Challenges ahead for the newly established NHS Improvement

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The creation of NHS Improvement comes at a critical time for the NHS. In the next few months the service in general – and providers in particular – will be attempting to reverse the steep rise in deficits and, at the same time, stop the downward drift in performance in key areas such as A&E.

Beyond this, the NHS and its partners are also busy re-designing care through the vanguards and other initiatives, and re-thinking how the health and care systems work together as areas create their place-based sustainability and transformation plans – all working towards the vision of the NHS five year forward view.

The finance and performance challenge is daunting, but at least it is relatively well understood. The longer-term direction for NHS providers is less clear, with two big and intertwined questions to answer: first on autonomy, and second on structure and governance.

On autonomy, many of us thought the policy landscape was clear: partially autonomous NHS trusts would be progressively replaced by more independent foundation trusts, with a relatively well-established approach to governance and much broader set of freedoms all grounded in legislation. Driven by the deterioration in finance and performance, this no longer holds true. Central control has been dramatically extended to include overseeing aspects of finance, workforce and detailed operational management. As the furore over finance (hopefully) recedes, NHS Improvement will have to invent a new approach to earned autonomy for NHS providers, as we now know the foundation trust model could not ultimately protect the freedoms of local organisations however they were performing. At least for now, the genie is well and truly out of the bottle when it comes to unfettered central intervention in local decision making.

As we look to the Forward View and its new models of care, this is no less important. You cannot re-design health and care to meet the needs of local people by setting lots more national targets or by ever-tighter regulation. Instead, the evidence tells us that the way to bring about sustained improvements in the quality of care is to provide freedoms to local leaders and their organisations, giving them the necessary tools and space. This requires a supportive national framework but not central control.

Re-inventing autonomy needs to go hand in hand with re-thinking the structure and governance of NHS providers. We are seeing the rise of new relationships both between providers and between providers and commissioners. These include binding primary care and secondary care more closely together in some of the vanguards, sustainability and transformation plans that are intended to enforce a place-based approach to services, and of course devolution. Yet the model of governance remains – trusts or foundation trust boards responsible for the performance of their own organisation. For the future, NHS Improvement will need to think through how the undoubted importance of having well-run organisations meshes with the equally important need to deliver integrated care across an entire geography – a responsibility that goes well beyond the boundaries of organisations as currently configured.

Finally, to return to the current finance and performance malaise in the NHS. The current stresses in the NHS are clearly worst in the provider sector. To overcome this, NHS Improvement will need to provide an honest assessment of what NHS providers can realistically deliver and ensure that its voice is heard. This does not mean becoming the national representative of NHS providers, but it does mean ensuring national plans are built on a solid understanding of the challenges and opportunities facing the provider sector.



Comment date
19 April 2016
After reading Richards blog ---and after witnessing what is presently going on in Lancs A/E Chorley the lack of permanent junior doctors for a/e ---I dispair at the 5year plan and the possibility of Trusts becoming independent trusts smacks of private health care coming in by the back door
I cannot speak for the London and the south but here in Lancashire things are deteriorating quickly
When is someone going to say enough is enough

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