models of Care Vanguards were a pragmatic attempt to improve or transform service delivery within the resource we have. And many of them have begun to deliver modest, early benefits. It's hard to argue against some of the innovations e.g. better health care for nursing home residents.
It could also be argued that within the current funding envelope, attempts to maximise population health and look at population medicine as well as value and variation in processes and outcomes and to plan more joined up care for populations of around 400,000 to 1 million as in STPs with more collaboration and fewer boundaries between organisations and permissions to scrap the purchaser provider split and tariff have some virtue.
In another context, such approaches would be seen as collectivist and "socialised medicine" par excellence and not dissimilar to what already happens in Scotland, Sweden and other state-leaning European nations.
When I talk about falsely polarised or binary interpretations in health policy this is just such an example.
Either Simon Stevens - fresh from United Health Care, one of the architects of new labour's more pro market "reforms" and with the business brain of a global health consultant and a tendency to use US Health Insurance type terms like "Accountable Care Systems" - is part of a neoliberal conspiracy to defund, destabilise and destroy the NHS with STPs being the nail in the Coffin before it is chunked up into units that the medical industrial complex can then take over and monetise.
Or...he is a very politically savvy operator, doing as good a job as any NHS CEO could in the circumstances, realistic about how much money is likely to be on the table and being responsible in trying to get the best value from limited public money he can whilst also trying to kickstart improvements in services and allowing localities to make decisions around more integrated care for local populations. The alternative of just asking for more resource (as he has done repeatedly) and deciding that issues like value, variation, efficiency, integration, population medicine, etc, are off the table as even discussing them is colluding with the Tory desire to finish the NHS as we know it isn't realistic
The nuanced truth lies somewhere in the middle, I suspect.
Competing interests: No competing interests
David Oliver states that STP could “in theory” deliver benefits while acknowledging that they have been criticised for “being rushed, for overpromising savings and for lacking clinical engagement”. The key words here are “in theory”, since in fact there are much more fundamental problems with STP. As the mechanism for delivering the new models of care envisaged in the ‘Five Year Forward View’ (1), STP are based on flawed financial assumptions including the availability of sufficient capital to transform NHS services; a fall in the rate of growth of health care in acute hospitals; a continuing 1% pay cap; falling agency staff costs; investment in public health and education to rapidly reduce patient demand; adequate investment in social care (2).
Furthermore, no STP demonstrates any evidence for the central assumptions it makes or its ‘innovative solutions’ (3). Worse still, the ‘Five Year Forward View’ is drawn directly from the World Economic Forum’s diagnosis of the healthcare crisis, and also reproduces the Forum’s prescription for supply-side change and the various levers available to policy makers (4). This is ‘reform’ in the interests of big business not for patients. It is difficult to disagree with the thesis that an intentional market failure has been created in the NHS by underfunding, paving the way for treatment rationing and shifting the costs of care to patients. Of course, STP could “in theory” deliver benefits through empowering local teams and integrating care, but the reality is their cost saving imperatives mean they are not actually designed for this purpose. To many supporters of the NHS they articulate something altogether sinister in health policy.
Competing interests: No competing interests