North London Partners in health and care

My reflections on system working

Nigel Edwards
Chief Executive of the Nuffield Trust

The question of how to create local systems that will be capable of meeting the challenges of growing demand, increasing complexity and constrained financial and staff resources is one that is exercising systems around the country. 

I spent the morning with leaders from north central London who had spent the previous day trying to unpick these difficult questions.  From this and other work I have been doing, I took away several insights. 

The first is that after nearly twenty years of running the NHS through some form of commissioner-provider split it is difficult to make the adjustment to what is a quite different way of working.   This is complicated by some uncertainties about how the national bodies will work together in future.  London has worked through these issues more than some areas but there is more to do. 

There is an exciting opportunity to recast the relationship with local government but the differences in culture, accountabilities and ways of working have proved difficult in the past and certainly introduce a new level of complexity.  This too needs some new thinking and many places are having to work hard to do this.  There is however, a clear determination to realise the clear advantages in terms of improved prevention and outcomes that a coordinated approach can bring. 

A lesson that is emerging that for these systems to work they need to be based on a very strong primary care platform such as formal federations with community services supporting an extended primary care team including mental health and adult social care.  In retrospect, the Five Year Forward View did not pay sufficient attention to this.  These will support better standardisation of care, improve the capability of the system and hopefully create opportunities to improve the working lives of practice staff.  This means that boroughs within an ICS will progress at different speeds from each other – the NHS has never been very comfortable with this. 

The mechanisms for governance for these new approaches could be very complex and potentially use up a lot of scarce management time as well as creating new problems.  The idea of subsidiarity where decisions are taken at the lowest level appropriate to the problem is a helpful start but there are some complex issues about local discretion and the need for standard approaches across the system.  For example, the interconnected nature of care means that local decisions can undermine a strategy for the whole system.  There are similar challenges for the design of care given the considerable costs and practical difficulties for large providers to work with multiple pathways for different conditions and the advantages of having standardised approaches.  

Working out the rules that will govern the relationships between levels and between the many different actors will be important.  These will also need to cover what will happen when things go wrong or there are major disagreements.  Lessons from elsewhere suggest that formal agreements are a poor substitute for very good relationships and high levels of trust.  Unfortunately, these do not appear overnight and certainly not without effort.  I have always felt that the finding that success in this area depends of relationships is as banal as ‘more research required’; but unfortunately it is true. 

A key lesson is that to move forward the complex financial system needs radical simplification and providers need to be given more certainty about the financial envelop they will work in.  One of the mindset adjustments is to move to thinking about real costs and value rather than the tariff and to stop expending large amounts of energy on transactions which simply move the problem round the system.  This requires the development of a shared understanding of how costs and value change when decisions are made. 

The extent to which the workforce represents both a challenge and an opportunity is widely recognised.  There is more need for urgency in this area and I was left with the strong impression that systems as big as the ICS is going to be need to take more direct control over a number of aspects of workforce development and strategy.  In particular the development of community nurse, advanced practitioners and the range of supporting staff for social and primary care need urgent local action.  

Finally, delegates at this event and others I have attended were all clear about the need for a much better narrative about what is being done.  The HSJ recently reported that a lot of MPs were not familiar with the new NHS jargon – it is a surprise that any were.  The problem with the current narrative is the extent to which it is technocratic, about structures and governance and fails to explain how the experience of patients and staff will change.  It needs to speak to the intrinsic motivations of staff.  It also needs to be aligned with the agenda of local councils.  The framing cannot be that this is just about changing the NHS which has been a feature of some of the STP plans in the past.  

These are complex changes and my concern remains that trying to do them in the spare time of people who are already busy is going to be tough.  This does not mean we need to rush to create formal structures until we are clearer about how these new ways of working will play out.