234.The health and social care landscape includes a complex national system of executive agencies, non-departmental public bodies and regulators, as well as the Department of Health and Social Care. The roles, responsibilities, legal powers and functions of these national bodies in many cases were introduced in statute by the Health and Social Care Act 2012.
235.These bodies are responsible for a complex range of interrelated and interdependent functions. The extent to which these bodies collaborate has a significant bearing on the operating landscape NHS and social care providers work within. This chapter describes the key concerns we heard about the role of national bodies in the development of sustainability and transformation plans.
236.There is a widespread perception, particularly from health and social care providers and commissioners, including their representative bodies, of competing priorities between the key national bodies, particularly the Department of Health and Social Care, NHS England, NHS Improvement and the Care Quality Commission. This incoherence is manifested not only through conflicting policies, but also through the mixed messages local organisations receive from these national bodies.
237.Incoherent messages and priorities between NHS England and NHS Improvement have been evident since the beginning of the STP process in December 2015. The King’s Fund’s report on the development of the original sustainability and transformation plans concluded that there was a need for closer alignment, and clearer messages, between NHS England and NHS Improvement as well as from regional teams within these organisations. These inconsistencies between NHS England and NHS Improvement have persisted.
238.Local organisations, according to the National Audit Office, have continued to receive inconsistent messages from NHS England and NHS Improvement. For example, NHS England has encouraged local areas to explore the use of new payment systems that incentivise better ways of managing demands, whereas NHS Improvement has advised NHS providers to use payment by results to maximise their income, thereby improving the financial position of their individual organisations rather than that of the system.
239.Simon Stevens, Chief Executive of NHS England, and Ian Dalton, Chief Executive of NHS Improvement, both acknowledged that their organisations need to do more to provide consistent messages to those on the frontline. Ian Dalton said that:
if we expect the NHS to integrate and to work together across different bits of the NHS, then we, as the local superstructure that supports the front-line, even if we do not deliver care directly to patients, must give consistent and clear messages.
240.Since our oral evidence session, NHS England and NHS Improvement have published commitments setting out how they intend to work more collaboratively. From September 2018, the seven regional teams of NHS England and NHS Improvement will be led by one regional director working for both organisations. Also, where possible, the two bodies will integrate and align national programmes and activities. These changes are intended to ensure both organisations provide coherent messages, reduce duplication, use resources more effectively and, most importantly, are better equipped to work with commissioners and providers in breaking down barriers between health and care services.
241.We welcome these commitments, although we are aware that sometimes the rhetoric of national leaders can be at odds with local bodies’ experience of their regional arms. Professor Chris Ham, Chief Executive of The King’s Fund, told us:
They are becoming more aligned, and they are making efforts to do that by having a single regional director across the two regulators to relate to places like Cornwall, but the lived experience of leaders in the NHS is that it often does not feel like that. There may be alignments at the top between Simon Stevens and Ian Dalton, or indeed at a regional level, but when it comes to the day-to-day interactions of places like Cornwall you get very mixed messages.
242.To assess whether the commitments by NHS England and NHS Improvement to align priorities and incentives at national level have made a tangible difference to those on the frontline, we encourage those organisations to conduct a joint survey one year after their announcement on 27 March 2018. The real test will be whether this makes a positive difference at local level.
243.More joint working, clear priorities and consistent messages are positive steps forward. However, it is not clear how the suite of national bodies, particularly the Department of Health and Social Care, NHS England, NHS Improvement, Health Education England, Public Health England and CQC, and their respective roles, functions, policies and powers, interact to provide an effective approach to driving the move towards more integrated care.
244.Structurally, the main problem with the existing national bodies is that they were originally created, in some cases, to drive improvement through choice and competition between a diverse and autonomous landscape of providers. Since the NHS Five Year Forward View was published national bodies have taken positive steps, within the scope of their existing legal structures, to promote more placed-based care. Ian Dalton, Chief Executive of NHS Improvement, argued that the Single Operating Framework for NHS trusts and foundation trusts makes clear that NHS providers should “work together to join up care for their populations, and to be part of that strategic move locally.” Ian Dalton argued that:
We have moved a long way from the caricature of a hospital being able clinically to stand on its own. That is not the model that necessarily exists going forward. We will play our part.
245.This is encouraging, although the widespread perception, particularly from NHS providers and commissioners, is that the operation of the national system, whether fully intended or not, continues to perpetuate behaviours that act against the needs of local systems. NHS Clinical Commissioners described how even more recent policy changes present barriers to placed-based care:
The development of different control totals for providers and commissioners, the focus of the inspection and regulatory regime on individual organisations, and the supportive interventions that are undertaken, often with a lack of cross-organisational communication, all undermine the development of a coherent local approach to service development and delivery and encourage a retreat into organisational silos. Our members’ view is that top-down intervention and performance measurement may be the greatest barrier to local relationship building.
246.To introduce a national structure that is more conducive to place-based care would in many instances require primary legislation.
