NHS England’s chief executive sets out thinking on new models of careBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3842 (Published 12 June 2014) Cite this as: BMJ 2014;348:g3842
In a series of speeches and interviews, culminating in an address to the annual conference of the NHS Confederation this week, the new chief executive of NHS England, Simon Stevens, has begun to describe his priorities for the NHS.1 Foremost among these priorities is a desire to be radical about how services are provided. This entails further concentrating specialist services where evidence shows this will bring benefits, while continuing to provide access to local hospital services for the growing number of older people who need these services.
Stevens’s radicalism extends to how hospitals will be staffed in his questioning of the assumption that almost all NHS acute hospitals need a full complement of trainee doctors to keep service afloat. With a 76% increase in the number of consultants working in the NHS since 2000, he has raised the prospect of some hospitals emulating what happens in parts of Europe, where medical care is delivered by consultants only. He has also advocated more emphasis on generalism in medicine, echoing the work of the Royal College of Physicians on the future hospital.2
Citing medical historian, Roy Porter, Stevens has questioned whether the founding principle of the NHS under which “consultants got the hospitals and GPs got the patients” is durable.3 One idea is the development of multispecialty provider groups in which networks of practices work alongside specialists, community health services, and social services. These groups might take on population based budgets and join with local community or acute hospitals where there is an appetite to do so. Parallels with the United States are clear.
In putting forward this idea and others, Stevens has emphasised that he does not intend to impose a national blueprint. Instead he wants to encourage more creativity and flexibility, where each community chooses clinical and service models appropriate to its needs. This must ensure financial and clinical sustainability at a time when the NHS in England is arguably under greater pressure than ever, as more providers are in deficit and failing to achieve performance targets.4
Stevens put down a clear marker to the Health Select Committee that he expects NHS funding to increase in real terms as economic growth returns, even though the NHS budget is currently expected to face constraints until 2021.5 In this context he has committed to publishing a “Forward View” in the autumn on the NHS’s prospects over the next five years, in conjunction with Monitor and the NHS Trust Development Authority. This will draw on the five year plans currently being prepared by clinical commissioning groups and providers. It promises to be an important statement of intent that will shape thinking on the NHS for the foreseeable future.
As well as setting out the policy and regulatory changes needed to support the development of new models of care, the Forward View will probably identify the funding needed to implement these models. At a time when politicians of all major parties are not promising major increases in the NHS budget, it will need to spell out the consequences of not providing additional resources for investment in new and different services. Treading a careful line between speaking up honestly for the NHS and the people it serves, while not antagonising ministers as the general election approaches, will be a key test for Stevens.
Changing physiology, not anatomy
Stevens’s emphasis on improving services is a welcome contrast to the recent obsession with reorganising NHS structures. It indicates a preference for changing the physiology of the NHS rather than its anatomy—for example, by using financial incentives to reward providers who deliver better outcomes for populations and patients. He has also spoken of the need to improve commissioning by providing commissioners with better information and working with local authorities on joint commissioning of health and social care. A more radical option is flexibility in how the split between commissioning and provision is organised, as in the example of multispecialty groups taking on population based budgets to integrate care.
As head of the national organisation responsible for commissioning health services, and with experience in a major US based health insurer, Stevens’s focus on these matters is to be expected. His observation that England is unique in entrusting so much responsibility for funding to frontline clinicians could be read as an endorsement of clinical commissioning groups or as a marker that such a bold experiment carries risks.1 A new review cautions against believing that commissioning alone will succeed when similar attempts to deliver change have had partial success at best, and argues for more support for organisations that provide care to lead improvements.6
What is clear is that Stevens, his peers in other national bodies, and ministers need to develop a shared vision and strategy that is compelling and well understood and provides the direction for leaders and their teams throughout the NHS to work towards a better future. Only through sophisticated collective leadership of the NHS will it be possible to develop innovative models of care and achieve high standards of performance. His experience in helping to prepare the NHS Plan will undoubtedly come in useful in this regard, albeit in a context that is altogether more hostile than in 2000, when additional resources were about to flow into the NHS at an unprecedented rate. The opportunity this offers is to use the threat of an impending crisis to work with others in making changes that in normal times would simply be impossible.
Cite this as: BMJ 2014;348:g3842
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I am chief executive of the King’s Fund and worked with Simon Stevens in Whitehall between 2000 and 2004. The King’s Fund has done contracted work for NHS England.
Provenance and peer review: Commissioned; not externally peer reviewed.