My thoughts on two particular challenges have converged recently to lead me to propose one potential solution. The first challenge is the continuing difficulty of recruiting to top jobs and the troubling level of executive vacancies. The second is the fragmentation of the provider landscape at a time when collaboration and integration are needed more than ever.
My solution is that providers should work together to form local systems of care, with leadership provided by the most experienced managers and clinicians in the NHS. This is also something that the recommendations of this week's Health Service Journal inquiry into the future of NHS leadership point to. For the avoidance of doubt, this does not mean another top-down reorganisation. Rather, it requires providers to agree how they will collaborate in areas that are meaningful to them and the populations they serve. The establishment of new systems of care is also quite different from mergers and acquisitions, which typically take an age to transact and at best have a mixed record.
Virtual provider networks would be created based on well-thought-through governance arrangements. This would have to be done in a way that didn’t fall foul of competition rules but also defined the scope of the system to be covered by these networks. Neither of these challenges is trivial but both can be addressed if the case for local systems of care is accepted.
The scope of networks is likely to vary from horizontal integration in some areas to vertical integration in others. Both are of course possible and the involvement of independent sector providers is also an option.
Unlike some of the ideas in the Dalton review and Jeremy Hunt’s proposal to create foundation trust chains, local systems of care would be formed by providers working in the same area. The rationale is that it is difficult to provide buddying support at a distance and that for the most part health care provision is essentially local.
The intervention of NHS England and national bodies in Cumbria, Devon and Essex to create a so-called success regime suggests that planning and managing services in the way proposed here has already entered the thinking of national leaders. But it is not only in challenged economies that this approach has relevance. Areas of the country where performance is good would also benefit from such an approach, both to avoid falling into the success regime and to use available leadership talent as effectively as possible.
The creation of systems also offers an opportunity to focus on health and wellbeing, not just on health care. The Fund’s work has made the case for population health systems to be the next leg on the journey of integrated care, with the potential to involve local authorities and other partners. This thinking is reflected in Devo Manc, where the vision is to tackle health inequalities and promote wellbeing by joining up all public services.
In truth, the idea of systems of care is not new, having been put forward in the Fund’s analysis of health care in London in 2013. At the time the idea was greeted with polite interest but failed to gain traction. Since then growing pressures in all parts of the NHS and the speed at which these pressures have engulfed previously high-performing providers mean that it is an idea whose time has come.
This year’s Reith lecturer, Atul Gawande, has described the time we are living in as the century of the system. Making this a reality in the NHS requires a different type of system leadership, as we argued in a recent report. With time fast running out, the priority is to support the most experienced NHS leaders to work in this way as part of a concerted effort to make local systems of care happen.
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