ABHI Update: Summer Holiday Reading
For those without school age children (or perhaps especially for those with), August is a great time to be in the office. It is fertile planning territory. Deserted desks are an aid to unbroken concentration and there are fewer distracting pings of the e-mail, each one offering the promise of contents far more enticing than whatever it is you are actually supposed to be doing.
Spare a thought then for colleagues in NHS England. Skipton House will not be quiet this summer and there will be no let-up in the volume of electronic traffic. The NHS has a new 10-Year Plan to deliver by the autumn to sit alongside the fine detail of a new, improved funding settlement. True they have had time to prepare, the announcement about the plan, and the money, was made by the Prime Minister as long ago as March. Michael MacDonnell and the big brains at NHSE’s Strategy Directorate have also seen enough of promise in the Five Year Forward View, and its New Models of Care programme, to have a sense of what the future needs to look like.
On the other hand, they have had the unexpected distraction of a new Secretary of State. Few would envy Matt Hancock and the notoriously difficult health brief so early in his ministerial career. Following the post’s longest ever incumbent might also not be too easy. Time, I think, will judge Jeremy Hunt as having emerged in credit, and Hancock recognises this. He has been quick to differentiate himself. If the era of Hunt will be characterised by a laser focus on patient safety, then Hancock has set out his stall to be known as the technology guy. I have yet to read an article about him, and there have been a few, that does not reference his expertise in the area, or his comfort of living in an App driven world. He has even, rather cheekily I thought, and completely unashamedly, re-announced the creation of Digital Innovation Hubs in his own name.(1)
It is a smart move, not least because the likelihood of quick, impactful wins is very high. Hancock knows that what he has to do first is, or should be, relatively straightforward. He has to fully digitise the NHS(2). Granted the NHS does not have a great track record of big IT projects. The National Project for Information Technology (NPfIT) has cast a long, lingering shadow over the service. NPfIT was implemented in 2002 to make the NHS more technologically advanced, but after 10 years, and almost £10bn, the project was scrapped and labelled as the biggest IT failure ever seen. It was also one which blighted a number of hitherto glittering, public sector careers and delivered close to zero of its initial intent.
But the digital world has probably evolved more in the last 10 days than it has since a time before the iPad existed. Some things also just seem dafter now than they did then. One of the metrics Hancock has set himself, for example, is to eliminate the use of fax machines in the NHS(3). My home is in West Cornwall and on a clear day, and we do have some occasionally, I can stand outside my house and look across Mount’s Bay at the Lizard Peninsula, where there is the greatest concentration of satellite connectivity on the planet. If I go 40 miles up the coast in the other direction, I get to Newquay, where they are building a Space Port. An actual Space Port. It is science fiction, yet I cannot go on-line and book an appointment to see my practice nurse. The fact is that we are now living in a time when, and amongst a generation for whom the delivery of analogue NHS services in a digital age is unacceptable.
Make no mistake, when Hancock talks about technology, and the money earmarked to support its use, it is that basic digitalisation he means first and foremost, and it is where he will focus his energies. So whilst there may not be an immediate windfall for us in the HealthTech sector, there is a bigger prize for all. The increase in efficiency and productivity that using the same technologies that have revolutionised the rest of our lives can bring, will free up any amount of resources to be deployed elsewhere. It will, most of all, give the NHS the space it needs to get on with the transformation it knows it has to deliver.
Technology will, doubtless, be a major enabler of the new 10-year plan. Simon Stevens, like just about every other senior civil servant not on the Brexit frontline, has maintained a rather low profile in recent months. However, he has begun to think aloud, and publically, on what his priorities are for the next period.
Stevens has highlighted five long-term priorities which will form a core part of the 10-year plan. Some will be recognisable from the Five Year Forward View, others are new.
First, mental health, especially for children and young people, so called CAMHS. There is no doubt that mental health is the single biggest challenge of our time. Our police cells and A&E departments are filled with people who should be in the care of mental health services. Some of the most successful “Vanguard” programmes have seen street triage initiatives almost immediately reduce A&E admissions.
Furthermore, workplace-based stress, relationship breakups and other factors that increase absenteeism, are hammering our productivity. Nobody recognised this better than Sir Howard Bernstein in his vision for the devolution of Greater Manchester. Sir Howard, passionate about rebalancing the economy of the UK from South East to North West, recognised that he did not have a competitive workforce across his city. Part of the reason was that generations of families had been failed by the health and care system, and it is why he fought so hard to have it included in the deal. The Greater Manchester Health and Care Partnership remains revolutionary in many regards, and you can see why we have been keen to agree a Memorandum of Understanding(4). Nobody, anywhere, ever, has articulated the “health is wealth” argument better than Sir Howard Bernstein.
Opportunities for our sector in the mental health arena may not be immediately intuitive. However, connectivity, digital platforms and the delivery of care remotely are all generic elements that will play an important role in the mental health services of the future.
