NHS: It is system not a service and needs a strategy not a plan

20 September 2018

By Sir Cyril Chantler and Roy Lilley

Eighteen years ago the government published its 10 year plan for the NHS followed 2 years later by extensive documentation on how to deliver it. Now we are at it again in order to justify another welcome round of investment. The trouble is that when you consider the strains on the service pretty well everyone now realises that the NHS cannot solve its problems on it own. It needs to engage its partners and these include local government that is responsible for social services and employs health visitors as well as running children’s centres. Public Health is crucial and this again includes local government which spends 90% of Public Health England’s money. The NHS commissions services from General Practitioners and Community Nurses and until recently solved its waiting list problems, in part, by using private hospitals. Much care in the community involves the voluntary sector. Health and Health Care needs a system not a service.

Systems need a different kind of leadership, one that that facilitates collective leadership (see Peter Senge, Hal Hamilton, John Kania, The Dawn of Collective Leadership). Collective leadership is fostered by the ability to see the larger system rather than focusing on parts from your own perspective. This is essential to build a shared understanding of complex problems. It requires reflection to enable people to achieve this from the start not after one part of the system has determined its own view of what needs to be done. This means shifting from reactive problem solving to co-creating the future. After all most of the problems we face are not simple or tame but complex or wicked. This means developing an agreed strategy before thinking about detailed plans. Is this what is happening now or indeed what happened last time?

We have talked a great deal about bringing together budgets at national and local level for health and social services and the Department of Health has been rebranded as the Department of Health and Social Care (DHSC). How involved are Local Councils in the planning that is taking place? Should we not start by looking at national and local strategy? Nationally this should involve deciding how many agencies and regulators are required for the NHS in England and rationalising radically to reduce confusion and costly bureaucracy. Locally the NHS and Local councils should agree their strategy and then work out plans to deliver services that provide value i,e. outcomes per pound spent. Local Government has had to do this drastically over the last decade and this experience might be helpful. Together they can agree how to provide or commission and measure the value of the services that are needed to improve the health, and provide the treatment and care for the population they serve.

Out of such a process should come agreement on the role of the DHSC and NHS England, Public Health England, and Health Education England and the role of a reduced number of regulators and the new Health and Safety Investigation Branch. It should also be clear which services are to be commissioned nationally or regionally within the new Strategic Transformation Partnerships and Local Maternity Systems and how health and social care including primary and community care is to be commissioned and managed jointly by the NHS and Local Councils. Finally systems require information to work smoothly and this is necessary to measure outcomes, to plan and administer, to research and to provide care. Here we can at last develop the full potential of a digital information system for a national publicly funded health care system using patient information, identified with proper consent where appropriate. There is of course more to be done but without agreement and leadership across the system as opposed to the service, we may be destined to be here again in a few years time.

Roy Lilley is a health policy analyst, writer, broadcaster and commentator on the NHS and social issues.

Sir Cyril Chantler was Dean of the Guy’s, King’s College and St Thomas’ Hospitals’ Medical and Dental School, is an honorary fellow of UCLPartners Academic Health Science Partnership and is a member of CPP’s health advisory group.

This article was first published by the Institute of Healthcare Management.