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The Future of Primary Care - Is there one? 

HealthChat with Mike Bewick, Clare Gerrada and James Kingsland.

19th January - HealthChat evening - details here 

News and Comment from Roy Lilley

In the time it took Simon Stevens to accept the job, fly halfway around the world, buy a house, move his wife and kids, become the CEx of the Carbuncle, visit just about every nook-and-cranny of the Service and write the Five Year Forward View, St David Dalton was still dotting the i's and crossing the t's of his review of the future of the NHS.


The 5YFV; 39 pages of liberating, free flowing future. Dalton; sixteen volumes of closely argued minutiae... not just the difference between the two reports but the difference between the two men.


The 5YFV must have taken Dalton by surprise. There are references to it, the look pasted in; "Boards should consider their response to the 5YFV".... like they are not going to.


Dalton's theme is based on failure.  Bigger and better hospitals should take over, or subsume the rest. That's his first mistake. The commercial world and the public sector is a graveyard for avaricious managers who do not understand two turkeys don't make an eagle.


Because one complex organisation is trotting along nicely does not mean they can run rings around hospitals that are not.


Take your eye off the ball and you pay the price, as Dalton found when he discovered, last June; 100s of patients had been left off his orthopaedic surgery list. Over three hundred patients breeched the 18 week target. It took a GP to blow the whistle. Dalton's fingers were burned and sends a salutary warning to other acquisitive CExs wanting to poke their fingers into the pie; get your own house in order and keep it there.


Riding two horses with one backside is a job for a circus clown.  Successful CExs and Boards won't risk it; the regulators will make their lives a misery.  Dalton says CQC and Monitor should give them a break.  If they do there are plenty more Trusts deserving of respite whilst they sort themselves out... it opens a door regulators will want to keep closed.  In terms Dalton is saying what the NHS has been saying; regulation is getting in the way of progress and quality.  Something the 5YFV recognises.


Dalton seems keen to have more CircleBrookes, private companies running Trusts. Perhaps he should take a look at the problems CircleBrooke is struggling with; performance no better than the rest of the NHS and no profits for shareholders.  Ministers are turning their backs on the idea.


Dalton talks of a 'five year strategy'. In a fast changing environment strategy doesn't work. Strategies lack focus, they can't be practical as they are never able to guarantee resources and they get confused with operational planning. They always lack accountability and follow up... what happens if no one 'does a Dalton'? Answer, nothing.


Dalton is a methodical bureaucrat and it shows in his manicured report. There is a welter of evidence, templates, parameters, prospectus and standardised documentation. The TDA is dragged in to 'categorise' Trusts. Dalton makes the mistake of trying to create the future, today.


He runs out of steam with this: "Where Monitor determines that a FT is in 'persistent difficulty', it should require that FT to produce a plan with clear improvement timescales. If the FT is subsequently unable to demonstrate improvement against this plan, Monitor should compel that FT to present a new sustainability plan..." Thank you St David.


Intuitively we know the NHS has got to 'do something'. I can tell you it is not another bureaucratic layer of 'credentialing'; one Trust good jockeying to take over another.


Stevens has already moved forward from his 5YFV baseline; in a recent speech he cut though the crud, the bureaucracy, the forms, the committees, rolled up his sleeves and set out his 'success regime'... remember that word 'success' a rarity in the NHS lexicon, the word 'failure' more favoured by Ministers and bureaucrats..


What do we need to do that wouldn't require legislation?  Drive this out of the blocks.  Here are 6 for a start.

  • Turn LATs into, strategic interlocutors, empowered to facilitate and sign-off change, superfast.  One flat layer of assumed approval unless otherwise. 
  • Stop forcing Trusts to balance their books individually. Some will never do it. View the local health economy as a whole and balance that.
  • Wherever possible push vertical integration between all the health and care systems, with a population based, capitated budget.
  • Roll the TDA into Monitor as a two man back office; stop Monitor's forays into quality and reorganisation, strip them back to the basics and make them responsible for monitoring the money in the system and that is all.
  • Strip the CQC NHS work back to a man and a dog; give half the money to the CCGs and make them responsible for the quality of what they buy. Get CQC tanks off the Trust's lawns and help them to know what good looks like and help them achieve it.
  • Establish a national campaign to recruit staff into the NHS and a proper easy, cheap, return to nursing programme. Encourage and fund Trusts to beef-up HCA training to EN levels.

Dalton's heroic effort to rewrite the future is pedestrian at a time when we need to sprint.  It is a Mondeo when we need a Maserati.   His report is like the sun last October, eclipsed. 


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