247.We heard repeatedly during our inquiry how the allocation of support and resources by national bodies have been targeted towards those local areas that are furthest ahead, leading to the likelihood of perpetuating “success to the successful”, with the risk of leaving less advanced local health economies further behind.
248.As well as preferential receipt of funding, particularly capital funding, the more advanced local areas, particularly integrated care systems, have benefited from more autonomy and support, which are described in more detail in Chapter 4. Describing the factors that have contributed to differences in the progress of local areas so far, Saffron Cordery from NHS Providers told us that:
One of the factors that underpins the diversity is that those right at the front, the top five—I do not want to rank them necessarily—that have been making real progress have been fully supported by the national system, so there is a full support programme in place.
249.Niall Dickson described how STPs in the middle of the performance curve often feel neglected by national bodies, while often those at the bottom find that the approach adopted centrally exacerbates, rather than alleviates, the difficulties they experience. Speaking about those at the bottom of the performance curve Niall Dickson said that:
There is a sense in which some organisations find themselves in a really difficult position. Just taking their STF money away from them is like somebody digging a hole. Instead of the regulator helping them to get out of the hole, they jump in with a larger spade and dig even faster. I think the regulators have started to do some of those things, but the whole system of how we performance-manage the process needs to be looked at.
250.Instead of targeting resources at those furthest ahead, we heard that national bodies should describe how they plan to offer “differential support to different STPs depending on where they are on their journey.” Professor Chris Ham from The King’s Fund told us how NHS England and NHS Improvement have begun to provide this sort of development and support at a small scale.
251.One option is to extend some of the benefits given to integrated care systems to other areas. For example, Simon Whitehouse from Staffordshire and Stoke-on-Trent STP argued the case for greater autonomy, funding and resources to be targeted towards areas that are less advanced:
With Staffordshire and Stoke-on-Trent being one of the more challenged areas in terms of both performance and financial viability, we have a real challenge. We need some of the flexibilities that are being offered and talked about in the more successful parts of the patch to enable us to make the scale of changes we need to make, but the resource, effort and focus is going to areas that are doing really well; they are advanced and probably had strong and robust relationships in place previously to enable some of that to happen. I would make the case, and articulate really strongly, that while we understand that and we need to learn from those areas, if all of that resource and effort goes into the ones that are at the leading or cutting edge, we are creating an even greater gap in terms of what that looks like.
252.There is a widespread concern that the pace of transformation is too slow. A survey of NHS trusts and foundation trusts by NHS Providers in April 2017 found that 62% of local leaders were concerned that their local area was not transforming fast enough. Nevertheless, during our inquiry we have seen and heard of encouraging examples where local efforts to pilot new, more integrated, ways of delivering care, such as the vanguard programme or local initiatives such as the Primary Care Home Model, have resulted in benefits to patient care. However, it is unclear how these positive examples will be scaled up and spread at pace across the system.
253.The Department of Health and Social Care and the other national bodies recognise the widespread variation in performance and progress across the system. The Minister of State for Health, Stephen Barclay MP, said:
The NHS is very good at pilots and innovation, partly because it has brilliant people who will innovate. Where I think its performance needs to improve is in how it industrialises that innovation across the system.
254.National bodies are clear that a critical task will be to accelerate progress in local areas that are less well advanced. NHS England’s National Medical Director, Professor Steve Powis, told us:
I agree that that is the challenge, to focus on how those systems that are further back in their development can be brought up to the levels of the systems that we have been describing.
255.The 10-point efficiency plan described in the Next Steps to the NHS Five Year Forward View mandated a series of efficiency opportunities to be pursued across the NHS to contain rising cost pressures on the system. Within the list of mandated efficiencies, there are several recommendations which relate to improving patient care and experience through prevention, better self-management of existing conditions and more joined-up working between services.
256.What is not clear from the evidence we have received during this inquiry, including from national bodies themselves, is how the arms-length bodies, particularly NHS Improvement and NHS England, are seeking to accelerate the scale-up and spread of transformative changes to the delivery of care, such as the new models of care.
257.Three main ways national bodies described their role in accelerating transformation were clinical leadership, intelligent transparency and opportunities to learn from those furthest ahead, either through direct support or the sharing of best practice. However, there was no clearly articulated approach which explained the role of national bodies.
258.Efforts by national bodies to facilitate learning and share best practice have included “speed-dating” sessions for local leaders in different health systems to learn from those furthest ahead, such as South Yorkshire. NHS England is also planning to publish learning reports to share best practice from the vanguard programme. Similarly, with regard to intelligent transparency (the use data to highlight variations in performance), Simon Stevens informed the Committee of Public Accounts that initiatives such as NHS Right Care are programmes that are “now being layered across the country.”
259.We support all of these approaches. Holding up a mirror to local organisations so that stark variations in the quality and efficiency of patient care are clear is undoubtedly a useful tool to drive improvement, especially where such programmes are led by those with clinical expertise, as is the case with NHS Right Care and the Getting it Right First Time initiative.
