“The NHS is broken,” says the government. But how to fix it? The recent Darzi Review diagnosed the challenge. Much is not necessarily new, but Darzi gives a coherent narrative which, while prohibited from offering explicit recommendations, implies what the government’s forthcoming 10-Year Health Plan should do. NHS and political leaders have long “promised to shift care away from hospitals and into the community,” Darzi says. However, “the reverse has happened.” In other words, we know what we want to do, but not how to do it. The reason that governments have found this so hard is because their own levers to effect change – structures, oversight, regulation, financial incentives and targets – point in contradictory directions.
Structures
Start with structures. Indeed, the last government did – but they also stopped there. In 2022, Parliament passed a new Health and Care Act which rejigged the structure of health and care systems and their legal duties. New integrated care boards (ICBs) and integrated care partnerships (ICPs) enable collaborative decision-making, convening GPs, trusts and local authorities to decide how best to use their collective resources across 42 areas. This approach encourages systems to get best value by shifting services from acute to primary and community care, as well as to local government-commissioned public health and social care services (‘allocative efficiency’). Although NHS structures aren’t perfect, obsessively tweaking them won’t address all the problems identified by Darzi. The health sector welcomes the new government’s commitment to keep the current ICS structure in place. However, reforming structures is only one of the levers available to drive change. Local NHS leaders on the frontline are inevitably frustrated when Government’s other levers push them in competing directions.
Oversight
The purpose of central government oversight is to ensure that local systems are delivering care quality, safety, and financial balance, as well as cutting waiting times. However, NHS leaders say most conversations with NHS England focus exclusively on short term pressures, overlooking longer-term efforts to shift care from hospitals to the community. Similarly, national efforts to drive productivity too often focus on simply driving greater activity, rather than getting better value from preventing worsening ill health. It’s right that there is accountability for performance on access to and quality of care, but government should reform NHS oversight so it is more holistic and considers access and prevention.
Regulation
Regulating care quality is essential to ensure healthcare services “first do no harm” – by taking robust action when needed. However, the Dash Review’s interim report showed that the Care Quality Commission (CQC)’s approach “requires improvement”. Echoing the view of many NHS leaders, Lord Darzi argues that “there appears to be no problem for which the CQC believes the solution is something other than to add more staff.” As acute hospitals are often the biggest and face the greatest pressures, this has driven a sharp rise in staff and spending, without corresponding increases in activity in primary and community care. Beyond the CQC, the volume of instructions from over 100 different health and care regulators also creates contradictory demands. Fewer regulators focusing on how staff do things, not just how many staff there are, would be a start.
Financial incentives
Financial incentives are also crucial. Currently, acute hospitals are paid by the quantity of elective care they deliver, while urgent and community care receive block contracts. Primary care meanwhile is paid through a confusing labyrinth of incentives in the GP contract. Darzi is clear that the NHS must “lock in the shift of care closer to home by hardwiring financial flows.” However, the present NHS Payment Scheme encourages the opposite shift, from community to acute, and this is exactly what’s happening. With three million people waiting for elective care, there is a clear rationale for paying by activity for elective care. But if demand for care continues to rise as forecast, just delivering more activity will struggle to ever keep up. To enable reform without denting efforts to cut waiting lists, the NHS Confederation’s research suggests that Government should change the NHS Payment Scheme to pay providers collectively for the actual health outcomes they achieve.
Targets
How do we know if we’re succeeding? Although NHS ‘target culture’ is much lamented, any attempt to answer this question and set standards will require metrics and targets. This will inform course correction and shape behaviour. The most politically salient NHS target is for 95 per cent of patients in A&E to be seen within four hours, a target not hit since 2014. Yet there are no targets for shifting to community care and monitoring healthy life expectancy. It’s therefore no surprise that Patricia Hewitt’s first recommendation in her review was for an accounting definition of ‘prevention’ to measure prevention spend. To assess whether its 10-Year Health Plan successfully shifts more money towards prevention, Government should urgently develop such a measure. With excessive target-setting overwhelming the NHS, and undermining its focus, it may be necessary to reduce the overall number of targets as new, mission-oriented targets are introduced.
So what needs to change?
Talk of levers, targets and financial incentives may irk some people, but they are inevitable and shape behaviour. Change also needs bottom-up and lateral drivers, however top-down levers, if properly aligned, have a vital role. Yet today, most top-down levers are misaligned, and actually block the shift from sickness to prevention and hospitals to the community. Aligning levers to achieve this change is the art of strategy, but too often the NHS mistakes “strategy” for an extensive “to-do list” without a co-ordinated approach to deliver it. Delivery requires real prioritisation to mobilise change. Although health and care systems need to do several things at once, not everything can be a priority. Trade-offs must be made. The Hewitt Review argued that shifting resources to better intervene early and prevent worsening ill health is “not “a ‘nice to have’ that must wait until the immediate pressures upon the NHS have been addressed,” but “the key to sustainable solutions to those immediate performance challenges.” Until the levers of government are reorientated to do this, a bold vision of reform won’t translate into delivery.