Cancer will remain a priority, and early diagnosis features in other elements of government policy, notably the Life Sciences Industrial Strategy. Stevens, however, does recognise that reforming early intervention and diagnostics will be dependent on changes to the NHS workforce.
“New” priorities are a focus around cardiovascular disease, with a particular emphasis on stroke, where it is felt the NHS is some way behind international standards. There will be a renewed focus on children’s services, and prevention and inequality as they affect children.
Finally, there will be new objectives for reducing health inequalities. The “war on variation” has been a familiar theme of ABHI’s outputs in recent times, and outcomes will be measured across a variety of factors including socio economic, race, gender and culture.
The coming weeks will also see priorities emerging from discussions with NHS organisations, sustainability and transformation partnerships and integrated care systems. But there is no Plan B, and the joining up of care as described in the Five Year Forward View will continue apace.
Members have expressed concerns over what appears to have been a relaxing of the 18 week RTT (referral to treatment) target, although speaking as a Non-Exec at an NHS acute Trust, it really does not feel like it. There was certainly a fall-off in elective activity over the winter period, which is something we are addressing with the Royal College of Surgeons. We are, of course, in a zero-sum game and the new money, which we do not see until 19/20 anyway, will not support the growth in activity experienced in the first decade of this century, but we should expect to see some relief. However, the fact remains, we ration care one way or another. Stevens believes that waiting times should be based on clinical need and that the 18 week target is helpful, but not the only way of doing things. Our work with the GIRFT team and through the newly constituted Health Technology Partnership will highlight ways in which we can improve patient flows and free-up capacity.
Stevens has promised that the next three years will bring a “wholesale shift” in NHS funding rules, including the end of “sustainability funds.” The funds were always a bit back to front. Basically, they were allocated to providers on their performance against locally agreed indicators. So hospitals that performed the best got given money to help them get better, whilst those that needed help, and were probably in financial distress, got nothing. The same goes for “control totals,” the overdraft limit of an individual NHS organisation. It makes little sense for commissioners and providers on the same patch to focus only on their own control total, rather than considering the system as a whole.
Changes are afoot.
The most fundamental change is likely to be a move away from activity-based payments and, thus, the national tariff that we have grown to know, if not quite love. This was inevitable once the direction of travel to integrated, place based, care systems was signalled, but it presents challenges for everyone. The tariff is one of the few levers the centre has that can affect change instantly. I remember former Health Minister Lord (Norman) Warner telling me how he and, then Secretary of State, Patricia Hewitt, used to play tunes on spreadsheets in Richmond House. That type of control will be hard to relinquish. Note, for example, the increase in what was defined as “specialised” and therefore commissioned centrally, after the 2012 Health and Social Care Act moved the money out to Clinical Commissioning Groups.
One of the reasons behind the national tariff in the first place, was to facilitate choice and allow providers to easily contract with commissioners outside of their local area. Hospitals have always worked across multiple footprints, and will continue to do so. The development of integrated care systems will not preclude the need for large and specialist providers to deliver care on a regional and national basis. In the absence of a national tariff, new mechanisms will have to be developed and the risk is that they will be heavy on administration and remove yet more control from the centre. Extra Contractual Referrals were abolished almost two decades ago, and before the national tariff, for that very reason.(5)
For us, the shortcomings of the national tariff have presented opportunities. The creation of an exclusion list for high cost devices came as a result of ABHI lobbying at the time, and the Innovation Technology Payment provides a way to pay for products that might otherwise struggle to be picked up in the tariff.(6)
The challenge at ABHI Towers will be to see the end of the tariff as the same opportunity. Members should also think about their own business models. Radical, innovative approaches to recognising value are likely to be well received in the foreseeable.
A plan covering the financial years from 2019-20 to 2021-22 is being developed with NHS Improvement, and in discussion with the service, which will be set out at the end of September, with confirmation the following month.
That, then is the state of the NHS as we head into the summer holidays. These themes will be considered further and by many of the key actors on 6th November at our UK Market Conference, so make booking that the last thing you do before switching off the lights and locking the door.
Travel well.
Notes
1 – If there were any IP associated with the hubs it would belong to Professor Sir John Bell whose idea it was. It is the jewel in the crown of his Life Sciences Industrial Strategy crown. Plans for the hubs, and the separate but inextricably linked Local Health and Care Record Exemplars (LHCREs) are also well advanced.
2 - Getting the NHS to behave like it is fully digitised will be a challenge of an entirely different magnitude.
3 - Best not to forget they were introduced because they work and remain, without that full digitalisation the best way to instantly transfer data between organisations.
4 - Expect news from this year’s EXPO
5 – Actually, after a campaign in which Yours Truly, was involved they reappeared as Named Patient Service Agreements
6 – A real issue for IVDs and other technologies that are regarded as “overheads.”
