Health Service Focus

NHS Confederation: The reset year

NHE’s David Stevenson, Luana Salles and Rosemary Collins look back at the key points from this year’s NHS Confederation Annual Conference & Exhibition.

There was an air of uncertainty and trepidation at this year’s NHS Confederation Annual Conference & Exhibition, which was held at Manchester Central from 15-17 June. The main drivers for the uncertainty centred around finance, as the provider sector faces a potential deficit of £550m this year; delivering new ways of working against very tight timeframes; continued workforce challenges; and the fact that the country was about to vote in the EU referendum. 

Since then, NHS Improvement has come out with plans to reduce the provider deficit, the sustainability and transformation plans (STPs) have been submitted – though there are concerns about how wide-reaching they are – and the decision to Vote Leave has left the health sector with many unanswered questions. 

Best of times, worst of times 

Former health secretary Stephen Dorrell, chair of NHS Confederation, had made a plea to stay in the EU at the conference, saying: “We need a strong economy to guarantee the growth in funding that the health and care service requires, and evidence suggests leaving the EU would undermine this.” The British public disagreed. 

In his speech to delegates, he read the opening lines from Charles Dickens’ ‘A Tale of Two Cities’: “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair.” 

The opening lines, he said, have a “compelling resonance as we reflect on the NHS and wider care sector today”. But Dorrell added that STPs, which were the main topic of debate over the course of the three days, were a “golden opportunity” to rewrite the rules. 

“Rather than being stuck in sterile debates between secondary and primary care, commissioners and providers,” he said, “the planning guidance issues us with a challenge: planning by individual institutions will increasingly be supplemented by planning by place for local populations. 

“It is what many in the health and social care system have been seeking for years. An end to top-down re-disorganisation and an opportunity to reach beyond the silo to create joined-up services that meet the needs of local people.” 

Stepping up 

Stephen Dalton, the interim CEO at NHS Confed, who is celebrating 40 years in the NHS, added that he believes there is a consensus about that the way forward for the service. “But it won’t be found in leaders circling the wagons and launching another internal sterile debate about who is to blame or the magic being more money,” he noted. 

In his opening address, Dalton added that the conference should be “all about the future, optimistic and looking ahead”; he also made a plea for a more diverse next generation of leaders. 

“If you haven’t been around forever, share my ethnic background, sexual orientation, and if you’re not male, let me send you a very clear message: you look like the future of NHS leadership,” he said. “To all the white heterosexual males who are aspiring to be leaders, there is room for you too. It’s just your place in the queue isn’t as secure as it used to be.” 

Dalton also launched ‘Stepping up to the place’, a joint report from the NHS Confederation, Local Government Association (LGA), Association of Directors of Adult Social Services (ADASS) and NHS Clinical Commissioners (NHSCC) which argues that local systems should embed integration as ‘business as usual’ in order to achieve it by 2020. 

The LGA’s community wellbeing spokeswoman, Cllr Izzi Seccombe, said that it was first time that the LGA has been present at the NHS Confed event, but highlighted the need for greater collaborative working going forward. Sir Howard Bernstein, the CEO of Manchester City Council, also discussed how Greater Manchester, the first area to have health funding devolved to it, is pushing to develop single commissioning hubs for all public services across its 10 localities. 

“[This will] ensure that when we talk about early intervention, when we talk about early help, when we talk about the type and quality of public services that people of this conurbation, and I suspect in other places in this country, require, we are going to be able to deliver the outcomes that are necessary,” he told the audience. 

Sir Howard added that partnership structures and locality plans must be created in order to give the sector a chance of becoming financially sustainable in five years’ time. 

STPs like bringing up the children 

Dr Amanda Doyle, co-chair of NHSCC, chief clinical officer of Blackpool CCG and the STP lead for the Lancashire and South Cumbria footprint, reiterated the point that “we’ve got to do things differently and do it quickly”. 

She said: “It takes a different way of working, but we’ve got to play to the strengths of our teams. Leadership has to be collaborative, open and transparent.” 

Dr Doyle added that the STP lead has no formal authority, but it feels a lot like being a parent: “People don’t necessarily do what you say, but you role model behaviour and create an environment for change.” 

Sessions throughout the day covered health and care partnerships, putting parity into practice, commissioning for the future, self-care, public health cuts, and the workforce challenge. 

International comparison 

At the end of the day, delegates heard from Jason Helgerson who highlighted his experiences from directing the Medicaid programme for over five million people with an annual budget of more than $54bn. His session focused on his learning from leading the effort to fundamentally reshape care in New York State, in order to lower costs and improve quality. 

He reflected on the need for health organisations to see the “broader picture” to deliver changes:  “At the end of the day, complex patients, especially low-income complex patients, oftentimes have social needs that trump their healthcare. If a person with diabetes is living on the street there’s no way to manage their disease, why? Because there is nowhere for them to put their insulin if they are living on the street. Without that insulin, without that ability to manage their disease, guess where they end up – in the emergency room over and over again. In order to address those challenges we have to take on housing, employment, and be willing to see the broader picture of the populations we serve.” 

At the start of day two, Dorrell was involved in a session looking at the Carter Report recommendations for creating a happier workforce to deliver productivity savings. However, the Nuffield Trust’s Nigel Edwards and Paul Scandrett from Allocate Software highlighted the issues of a growing workload in an intense environment. 

Edwards also discussed the principle of a ‘psychological contract’ with workers, and the need to tackle bullying in the NHS. 

Addressing mental health 

In another session, Claire Murdoch, the newly appointed national mental health director, laid out ambitious targets to be achieved by 2020 as part of the government’s commitment to improving mental health care. These included ensuring that at least 50% of hospitals had 24-hour psychiatric liaison services, that the Improving Access to Psychological Therapy (IAPT) programme reached 25% of people in need, reducing suicides by 10%, and ending the practice of placing children in out of area psychiatric services.

