A new operating model for health and care

Key points

• To quickly address operational and financial challenges, adapt to major reorganisation and deliver the ambitious reforms anticipated in the ten-year health plan, the health and care system requires a simple and effective system operating model where every part of the system is clear on its purpose, what it is accountable for, and to whom.

• Based on engagement with senior leaders across the health and care system, this paper describes, for the first time, how bodies operating at the health and care system’s five geographical scales – national, regional, systems, place and neighbourhood – could work together to achieve a more integrated and devolved healthcare model that delivers the government's three shifts. This must always start with communities, empowering them to be active agents in their own health and wellbeing and to be partners in the design of public services. 

• Change should be guided by three key principles: 
   

  1. Devolution and subsidiarity – A system as large, complex and diverse as the NHS cannot be commanded and controlled effectively from the centre. The operating model should devolve decision-making to local leaders to drive change, while holding them accountable for outcomes. To deliver neighbourhood health and shift towards prevention, the NHS must become a more effective partner within the system and with local communities. This requires alignment between two of the largest reforms and reorganisations ever seen in both the NHS and local government. 
   

  2. Change-led improvement – The health and care system needs a change model which empowers the public with greater choice and local leaders with greater autonomy over how the changes are delivered. The system’s drivers of change must be rebalanced, with greater focus on lateral peer learning to drive improvement and bottom-up accountability to patients and the public, alongside top-down policy incentives.
  
  3. Clarity and accountability – The core objective of the health and care system is to shift to a more preventative, cost-effective and empowering model of care. To achieve this, the system must both reduce acute demand and redistribute resources out of hospital. There should be clear accountability in each area for who is responsible for delivering the shift, although the decision about which organisation leads change should vary according to local context and be agreed locally. Clear metrics, financial and regulatory mechanisms are needed, including a metric to shift a greater proportion of the NHS budget towards primary and community care by the end of this parliament.

• Commissioning and delivery models should emphasise a person-centered and outcome-focused approach. Local leaders should be empowered to elevate the things best delivered at scale and be held accountable for outcomes. 

• The ten-year health plan must provide a consistent and aligned set of policies that incentivise and enable the three shifts, including: proportionate oversight, payment mechanisms which incentivise improved outcomes, multi-year funding and planning cycles, and improved pooled budget arrangements to deliver neighbourhood health.

• The NHS Confederation looks forward to supporting members and partners in the centre and wider health and care system, to embed a new system operating model. This will involve more detailed work on delivery models for the left shift and for neighbourhood health.