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The annual report from Cold Comfort Farm

 

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Friday, 25 June 2010

The annual report from Cold Comfort Farm

It was this time last year that David Nicholson invited Jim Easton to take up the challenge of fixing the financial hole in the NHS

At the Confederation yesterday, the national director of improvement and efficiency reported on the progress of the QIPP programme.

Easton noted with grim satisfaction that although teams of consultants had crawled all over the figures, his team’s initial estimates of a £15-20bn funding gap had been about right. He conceded that the range of opinions was wider – from £10bn at the low end to a fairly terrifying £25bn at the other. Explaining the target was difficult, he acknowledged, because there is still a widespread belief that it represents cuts or cost savings. It doesn’t. There are two distinguishing features about the NHS financial settlement and other parts of the public sector. The first is that where other services face real terms cuts, funding for the NHS will be flat.

Even so, Easton makes no secret of the fact that even with flat funding, increasing demand and rising costs mean that it will feel like a budget cut to an organisation used to 10 years of higher than inflation increases year on year.

To describe the second difference, Easton said: “The efficiency requirement on the NHS is at least equivalent to every other part of the public sector. The difference is that we get to reinvest every penny we save.”

The fortunes of the rest of the public sector are not just of academic interest to the NHS. “Just think about what a 25% cut in social care funding means for us,” Easton said.

He went over some ground that will be very familiar to anyone who has followed the QIPP programme – efficiencies will, at best, account for half the shortfall. The rest will need to come from moving services out of expensive settings into more appropriate ones, typically out of hospitals and into primary care and community settings. “There is nothing revolutionary about that, it’s just that we’ve never done it at scale,” he said.

He rejected both of the traditional models of change in the NHS: “Model number one: the centre will tell me what to do and it will sack me if I don’t do it. Model number two: leave me alone and I’ll get on with it.”

Change at scale, he said, does not mean that the centre will organise it. The government’s role would be to provide support of the kind that could only be managed from the centre, around changes to service pricing or the GP contract, for example.

There were moments when Easton fought to hide his frustration at NHS management.

He cited conversations with managers who have led successful well-publicised local change programmes and were surprised that none of their peers had been in touch to learn from their experiences. This lack of curiosity was “pathetic”, he said.

The QIPP programme itself did not escape criticism. The incoming government had asked challenging questions, Easton said, about the evidence base for QIPP and about its success in engaging with the right people. He admitted that the move from a PCT centric to GP led commissioning system had exposed some weaknesses. Referring to GPs, he said: “There is no doubt that we have excluded – or downplayed the role of – those key players in many consultations.”

This point reveals the fundamental problem of the QIPP programme, which is that it cannot succeed as a purely top-down initiative. Easton is the first to recognise that the kind of cultural change needed to bring about QIPP is beyond the power of governments and civil servants to deliver. QIPP requires new thinking and behaviours and it means people at every level of the NHS taking ownership of quality, patient safety and other aspects of service improvement. It requires collaboration, which means more than working together; it means redistributing power. As the senior managers who attend the Confederation know, putting clinicians and patients in charge of the NHS has consequences for the people who are in charge now.

Without invoking clichés about turkeys and Christmas, the government needs to work out how PCTs can be motivated to play their part in the creation of a new, more efficient NHS in which many of them will have no future.

The other stiff challenge facing the QIPP programme is what Jim Easton is now calling mobilisation, the process of converting the hunger for change into co-ordinated action at every level of the NHS.

See a video interview with Jim Easton at NHS Networks’ Youtube channel: http://www.youtube.com/user/NHSNetworks