‘You know, it’s all quiet and tranquil,’ says NHS England’s chief executive sarcastically, laughing as he greets GP in his central London office.
It has been a busy, no doubt hectic time for Simon Stevens along with the rest of the NHS. Just outside his office sits a long desk lined with policy wonks working on implementation of the Five Year Forward View, the ambitious NHS plan launched in October.
This, Mr Stevens says, is ‘a moment to take stock and make some big decisions about how care needs to develop’.
The Forward View sets out ambitions to develop new integrated care models - most importantly, integration of out-of-hospital care around groups of GP practices and vertical integration of acute and primary care.
Many GPs’ biggest fear as election day looms, is more reorganisation, restructuring and change. They remember bitterly the Conservatives’ 2010 promise there would be no more top-down reorganisation. They look with scepticism at Labour shadow health secretary Andy Burnham’s insistence that his plans for health and care integration do not mean more of the same.
But aren’t Mr Stevens’ radical ambitions to redesign frontline provision, which in some cases could mean hospital trusts running GP services, changes to the clinical workforce, development of new contractual models and changes to service procurement, just another form of reorganisation?
No, he says. Mr Stevens draws a distinction between the kind of reorganisation which results in new organisations, management structures and letterheads, and his plans to radically redesign care.
New models of care
GPs and other clinicians themselves have designed the 29 proposals which will be funded from a £200m pot as ‘vanguard’ sites to begin rolling out the new care models, he says.
‘This was definitely something that they were coming to us to say, this is how we think our future should develop: will you back us?’
‘I think that is a radical departure from the way in which these things have often happened,’ he adds.
Where vertical integration between GPs and hospitals takes place through ‘primary and acute care systems’ (PACs), they must be a ‘partnership of equals between general practice and hospitals’, he says.
For GPs, the big breakthrough of the Forward View was recognition that primary care was underfunded compared to secondary care, and that that must change.
Mr Stevens’ words are stark, echoing warnings from within the profession. ‘The historic strength of general practice risks being weakened unless we rectify the relative underinvestment in general practice which has occurred over a decade or more,’ he says.
‘We need funding for primary care services, GP services in particular, to go up.’
Primary care funding
He adds that with the £250m infrastructure spending earmarked for primary care in 2015/16, ‘we are making a start’.
‘But we know we have to put our foot on the gas when it comes to recruitment, retention, and returners,’ the NHS chief executive admits.
Over more than a decade the service has not got the balance of funding right, he admits. ‘We've got to change that. We are changing that.
‘Since NHS England came into existence, two years [ago], we've seen each year real-terms increases in primary care funding with further progress for 2015/16. All at a time when overall funding for the NHS is obviously tight. So, the point is, that if we want care that is more integrated around the needs of particularly older, frail people, high chronic conditions, then that form of personal, population-oriented primary care, which is one of the great design strengths of the NHS - we need more of that.’
At the moment, where there is extra funding going in it has, for often good, but sometimes bad reasons, ended up in the most expensive parts of the service, he says, because the hospital sector has not recognised the rising demand in general practice.
‘Let's face it, there are some difficult decisions here, and some of the big teaching hospitals are not happy with the decisions that have been made for 15/16 to use more of the money in primary care and in mental health, than has been the case in the past. So, look, there are some difficult decisions to be made here, and we are making them.’
In January, providers of 75% of NHS services rejected a proposed hospital tariff which cut prices by 3.8%.
With the general election weeks away, Mr Stevens suggests he does not think either of the two main parties will commit this side of polling day to the additional £8bn a year by the end of the next parliament which the Forward View says the NHS needs to plug a projected £30bn funding gap.
‘I don't think anybody is expecting that whoever is the next government would write their first budget right now,’ he says. Having said that, the Liberal Democrats have committed to funding that increase, and both Labour and the Conservatives have made NHS funding pledges in recent months.
Whoever forms the next government, though, will have to address the funding question, he says, in the spending review within the first six months of the next parliament.
But, he adds, ‘uniquely for the NHS, we have set out our stall, without fear or favour, before the British people, saying, if you want this sort of health service, which we think is right for this country, then this is what it will cost.’
The other side of Mr Stevens’ double-edged approach to funding is the need for more savings. He believes the new models of care along with efficiencies will save £22bn by the end of the next parliament. The NHS, he says, must ‘get very serious’ about efficiency. Although that could benefit primary care, with money saved employing permanent nurses instead of expensive agency staff invested into primary care.
With the Houses of Parliament visible through the haze over the Thames from NHS England’s offices, Mr Stevens is careful, with the pre-election period in sight, not to discuss specific manifesto commitments. But, he says, the Forward View has revealed a ‘wide consensus across the health service and more broadly about how care needs to evolve and the idea of more integration between primary and specialist services, physical and mental health services, health and social care services’. That, he adds, ‘is a widely understood part of how we are going to have to change’.
Mr Stevens’ plans have certainly received a generally enthusiastic response from politicians and policy leaders as well as from many within the service including the RCGP. Mr Stevens’ plans and the timing of the roll-out ahead of May’s election could begin to put into practice an NHS vision drawn up by its own staff, limiting the space for the next government to impose another reform.
Mr Burnham has suggested his plans for integrated care organisations had influenced Mr Stevens’, and that he had altered his own policy in response to the Five Year Forward View. Does the chief executive, himself a former Labour party councillor and advisor to Tony Blair, think his bold move has galvanised the plans of the parties? ‘I think that the forward view goes with the grain of what most people in the health service think, and what is being proposed for the next five years,’ he says.