Another structural reform is coming to the NHS. Through consultation on its ‘Integrating Care’ paper, NHS England and Improvement (NHSE/I) is currently gathering views to inform legislation to underpin its policy agenda.
Something is needed. The current legislative framework – provided by the 2012 Health and Social Care Act – hampers and distorts the efforts needed to make integrated care a reality.
In broad terms, the direction Integrating Care sets out seems right. In place of hard purchaser-provider splits, supply-side competition, patients as consumers, and technocratic tweaks to contracting, Integrating Care describes a world of collaboration. A world of relationships over contracting rounds. Of locally-devised approaches over nationally-prescribed models. Of Integrated Care Systems over Any Qualified Provider.
History cautions against betting too much on structural change leading to better results. But the agenda in Integrating Care would remove some barriers to collaboration, reduce unproductive regulation and ‘assurance’, and avoid waste associated with procurement and competition.
In short, this gives the NHS broadly what it needed in 2012. It better fits a reality of an ageing population, long-term conditions, constrained resources and the limitations of healthcare in improving outcomes.
If enacted, it could also effectively end an era of health policy - running roughly from the late 1980s to the middle 2010s – which was animated largely by the logic of the market.
This era was itself was fuelled by an increasingly extreme form of economic and social liberalism: an ideology which has been badly exposed by the pandemic, and which has recently been rejected several times by the electorate. The political tides are turning, and they seem to be taking health policy with them.
So given the price of passing NHS legislation – in political and managerial capital – is Integrated Care ambitious enough? Is there a risk of passing up an opportunity to pursue more meaningful reform?
If so, what direction should this take? And are there any Covid-related break points or broader trends that the NHS could usefully work with?
This is thesis, rather than blog territory. But my brief take is that:
- Post-Covid, we will be increasingly certain that the state is over-centralised and under-powered. There will be many examples of expensive central failure, alongside well managed local success. At a very broad level, the UK may cease to exist as a political entity; the centrifugal force that will pull it apart is a desire for greater local control – and this could be harnessed positively.
- State capability may expand. The relationship between state, market and citizen has changed so radically under Covid that wartime is the usual analogy. Desires for security are likely to remain strong; and voters may struggle to understand why the state is so reliant on contractors and so unable to act itself. Evidence of inevitable profiteering and price gouging will fuel this.
- Voluntarism will grow. The pandemic has provided plentiful examples of voluntarism and community led action. People will commit time in return for meaning and a feeling of contribution.
- Individualism will be found wanting. This is near-pure speculation, but my sense would be that countries will high levels of community-mindedness will be seen as performing better than those with a very individualist mindset. Covid has exposed the flawed assumptions of liberal individualism and its attendant inequalities. It is then a very open question whether we then pull together, and embrace a more communitarian culture, or fall further apart.
- The role of expertise will be better understood. Doubtless, multiple ‘wrong calls’ will have been made by experts during the pandemic. But the overall conclusion is likely to be that expertise was an essential and strong part of the response. More precisely, its value will be better understood as an input to decision making: not as a substitute for it.
If the above is speculative, saying what this might mean for the NHS is even more so. Yet much of what would be implied would be going with the grain of Integrating Care. It might mean:
- A far greater presumption in favour of localism. Integrating Care is strong on this – even mentioning the principle of subsidiarity – but there are still multiple pulls back to national instruction and oversight. Accountability runs up the bureaucracy, not out to the citizen. So could more local accountability be built in? Could the current local authority role be extended here?
- A stronger emphasis on community action, voluntarism and non-state / non-market organisations. Could more be done to trust, support and work with the desire to participate and lead coming from this direction? Could volunteer efforts made under lockdown be harnessed to help address resulting backlogs? Our work has found huge surges in demand for mental health services, could peer support and the voluntary sector play an even more significant role in supporting recovery here?
- Regenerating through the NHS. With a clearer recognition of the NHS as a local economic actor, and with a desire to build state capacity to act, how can the NHS privilege public value over shareholder returns? And in building capacity to act, can it also consider resilience as a goal, rather than (the illusion of) efficiency?
- A renewed focus on inequalities. This will be a tall order. Debates on inequality are increasingly complex. It won’t be the first time the NHS has prioritised this topic and we frequently fail to provide equity of access, let alone outcomes. So can the focus on this be made sharper and more serious? In working through waiting list backlogs, will inequality be a consideration? The more fundamental question here is political and societal, but the NHS could play a vastly greater role.
- A clearer role for expertise. How could the NHS better balance its technocratic power with desires for local participation? We could make far more use of approaches such as citizens panels and participatory methods for decision making – alongside our use of data and empirical evidence. Citizens can say what matters; experts how it can be realised.
In very many and very obvious ways, these are dark and difficult times. Yet the above is enough to give me some hope. The approaches and assumptions underpinning recent decades of health policy appear to have run their course.
As with broader political trends, it is not entirely clear what will follow. But shifts towards localism, empowered citizens - and maybe even some sense of common good – are welcome within the mix. Policy seems to be drawing closer to the demands of circumstance and pragmatism is re-emerging.
While these trends are playing out and legislation takes its course, the Strategy Unit is putting its weight behind improving local decision making. The value of this was recently recognised by Simon Stevens. Through the development of Decision Support Units, we are supporting areas in the Midlands to gear up for a world of (hopefully) increased responsibility and latitude.