Lost in Translation

It’s everywhere isn’t it!? The conundrum that is funding the NHS I mean. The announcement a few days ago by the Prime Minister of £20bn over 5 years may have taken some of the heat out of things (at least temporarily). However with Jeremy Hunt insisting that a credible plan for the NHS needs to be in place and that the funding is “conditional” and with Lord Darzi (through the Institute of Policy Research), Nigel Edwards at the Nuffield Trust and the Kings’ Fund all chipping in (as well as the popular and serious press), it is unlikely to be quiet for long.

My view is that this focus on the “pot” of money erases any subtlety from the message of what the NHS needs to do and how it needs to be. Let’s not forget that at the end of 2014 a case and a vision for/of NHS change were made in the 5 Year Forward View1. Most saw merit in the general thrust of that document. Soon after Sustainability and Transformation Plans/Partnerships started to map around the needs of whole areas rather than individual organisations, but they also (as the Nuffield Trust reported2) were  “targeting up to 30 per cent reductions in some areas of hospital activity, including outpatient care, A&E attendances and emergency inpatient care over the next four years……… planned in the face of steady growth in all areas of hospital activity – for example, a doubling of elective care over the last 30 years.” This was done on the hope and expectation that “moving care out of hospital will deliver the ‘triple aim’ of improving population health and the quality of patient care, while reducing costs”. In truth the impact of planned STP changes has a very mixed impact on costs and in a timescale that doesn’t necessarily fit with political imperatives.

But it appears that what quickly happened – as my Healthcare Financial Management Association colleague and experienced finance director Paul Assinder asserts3 is “….that plans (STPs) have led to an almost exclusive focus on reducing NHS spending or future NHS cost avoidance, sidelining the original triple aims (and arguably local authorities and the third sector)”. He also states that STPs have “shrunk their scope to major on resources to the near exclusion of outcomes”

We also should not take for granted that an increase in promised funds can be easily tied to reform as the “conditional” offer seems to imply. Nigel Edwards From Nuffield Trust in a series of tweets makes important points about the need to a) repair the foundations of the NHS first before looking to put money into new initiatives, b) be realistic about timescales and costs of large-scale reform c) place importance on developing the workforce required to deliver the plan d) be wary of structural change which is usually a massive distraction and e) get enthusiasm from staff for reforms rather than it being seen as an imposition. All in all a challenging agenda (and I have edited down Nigel’s even longer list!)

My argument therefore is that the big messages have got “lost in translation”. Defining the reason for large-scale change from a user perspective – improving health, improving quality of care and making the experience of care less onerous/more in tune with today’s society should continue to be made regularly and loudly! Without this focus on the big picture of change, the important but all pervading issue of money will continue to dominate. The NHS’s own Change Model (developed in 2012) puts this shared purpose at the centre of things – let’s get that need for change and the problems we are trying to solve firmly in focus going forward.

1 NHS England Five Year Forward View October 2014
2 Imison C, Curry N, Holder H, Castle-Clarke S, Nimmons D, Appleby J, Thorlby R and Lombardo S (2017), Shifting the balance of care: great expectations. Research report. Nuffield Trust.
3 Healthcare Finance October 2017