Inspection and Regulation

NHSI ‘should be able to tell, not ask’ providers to comply

Going forward, NHS England and NHS Improvement (NHSI) will face a difficult conundrum: deciding whether they should be able to tell, rather simply ask, organisations to push forward with necessary changes, especially in situations where service reform is met with resistance by parts of the system.

Lord Carter, who leads on the ongoing efficiency review of the NHS – which is now looking at mental health, community and ambulance services, with a report due imminently – argued that would be one of the greatest tasks national organisations will face as the system begins to implement significant reforms.

Using pathology consolidation as an example, he said organisations will likely be faced with hospitals unwilling to give up their labs, even if changes are based on a greater long-term benefit.

“The pressure we’ll face all the time is, when do we ask and when do we tell? That’s the thing we’re going to need guidance on,” he told delegates. “Because sometimes, the greater good requires people to give things up, which instinctively they would not do unless there was some pressure applied.”

An audience member later asked Lord Carter to expand on his point, arguing that as a taxpayer and future patient, she finds it “quite criminal” that parts of the system are still stuck having conversations about whether certain services should be merged or changed.

“Should NHSI tell, or should NHSI ask? It seems to me there is a role for NHSI to start telling people,” she stated.

Influential health commentator Roy Lilley, who was chairing the debate, called hers a “very good point”, suggesting that there comes a time when NHSI has to look at the data available and simply tell organisations: “this has got to be done, so do it”.

“You say to the NHS ‘we’re going to change how you do things’, and they say ‘oh, we’re going to have a consultation, a stakeholders’ meeting, we’re not sure we can do it in time’. You do bugger about, Patrick [Carter], don’t you?” he joked.

When Lord Carter agreed that the “point is well made” and claimed that “it’s like driving a car – you have to change gear sometimes”, Lilley decided to throw the issue to the audience, made up of health and care leaders from across the board.

Asked if they’d like to see a “more top-down approach to putting in pretty obvious changes that are for the better” – a pretty loaded question, by Lilley’s own admission – the majority of the audience agreed that there is definitely scope for NHSI to become “tougher” on regulation.

During his speech, Lord Carter said he was “cautiously optimistic” about the future of the system, but admitted it will require NHSI – which is currently undergoing leadership change as CEO Jim Mackey readies to leave his role – to push forward with its “great work”.

“I think it’s critical that the work with NHS England strengthens,” he added. “But the thing is, really, how to focus those resources in NHSI in helping people, getting the information into people’s hands, and then having quite robust discussions sometimes about the choices. These aren’t going to be easy, but you could argue, and I think I would, that if you look forward into the next 120 weeks, you can make significant progress.

“Sometimes we just do not get the pace right, and I understand that as providers you have a hundred other things going on that you have to deal with. So, we have to strike a balance between the continual improvement that we need, and actually living the reality of everyday life in a very stretched system.

“I think people have done incredibly well. If I had said to providers five years ago ‘you’ll be taking £3bn a year out’, I’d be laughed out of the room. You have done it, people have risen to the challenge – as ever, we’d like a little more, but this isn’t something we can’t do, because we’ve already done it.”

He also stressed that efficiency should be “an everyday thing”: while certain savings might be episodic and excitement may shift from one part of the system to the other as different achievements are secured, ultimately the NHS has to make “the pursuit of this excellence, both in quality and in operational efficiency” an everyday occurrence.

This was later emphasised by health minister Philip Dunne, who said during his keynote that despite the savings already made due to a “tremendous effort” from the NHS, maintaining financial rigour will be critical in order to keep delivering Five Year Forward View ambitions.

“There is a recognition across the system that making overall control totals is a big effort. It’s very hard to achieve that outcome, but it’s also very easily lost, and we need to maintain a sense of financial rigour and discipline on ourselves in order to ensure that we continue to do so in this year,” he concluded.