interviews

'A long way to go'

Rick Stern, the new chief executive of the NHS Alliance, has stepped up at a key time for the organisation, with its longstanding goal of clinical commissioning now enshrined in law: but big challenges remain, especially in improving primary care provision, he tells NHE.

The NHS Alliance was one of the few organisations that remained basically supportive of the NHS reforms throughout the tortuous legislative process of getting the Health & Social Care Act passed, despite its members’ disagreements with some aspects of the new law.

Via the Clinical Commissioning Coalition – its alliance with the NAPC – the organisation has kept up the pressure on the Government and NHS top brass to stick to the original principles of ‘Liberating the NHS’, and not to let centralising instincts step in to demand to control everything CCGs do.

Michael Sobanja stood down as NHS Alliance chief executive in April, to take the role of director of policy instead. Rick Stern is the NHS Alliance’s new chief executive, responsible for governance, members’ services and networks, while Julie Wood is taking the lead on clinical commissioning.

Culture and behaviour

We asked Stern how much pressure the NHS Alliance came under from its members over the non-clinical commissioning parts of the new law during the fight to get it passed.

He said: “We had a very active debate throughout the process about what we agreed with, what we believed in, and what we supported. Our view actually was that while we saw clinical commissioning as central to the Bill and central to our aims, there were other things, we were well aware, that members were less happy with.

“The reality is, that’s now finished: it is over. What we were always aware was far more important was the implementation, and given that we’ve been at the heart of decision-making, because we were supportive of a key aspect of the Bill, we are going to ensure that we remain there, and hold the Government to account in actually implementing the aims of this.

“We want to ensure it’s not just rhetoric, about putting clinicians at the frontline and giving freedom to local clinicians to be innovative and try new things: we want to make sure this happens, because we passionately believe this is the way forward for improving healthcare.”

But, he said, “we constantly get informed by members who are frustrated about not being able to move faster”.

“The really big challenge is less about the new structures, and more about culture and behaviour within the NHS. Can this complex institution actually behave in a different way, and allow people to take more local control, to avoid saying how people should do things? It’s a massive challenge, at a time when the finances are so tight, at a time when you would expect the centre of the organisation to be more in control, we actually have a commitment and promise to let go.

“These are very difficult tensions, but we will be constantly reminding policy makers and politicians that the only way this will work is if behaviour really changes, and we work in a more devolved environment, where people can deliver services in a different way on the frontline.”

On the question over CCGs being strong-armed into employing ex-PCT staff, Stern said: “As a basic principle, we need to use the skills effectively of people who have worked within the NHS. On the other hand, it’s important that CCGs should have some freedom who their staff are, how they’re supported, and what works best for them.”

Primary care provision

Stern, who previously led the Urgent Care Network at the NHS Alliance, and will still remain attached to it, is keen to develop the organisation in terms of primary care provision.

He said: “A lot of the focus has been around commissioning, for understandable reasons, and it’s been a key aim for the Alliance right from the beginning of its existence, a greater focus on frontline clinicians running and shaping the NHS – but, actually, provision is vital too.”

We asked Stern whether the focus would be on urging implementation of policies and ideas it has already developed, or on research and evidence collation and new discoveries.

He said: “We have ideas that we’ve been committed to for some time about improving primary care: we’re clear that reducing variation in primary care is an important issue. Some variation is because people live in different communities, and you need difference, but a lot of it is unnecessary.

“How do we reduce unnecessary clinical variation, and ensure people get good, timely, accessible services, across the country? These are difficult issues, and require a lot of thought, but certainly we’ll be thinking more about it.

“There are issues about organisations as well. There will be new providers coming into primary care: some commercial, some mutual, other former NHS organisations. How do all of those work effectively do deliver high quality outcomes in primary care?

“There are considerable challenges there, so part of what we will do is set up effective networks so people can have those discussions, develop new ideas, and share them – rather than people constantly having to reinvent things themselves.”

The road to integration

Integration with social care will also be key, he said, and can’t be seen as a separate problem.

“It is fundamental to any improvement and change. There is a lot of talk about integration, and our next conference’s title is ‘The Road To Integration’: the real challenge is to put that in simple terms that make sense for everyone. For me, integration is about how health practitioners, social care practitioners, people from the local community, from the third sector, work together as an effective team to deliver better care to patients.

“Social care is central. I don’t think the debate about health and social care integration has moved away at all, it’s right at the heart of this. For me, at the heart of it is an integrated primary care team, includes health, social care, and community support, frequently based around individual groups of practices as the ‘front door’ of the NHS that most people associate with.”

He noted that the NHS Alliance’s membership already includes new providers, such as mutuals, and increasingly independent and commercial providers too.

He said: “It is possible for different providers to sit alongside each other and share a whole range of information about how they work, because in the end, we all have a common goal: improving care for patients.”

Reconfiguring care away from the acute setting, except where absolutely necessary, is a goal of many in the health service and is key for the Alliance too, Stern said: “The Alliance has always been committed to more effective working across primary and secondary care. For many years, we’ve had a network of specialists: consultants and other clinical staff who work within hospitals, but who are focused on how they can provide a lot of what they do more effectively out in the community.

“It’s another area that we want to give more attention. We’re absolutely committed to finding best practice around how this can be done, sharing it and promoting it.”

Participation and democratisation

Stern is particularly keen to make more use of the expertise of the organisation’s membership, and to encourage more conversations between them to generate ideas.

At the annual conference, for example – which this year takes place in Bournemouth on November 21-22 – Stern says: “The most interesting people are in the audience, not on the podium.” He went on: “As soon as people register, they’ll become part of an online community, and the discussion and debate starts straight away: it’s not just a two-day conference, it’s a rolling process for getting involved.

“One thing that’s really important for me is that we develop a better and extended relationship with our members, that actually people feel they can participate in a whole range of new ways, which make the organisation more useful and more directly relevant to everything they do.”

The conference is to use Open Space Technology, which promotes broad engagement and multiple conversations rather than set agendas and speeches.

He said: “It’s a different way of allowing our members to decide for themselves what matters. Coming out of one of the workshops may well be an online debate that leads to a new discussion paper, that shapes policy for the future, for example. We want, as much as possible, in terms of the process, for our members to help decide what the issues are.”

He is also especially keen to keep costs low for members during these difficult financial times.

‘A long way to go’

Asked about the journey the NHS Alliance has been on since its founding in the 1990s, Stern said: “We are delighted that the mission of the NHS Alliance is now enshrined in law, but there is a long way to go before it is the reality in practice.

“Our big challenge now is helping to build an NHS where we turn policy into practice.

“It’s a great achievement to have got here, but this is not the Promised Land yet: it’s just the next step in trying to make it happen in practice. It’s exciting but the next set of pressures and priorities immediately come through.”

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