A huge task ahead: @NHSConfed #NHSReset

This year’s NHS Confederation conference saw health and care leaders facing up to a huge agenda: more Covid on top of a recovery programme and a shift to integrated care. The big questions: will the government find the money, will the latest round of structural changes help, and how to keep inequality on the agenda. Lyn Whitfield listened in.

Last summer, the discussion at the NHS Confederation’s annual conference focused on an end to the Covid-19 pandemic and an NHS ‘reset’. This summer, the tone was different.

Policy experts and system leaders agreed that the health service still has more Covid to deal with, and that it will have to run a waiting list recovery programme alongside a major programme of reform. Matthew Taylor, the New Labour advisor who has just arrived at the Confed from the RSA, told the virtual event the task ahead is “huge.”

He urged government to help by having an honest conversation with the public about the situation and by finding the money to get through a difficult winter, run recovery clinics, and deliver on the promises in the NHS Long Term Plan. At the same time, he urged NHS leaders to embrace integrated care systems and to use their ‘place’ agenda to tackle inequalities, build up local economies, and address net-zero.

“In five years, do we want to be looking back at Covid as a crisis from which we have not fully recovered, or as a spur for success not just for the NHS, but for the nation?” he asked. “Now is the time to make this the turning point: to make the NHS the best health service in the world, that people all the people in this country live the best lives that they can.”

Immediate challenges: Covid, recovery, money

The fact that Covid is not yet ‘over’ was spelled out on the last day of the conference by England’s chief medical officer, Professor Chris Whitty. He said it would be surprising if the UK didn’t see another wave of the disease this year, “because autumn and winter favour respiratory viruses” and SARS-CoV-2 is “a highly transmissible respiratory virus” (Guardian liveblog coverage).

He also said the NHS should be “braced for the fact that the coming winter may well be quite a difficult one” if the Covid wave is large or coincides with an outbreak of flu, and that it might be as much as five-years before there is a vaccination that can handle all variants.

Meanwhile, the true scale of the backlog is unknown. More than 5.1 million people are now on the waiting list. But some 7.4 million people who might have been expected to “clock-on” last year didn’t. Some of them will now come forward, adding to the pressure caused by long-Covid and the mental health problems stored up over the past 18 months.

A vigorous debate is now underway in government about whether the NHS will be funded for this on top of all the other demands being made on it. But for the moment, Julian Kelly, NHS England’s chief financial officer, said trusts should assume that belts will be tightened rather than loosened later this year.

Heading into the autumn comprehensive spending review, he said the NHS needed to be ready to remove “waste” that had built up during the pandemic and to “address productivity” if it wanted to make the case for sustained increases in funding and the capital required for innovation (Health Service Journal report).

Medium term challenges: legislation, reform

As Whitehall conducts its comprehensive spending review, Parliament is due to debate the legislation required to implement the Integration and Innovation white paper. In a session titled “what could possibly go wrong” an expert panel concluded that plenty could.

Patricia Hewitt, a former health secretary who now chairs an integrated care system, said one would be that “too many people will try and tell us what to do.” For instance, she warned there is a danger that legislative amendments in Parliament could hem-in ICSs and make it difficult for them to respond flexibly to local needs.

Paul Burstow, another former health minister and ICS chair, said this danger would get worse if the government tried to “stick to milestones” that it was already missing, and establishing ICSs became “a tick box exercise.” However, Professor Chris Ham, a long-term observer of NHS reorganisations, said “culture trumps legislation.”

He argued that whatever the law comes out like, it will be the “personality and style of the health and care secretary and Sir Simon Stevens’ successor [as chief executive of NHS England]” that will shape the priorities and operation of the new system.

That, and relationships between the NHS, local authorities, and other stakeholders. “It is back to us. We are the people who will make this work, or not, as may be,” he told his online audience. But he agreed with Matthew Taylor, that it will not be easy and that it will be a long haul.

