Listening again to NHS chief executives

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Re-reading our new report on being a chief executive in the NHS, published in partnership with NHS Providers, I was struck by three recurring themes.

The first is their reflections on the organisation of the NHS. Time and again, those who were interviewed bemoaned the impact of the Health and Social Care Act 2012 and the complex and fragmented structures that resulted. Their plea was to find a way of simplifying and streamlining these structures, including at a national level, in order to bring back a focus on populations and systems rather than organisations.

The second is their questioning of the value of commissioning, at least in its current incarnation. Given that most of the chief executives were from providers, this is perhaps not surprising, but their view that commissioning adds cost as well as complexity needs to be taken seriously. At a time when restoring financial balance and finding £22 billion worth of productivity improvements are major priorities, all avenues should be explored.

The third is their view that the NHS is over regulated. It’s important to understand that they were not arguing that regulation is unnecessary. Rather their view is that the work of the Care Quality Commission, Monitor and others has taken regulation to levels that are difficult to justify, resulting in chief executives and senior colleagues spending much of their time responding to the regulators when they could be employed more productively.

Reflecting on these themes, it is difficult to escape the conclusion that fundamental changes are needed to the organisation of the NHS, the role of commissioners, and the reliance on regulation as a means of improving care. The Fund’s work has set out what these changes should be, with an emphasis on rapid evolution and much more priority given to reforming the NHS ‘from within’.

Our view is that the future lies in place-based systems of care, in which commissioning becomes much more strategic and integrated. This means bringing together budgets for health and social care and focusing on the outcomes to be delivered. It also means agreeing longer-term contracts and commissioners working across wider geographical areas than they do today.

This is beginning to happen in the footprints that have been identified for the development of sustainability and transformation plans. A major challenge is for the organisations involved in sustainability and transformation plans to agree on governance arrangements that will balance the accountability of NHS boards with the need for decisions to be taken collectively on future care models and the use of resources.

Local government has some experience of doing this through combined authorities in major conurbations such as Greater Manchester and the Sheffield City Region. The Cities and Local Government Devolution Act 2016 has created a new impetus for councils to work together to undertake functions that are better carried out collectively, such as economic development and regeneration and transport planning.

Combined authorities are voluntary and depend on constituent councils agreeing to work in this way. Devo Manc is based on a history of councils in Greater Manchester working together in a combined authority indicating what is possible when combined authorities work effectively. There is currently no comparable legal framework for the NHS and one option would be for the government to legislate to make it possible for an NHS version of combined authorities to be used in sustainability and transformation plans, where there is a local desire to do so.

We have also argued that now is the time to recognise the limits of regulation and inspection except as a means of quality assurance. What is needed instead is a national quality improvement strategy in which every NHS organisation invests time and resources in supporting staff to deliver better outcomes at lower cost. NHS organisations should work together in regional collaborations to share scarce expertise, as happens already in some regions, and there should be a modestly sized national quality improvement centre to provide leadership and oversight throughout the NHS in England.

It would tempting to listen to the view of chief executives and argue for another blueprint for reorganising the NHS. This temptation should be resisted, given the damaging and distracting impact of the Health and Social Care Act 2012. The challenge for leaders at all levels is to commit to rapid evolution rather than top-down restructuring, and in so doing develop an organisation capable of rising to the unprecedented challenges that lie ahead.



Member of the public,
Comment date
20 May 2016
We have listened enough.
We want shoulders to the wheel - getting on with the job that practitioners are paid to do and better serve the public. We are all in this cycle of more work with more pressure, not only the NHS.
Of course every service wants more and I wish them well in trying to get it but PLEASE spare us more excuses, scrutinies, meetings, reviews etc etc the public have had enough of these delaying tactics.

Andy Blsck

Ordinary bloke,
Comment date
25 May 2016
CEOs must also take some responsibility for their angst. They are highly paid leaders not sheep. They have perhaps allowed themselves to be herded too easily and now don't like their pasture. As well as kow towing to government, they have a responsibility to speak truth to power and to the public they also serve. It was not always thus.

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