Policies to enable change

The ten-year health plan must deliver the following policy changes as part of the new system operating model:

 

 1. Payment mechanisms which incentivise improved outcomes

To achieve long-term sustainability, the allocation of resources should be aligned with population health outcomes, such as reduced hospital admissions, improved access to primary care and enhanced patient satisfaction. This would help ensure resources are directed towards the highest value interventions, rather than being spread across low-impact services. Outcomes-based payment mechanisms should incentivise improvements in care quality, safety and experience; improvements in population health and health outcomes; and reductions in inequalities in health outcomes. This approach would incentivise preventive care and encourage more efficient use of resources. 

 

2. Multi-year funding and planning cycles

HM Treasury confirmed that multi-year budgets would be allowed for the NHS. DHSC/NHS England should translate this into the system by providing the NHS with multi-year funding and planning cycles that are focused on delivering outcomes and aligned with local government. A longer-term approach is crucial to providing greater consistency and certainty, allowing local leaders to focus more on what matters to residents.

 

3. An enabling centre

Strategy is the alignment of policy and incentives to achieve change, but too often the NHS interprets ‘strategy’ as an extensive to-do list without a coordinated approach to deliver it. There is a need to move towards a smaller set of national priorities that everyone is held to account for (via the NHS Constitution), with more local flexibility depending on the health and care needs of different local communities. The centre can help drive the strategic direction by offering clear outcome metrics and bolster systems to deliver by offering a ‘menu’ of options for them to choose from.

Moreover, national policy and incentives, including supportive oversight, regulation, financial incentives and targets, need to be better aligned to deliver the three shifts. The centre should focus on defining things which support delivery of national priorities, including the three shifts.

 

4. Procure digital services at scale

Implementing large-scale digital health services has consistently been a challenge for the NHS. Procuring digital services and delivering at scale requires continuously evolving and robust infrastructure which handles frequent, seamless updates. Health services can be both personalised and democratised with modern digital and data infrastructure with central, responsive and adaptive central authority, acting as a service provider and commissioner. Clarity on the governance regime for centralised procurement of digital services is urgently needed, and consideration must be given to capabilities for delivering specialist digital and data functions. 

In the longer term, every citizen can expect to have full access to their health data via the NHS App, linked to a digital health or single patient record. They will be empowered to access, monitor, communicate and manage their own health records, seek accessible advice, tools and clinical information, manage medication and have overall control over how they interact with the NHS and its services, including participation in research. This will be crucial for the successful integration and operation of digital health services across the country. Several obstacles must be addressed, including data security and privacy, ease of use, scalability, interoperability, equity and access, and trust and acceptance.

5. Improve data sharing to support population health management

Several changes are needed to support the integration of data to support population health management and the development of a single patient record to enable self-management.

 

The government should require suppliers to separate patient data in electronic patient records (EPRs) from clinical use data. This will ensure suppliers adhere to a standardised data framework established by the government, which includes implementable interoperability criteria. Consequently, standardised patient data can be shared seamlessly using Fast Healthcare Interoperability Resources (FHIR) between NHS organisations, eliminating barriers to data interoperability.

 

To support improved data sharing and population health management and encourage a robust data-sharing environment, the Data (Use and Access) Bill must strengthen interoperability criteria between systems and organisations to enable seamless data exchange. Mandating standardised data frameworks will ensure consistent and reliable data sharing across various platforms and between vendors and providers. In addition, the centre must deliver robust data security and privacy measures. 

6. Proportionate oversight and self-directed improvement

There needs to be an effective success/failure regime to support the shift towards an integrated, devolved system that is set up to deliver the three shifts. The focus should be on supporting self-directed improvement, with punitive levers being used as a last resort. This is a significant departure from the traditional NHS approach to performance management which incentivised organisational decision-making based on satisfying regulatory interests, not those of the wider system or populations. 

NHS England’s draft Performance Assessment Framework confirms that ICBs will no longer play a role in provider oversight alongside NHS England and moves from a system oversight to an individual organisational approach. [32] As this framework is tested and iterated, it is essential that commissioners have the right levers to support collaboration to deliver the left shift.

ICSs need holistic leadership and improvement support from the centre, including regions, to ensure they have the capabilities to effectively discharge their functions, particularly in the context of cost reduction programmes. For ICBs this should focus on strategic commissioning skills, including robust analytics, contracting and resource allocation capabilities. Providers should be given additional support as they move towards lead provider or ACO-type models, and with certain ICB functions likely to be delegated to providers in the upcoming health bill.

