I support the overarching aim of this White Paper well described in its title. I quote from the White Paper; ‘This paper sets out the legislative proposals for a Health and Care Bill. It aims to build on the incredible collaborations we have seen through Covid-19 and shape a system that is better able to serve people in a fast-changing world. At its heart, however, this Bill is about backing our health and care system and everyone who works in it. Our proposals build on the NHS’s own – those in the Long Term Plan.
Indeed, what is there to oppose? My fear is that though the aims are laudable, the words encouraging and the thinking progressive, we do not have even as a beginning, an NHS culture that is enabling of such a vision. Of course the White Paper rightly embraces beyond heath care but the sheer magnitude of the NHS can dominate if it so wishes.
Let me describe the context as I see it. Apart from the present incumbent Simon Stevens and to some extent Duncan Nichol (I go back a long way), no NHS CEO has shown any real understanding of or desire for a community based focus to the NHS. This despite it being the site for most of healthcare and more importantly if the pursuit of health and wellbeing is to be of any real meaning, where the community is. An area of contention in the White Paper is giving politicians a return to a bigger say in the running of the NHS. On this I am surprising ambivalent. In primary care since 1990 we have benefited in general from political leadership in particular Conservative leadership. Fund Holding being the ‘Jewel in the Crown’ as it devolved power and leverage to primary care clinicians, a hitherto un-heard of concept. New Labour struggled and failed with politically acceptable alternatives.
The centre piece of the White Paper is the Integrated Care System (ICS) around which are centred the hopes and aspirations of those who wish the delivery of what is promised. Its planned governance structure is sensible, ‘Statutory ICSs, made up of an ICS NHS Body and an ICS Health and Care Partnership (together referred to as the ICS).This dual structure recognises that there are two forms of integration which will be underpinned by the legislation: the integration within the NHS to remove some of the cumbersome barriers to collaboration and to make working together across the NHS an organising principle; and the integration between the NHS and others, principally local authorities, to deliver improved outcomes to health and wellbeing for local people.’
A White Paper that promises much but a prevailing NHS culture that is over focused on hospitals, a top down hierarchical mode of leadership and favours big is beautiful will not be the enabler of the stated aspirations the country needs. Who can lead is the big question? And in what style of leadership?
Will the big beasts in the NHS define integration to produce the biggest provider capture ever with less choice and responsiveness? Integration will only mean something if the individual patient can feel the benefit. For the wider community can they perceive the ICS as the New Zealand Prime Minister describes her country- a team of 5 million people? it is worth revisiting Philip Gould – ‘…must find a way of integrating the schism between the individual as consumer and the individual as citizen’. A challenge to NHS thinking as in any NHS ‘pyramid’ denoting influence, power and resource availability, hospitals would be at the top, lip service to a primary care led NHS and patients and the public at or near the bottom. In the NHS and for the community and the individual can we through the ICS deliver on those aspirations. If not it will be only yet another structural change which the authors of the White Paper certainly do not intend. It must be about the leadership and choosing new types of positional leaders and creating a culture of a dispersed leadership even beyond the professionals. As Disraeli ‘Next to knowing when to seize an opportunity, the most important thing in life is to know when to forgo an advantage’. Not a common NHS feature.
Primary Care hitherto virtually excluded from system leadership has much to offer in talent and an experience of localism and working within the community. The ICS is proclaimed as the necessary devolution the NHS requires but they are still large in population size and many of its constituent organisations and essentially distant from its community. And to whom we devolve often become the new centralists. We must systematically adopt the concept of concomitantly being ‘big and little’ as localism matters. Governance should major on behaviours rather than the over weening obsession with compliance and embrace subsidiarity. And the value of the ICS recognised by its community, then we might just have the ICS we need.