Murdoch pointed out that the clock is ticking on the Five Year Forward View and that it is now a three-and-a-half year plan. “My immediate priority is to drive transparency into the three and a half year plan,” she added. 

Dr Doyle added that mental health had to be “one of the key aspects” of an STP, saying that mental health considerations should be embedded in all aspects, including primary care, crisis care and A&E medicine. However, former care minister Norman Lamb, seems to suggest this might not be the case across the whole country. 

Still the right man at the helm 

Just before lunch, health secretary Jeremy Hunt MP took to the stage where he highlighted areas of achievement in improving access to cancer services and  talking therapies for mental health patients. However, he added that much more needs to be done to improve patient care. 

During his keynote, Hunt discussed, jokingly, how he had “scaled new heights in popularity” this year, following the junior doctors’ contract debacle.  He also told conference chair Anita Anand that, despite the industrial problems of this year, he was still the right man to steer the NHS through the choppy waters ahead. Since the conference, BMA members voted against the revised contract which Hunt has now, once again, said he will impose. 

Following his keynote speech, Hunt added that in these difficult financial times transformation is very important and the 44 footprints that NHS England’s CEO, Simon Stevens, is putting in place “are going to be very important to do this”. 

“I would say, though, that there is a way we can get this wrong and a way we can get this right,” he said. “The way we get this wrong is if people use their STP plans in a time-honoured NHS way to bid for extra pots of money, and then they go on and do what they want to do anyway, having put together the business plan, and ticked everyone’s boxes. 

“The STPs are very simply about reducing hospital bed days per thousand population and reducing emergency admissions. 

“I think the successful STPs will be the ones that have rigorous data in place that track whether or not the many initiatives they are doing is reducing hospital bed days.” 

He added that of the NHS’s £22bn efficiency savings, £4bn of that is around demand reduction. “That is what we need the STPs to do,” said Hunt. “That rigorous use of data is going to be essential.” 

The future is digitisation 

The main exhibition hall was full for Hunt’s speech and Q&A but, unfortunately, seemed to empty rather too quickly ahead of the ‘Digital Doctor’ Rob Wachter’s presentation on harnessing the power of digital to improve health and social care.

He shared some of the headline findings of his government-commissioned review of digitisation in the NHS, which is due to be published in September around the time of NHS Expo. He noted that digitisation is the ‘most robust mechanism for transformation’. 

Professor Wachter highlighted 10 “insights” from his review for the NHS. These were: digitisation is not an end in itself, it’s to improve quality/safety/efficiency/patient experience; clinical buy-in is “absolutely essential”; the US experience shows that central money and local spending can deliver digital hospitals; good central infrastructure, such as the Spine, should be leveraged; government should not over-regulate IT; interoperability is crucial, “so bake it in early”; user-centred design must be a core value; IT needs to evolve to help overcome the productivity paradox; IT is a backbone for working in new ways, but must have culture, people and flexibility to change; it is important not to “overpromise”. 

Dame Fiona Caldicott joined Prof Wachter on stage discussing digitisation, adding that her review into Data Security would be published soon. 

Getting on with the financial challenge 

In a well-received NHS Confed main stage debut, the head of NHS Improvement Jim Mackey used his speech to spotlight several examples of good work happening across the country, including Wexham Park, Bolton, West Midlands Ambulance Service and East and North Herts Vanguard.

However, he was clear that more still needs to be done and that the NHS will be dealing with its financial difficulties for “years”, but the health and care system “just needs to get on with it”. Mackey also revealed that NHS Improvement will be consulting on a new oversight framework, and that the regulator is working on a plan to try and utilise the NHS estate better to provide more affordable housing for NHS staff, especially for those working in the capital. 

The reset year 

Simon Stevens, NHS England’s CEO, took to the stage on day three, saying that he thought Mackey was “bang on the money”, but added that there are “bloody tough times ahead” for the NHS. 

He added that after making the case in the Spending Review, the NHS has a “U-shaped funding settlement which – against a very difficult fiscal backdrop – can be regarded as good as would be obtainable under those circumstances”. 

But he explained that there are three important consequences of the Spending Review which are really relevant for the conversations “we are having now, through the STP process, and things we’ve got to get right this coming year”.

“First, the capital is incredibly tight. So as we think about our plans – our care redesign in the 44 geographies across the country – solutions that are heavy on capital expenditure, right now it is hard to see how they are going to be financeable,” said Stevens. 

“The second impact is that a lot of the improvement we want to see in new funding programmes – be it mental health services, cancer, others – the extra purchasing power for that – regrettably in some ways, but just as a matter of fact, let’s be honest about it – a lot of that extra purchasing power is back-ended towards the 2019, 2020 period. 

“The third consequence of this U-shaped funding settlement is that this year now really matters. We have to use 2016-17 as the reset moment to get our finances, our performance, back in a place where we can then pivot off to the rest of what this five-year settlement looks like.” 

He added that it would not be “prudent” for the NHS to assume any additional funding in the next several years, and he said there is a strong argument that “were extra funding to be available, frankly we should be arguing that it should be going to social care”. 

The next generation

As the conference drew to a close, Health Education England’s chair Sir Keith Pearson, speaking before the inspirational Dame Kelly Holmes, called on delegates to consider the multi-generational staff in the NHS, the different values and incentives, and preferred balances between work and play. 

Showing a video clip showcasing the attractiveness of a career in the NHS through the lens of school children, he spoke of the need to ensure a happy and productive workforce that chooses to stay with, or return to, the NHS. Unfortunately, this is something which, against the backdrop of challenges facing the sector as highlighted at the show, may be easier said than done.

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