Peer review has been an effective driver of improvement in local government for many years. Greater use of peer review in and alongside formal oversight processes can support quality improvement while also helping to identify and spread best practice; all parts of the centre and the system should foster a learning culture.

Oversight should be proportionate, flexible and consolidated, seeking to reduce the burden on providers and ICBs and enable local systems to take ownership of delivery. A core metric for ICS performance should be preventive and empowered model of care, including effective delivery of neighbourhood models. ICBs will continue to have oversight of how providers deliver care against the health outcomes they have commissioned them to achieve for their population, with a focus on population health improvements, patient satisfaction and access to care. NHS England should define a clear pathway for providers to proactively share intel and/or request support from the ICB and/or NHS England to prevent issues from escalating and requiring formal intervention. This should be informed by a dynamic monitoring system which NHS England, ICBs and providers can access to inform decisions and oversight of quality and productivity.

7. Improve pooled budgets arrangements

DHSC and the Ministry of Housing, Communities and Local Government should review the Better Care Fund and Section 75 arrangements as part of a plan to make it easier to pool budgets across the NHS (including primary care) and local government and provide recurrent delegated budgets for place-based partnerships. 

Greater use of these arrangements would help make progress towards better sustainability of the public pound. The government could facilitate this by simplifying and broadening these arrangements, reducing reporting and governance requirements. One crucial part of this is allowing primary care organisations to pool budgets. They are currently unable to enter such arrangements, which is prohibitive to greater integration. 

8. Reset the relationship with citizens

Moving to a truly devolved model will require resetting the system’s relationship with citizens. The expectations of both ‘parties’ will change as part of a reciprocal relationship or ‘compact’:

• The system will give citizens greater ownership and choice over the care they receive and equip them with knowledge to improve their health and wellbeing.
• In return there is greater responsibility placed on citizens. This means the greatest support will need to be given to those who need it most. 

A deeper connection with citizens will ensure that services are built on a strong understanding of population health, promoting good health and wellbeing.

Within the current operating model, those who most need this approach are least likely to receive it.

While the majority of citizens won’t recognise a new operating model, they will notice its consequences. The public expects to see improved outcomes (such as improved access, joined-up systems, clarity on their health, responsiveness).  A clear operating model will be essential to achieving this.

This model should be anchored to citizens through optimising the trusted organisations and familiar expertise that are already rooted in communities. In health, this often means general practice or community pharmacies – visible and accessible services embedded in the daily life of many neighbourhoods. Yet for many people, especially those most marginalised, trust also lies in local voluntary and community sector organisations, peer groups and informal networks. To improve and simplify local access, we must strengthen these trusted entry points and ensure they are connected through local infrastructure and digital tools that make services easier to find and navigate.

The review of the NHS Constitution, which is currently underway and being aligned with the ten-year health plan public engagement, provides an opportunity to codify this new relationship.

9. Support the move to a neighbourhood health service

 

Neighbourhood working represents a transformative opportunity to address systemic pressures in health and care, declining levels of public satisfaction with the NHS and most importantly, declining healthy life expectancy and growing health inequalities. This model is based on the recognition that the most effective health creation occurs within communities and that long-term sustainability will depend on enabling more local, biopsychosocial models of delivery.

 

Across the country, promising neighbourhood work is already underway – led by primary care, mental health and community trusts, alongside VCSE organisations, local authorities and communities themselves. [ii] This work should not be about restarting, restructuring or rebranding, but about building momentum, recognising where we need to go further faster and creating shared commitment to neighbourhood working, even amid significant system pressures. Some delivery models for neighbourhood health are led by a place-based collaborative, others by a lead provider (including primary-care at scale, community and mental health trusts or local authorities). Each model has its own merits and drawbacks.

 

The form these models take should be based on optimising existing assets, expertise and capacity to provide the infrastructure for those working at neighbourhood level, giving them the autonomy and resources to work proactively and collaboratively. The approach should be driven by investing in place-based infrastructure (place-based collaboratives, lead provider models and/or provider collaboratives) to act as a sustainable driver for neighbourhood working. These partners would be expected to deliver against core outcomes for the neighbourhood health service, but with flexibility to respond to wider community and local needs, informed by neighbourhood teams, community insight and population health data.