260.Opportunities to share best practice between local areas, particularly from vanguards and integrated care systems, also have their place. For example, Professor Chris Ham described how the experience of integrated care system leaders could be utilised to accelerate progress:
Part of it is drawing on the experience of those already in the advance guard, if you like, of STPs and, now, integrated care systems, and using their experience and expertise to help those coming along behind. If we have 10, hopefully, in a year’s time we will have 20, and the people leading this work in Manchester, Nottingham, Bedfordshire, Luton, Milton Keynes and elsewhere will be able to free up some of their time to work with the second wave and perhaps the third wave coming along behind.
261.There are challenges and trade-offs for national bodies in the approach they decide to take to capture and share lessons from the first wave of integrated care systems. For example, introducing buddying arrangements to enable those furthest ahead to support the less well-advanced areas could arguably slow the progress of the frontrunners. This is not a valid reason not to capture and share lessons, but rather a risk that should be considered and mitigated. However, the greatest risks to accelerating progress are the lack of proper finance and the workforce capacity to design and implement change.
262.We also support NHS England and NHS Improvement’s intention to explore the role clinical leadership can play in accelerating changes across the system. There is ubiquitous support and enthusiasm for integrated care across health and social care, including clinical leaders and senior managers. A clear message from this inquiry is that many have spent large parts of their careers trying to integrate care for patients.
263.Simon Stevens has acknowledged that frontline staff and local leaders across the health and social care sector “are busy people and they are not out touring the country on fact-finding missions.” Many are overwhelmed by the task of maintaining quality standards and making efficiencies in the face of significant shortfalls in staff.
264.National bodies’ answer to the question of how they drive improvement fails to acknowledge the importance of ensuring staff have the capacity to engage in transformation by finding time outside of the day job to build relationships and think through the complexities of how different services and professionals collaborate. In such a scenario, Professor Chris Ham argued that:
Part of what the national bodies can do is no harm, and to get out of the way, facilitate and support people at a local level to do more of the good things already happening, and extend that to more areas. I want to be realistic, being a natural optimist: given the huge financial pressures on the system, and that there is absolutely a focus on sustainability as well as transformation, this will take time.
265.Local bodies’ experience of their national counterparts is one of competing priorities that perpetuate existing divides between services and encourage organisations to retreat into individual silos. While this appears to be improving, we have not heard clear and compelling evidence that the interventions of national bodies reinforce and enable more integrated, place-based care. Incoherence in the approach of national bodies is a key factor holding back progress.
266.We heard, and saw, outstanding examples of great care that frontline services have been able to build, implement and maintain even in periods of constrained resources. We also heard of promising results from the new care models programme. However, how national bodies plan to scale up and spread best practice and accelerate transformation across the system remains unclear.
267.We recommend that the Department of Health and Social Care and national bodies, particularly NHS England, NHS Improvement, Health Education England and the Care Quality Commission, clearly describe as part of a national transformation strategy how each of the bodies will work together to support transformation.
268.We request a joint response from the Department of Health and Social Care, NHS England, NHS Improvement, Health Education England and CQC setting out, against each of the following headings, how their roles, responsibilities, functions and policies support the following factors that are critical to transformation and integrated care.
269.NHS England and NHS Improvement should systematically capture, distil and disseminate key lessons from the local areas that are furthest ahead, including the governance arrangements and service models used in these areas. Careful attention should be played to striking a balance between learning from the frontrunners and not overburdening these areas. We recommend that NHS England and NHS Improvement undertake a review of the first cohort of integrated care systems starting in April 2019, and make the key findings available to all STP areas. That should include the level of financial support underpinning transformation.
223 The King’s Fund, November 2016, para 3.17
224 The King’s Fund, November 2016
225 National Audit Office, Sustainability and transformation in the NHS, January 2018 Session 2017–19 HC719
226 Q361 [Ian Dalton]
227 NHS England, NHS England and NHS Improvement: working closer together, 27 March 2018 accessed on 2 June 2018
228 Q243 Professor Chris Ham
229 The Health Foundation ()
230 Q360 Ian Dalton
231 NHS Clinical Commissioners ()
232 Q248 [Nigel Edwards]
233 Q203 [Saffron Cordery]
234 Q226 [Niall Dickson]
235 Q226 [Niall Dickson]
236 Q203 [Saffron Cordery]
237 Q252 [Professor Chris Ham]
238 Q181 [Simon Whitehouse]
239 NHS Providers ()
240 Q396 Stephen Barclay
241 Q311[Professor Powis]
242 NHS England, , March 2017, pages 38–54
243 Q311 [Steve Powis]
244 Q397 Jonathon Marron
245 Oral evidence to the Committee of Public Accounts 5 March 2018, Session 2017–19, HC 793 Q103 [Simon Stevens]
246 Q251 [Professor Chris Ham]
247 Q253 [Professor Chris Ham]
248 Oral evidence to the Committee of Public Accounts 5 March 2018, Session 2017–19, HC 793 Q106 [Simon Stevens]
249 Q251 [Professor Chris Ham]
Published: 11 June 2018