“The economic and health recovery is going to take five to ten years,” he said. “There are things that we can get on with right now, but funding is very hand to mouth, and for the longer term, the spending review is fundamental.”

The long term is, suddenly, digital

Parking the financial issue, Amanda Pritchard, NHS England’s chief operating officer, said health service managers needed to adopt the organisational change mantra of people, process and technology. She suggested the first priority should be to “look after people” who have “performed heroics” during the pandemic, but also been left “exhausted and even traumatised.”

But she also urged managers to “supercharge” some of the changes made during the crisis and “not to go back to doing things the way they were done.” As part of that, she urged her audience to maintain their interest in technology “to support everything from operational delivery to case finding.”

Technology (or, perhaps, the use of data, since there wasn’t much discussion of architecture or systems) was a recurring theme of Confed. Particularly on the third and final day, when conference sponsor Palantir and NHSX talked about the NHS Covid-19 Data Store and support for the vaccine roll-out.

Ming Tang, the interim chief data and analytics officer at NHS England, said the near-real time data delivered by the store had enabled the vaccine programme to “get the right vaccines to the right place at the right time.” It also helped local services to identify populations and areas with low take-up – and then fire up vaccine taxis or other interventions to address them.

Joanna Peller from Palantir said she wanted the NHS to secure a “legacy” from this work, in the form of real-time data for clinicians. “Not just dashboards, which describe the problem, but tools to act on that problem.” Unfortunately, it’s rare for the NHS to have millions of pounds to throw at a platform like the one built by Palantir.

And, as users of the conference’s chat and question functionality point out, public confidence in the use of data is at a low point right now, as a result of NHS Digital’s decision to announce the General Practice Data for Planning and Research extract in a blog.

The brand new, interim chief executive of NHS Digital, Simon Bolton, was asked about the now-delayed #GPDataGrab or care.data2 in another session. Gamely, he said “it is right to have a debate” because “privacy and security is so important.” But, in the end, he blamed poor communications for the row (digitalhealth.net report).

“We need to be open about saying we are doing the right thing,” he said. “This kind of thing gets caught up in politics. You just have to learn from it and keep your eyes on the prize” which is not selling data to pharma or companies to “get insurance at a lower price” but “delivering health and social care gain.”

The row has certainly not dented health and social care secretary Matt Hancock’s enthusiasm for technology. In a keynote presentation that started by thanking staff for the efforts they had made during the pandemic, he said the service the NHS would be able to provide in the future would be a function of three things: demand, resources, and innovation.

While demand is huge and unknown, he pointed out that the government has put £7 billion more than planned into the NHS this year, with £1 billion allocated to an elective recovery fund. He also insisted that he will fight for more resources within government and said it is recruiting more doctors and nurses.

But in the longer-term, he argued, the NHS and its new ICSs need to get demand down and make the best use of resources by focusing on prevention and joined up care, and the “golden thread” running through these changes is going to be making better use of data – as outlined in the new NHS data strategy (full speech on gov.uk).

And it was goodnight from him…

Back in the day, Confed used to end with a keynote speech from the chief executive of the NHS. This year, Sir Simon Stevens spoke near the start. He laid out three immediate priorities for the service, in the form of completing the vaccine roll-out, setting up long-Covid services, and recovering elective care, and said these were likely to dominate “for the next year or two” while ICSs came “on stream.”

But he argued the NHS knows how to get waiting lists down, because it has done it before. So, if it also keeps up the pressure on service redesign and clinical innovation, he said “there is no reason that [it] should not face the next five-years with great confidence.” Sir Simon himself will be long-gone by then. Indeed, he will be out of his present job this summer.

Asked for advice for his successor, he suggested they should do three things: “listen hard” for the germ of good ideas in any conversation; “keep an eye on your north star” which, in his case, was “think like a patient and act like a taxpayer”; and keep the NHS in the conversations that matter. “We need a view on inequalities, on funding,” he said. “Do not be afraid to speak out for what is right.”