Sajid Javid certainly doesn’t lack ambition. In his far ranging speech yesterday he positioned his ideas for change in the tradition of public service reform principles of Bevan, Burke, Thatcher, and Blair (where is Beveridge?). That takes some intellectual acrobatics. The promiscuity of this endeavour may explain the sense of incompleteness and lack of coherence.
Prevention, Personalisation, Performance, and People – Javid’s four Ps – are laudable objectives. But whether these terms will amount to radical change depends on how they are combined. Partridge, Pecorino, Peppers, and Pasta may make for a delicious dish, all depends on the right recipe and how the chef is preparing them. One is left asking how individually attractive elements fit together in one coherent vision that is more than the sum of its parts.
More fundamentally, the speech was surprisingly silent on the golden thread that runs through the current legislative changes in front of us: integration.
Mentioning it a couple of times in an 8,500-word speech suggests that he is maybe loyal to his heritage but doesn’t love it. He said as much by pointing out that the changes in the Health and Social Care Bill and the White Papers are not going far enough. Maybe he is also wondering whether simply integrating the components of a system that he thinks are not going to be fit for the future is the panacea that some believe it is.
At the heart of the integration challenge lies the perennial problem for radical health care reform: the crippling tension between national control and local autonomy. This is maybe the biggest omission of all. The speech did little to reflect the fundamental nature of that challenge nor did it articulate a coherent change model. Javid’s call to liberate the “thousands of innovators to make tens of millions of innovations” locally is therefore the right instinct. However, this will require funding and headspace, neither is readily available.
Meeting national targets is in the DNA of the NHS, a game it understands very well. Proactive local transformation at systems level is the exception and where the work really should be locally. Providing the psychological safety to admit that we don’t have all the answer starts with the Secretary of State.
The risk is that, for all the rhetoric about letting a thousand flowers bloom, what will be heard locally sounds very much like ‘innovate as long as “90% coverage of electronic patient records is reached by 2023, 75% of all adults in England have the NHS app, and 80% of social care providers have digital social care records by March 2024.”
Instead, if he is to make his vision a reality, Javid needs to clarify the relative roles of the centre and the local Integrated Care Systems. A new deal on autonomy and accountability is needed to unlock the desired transformation. We will set out in more detail how this might work in due course. In my view, this involves an element of symmetry between the opportunities in front of us (e.g. the personalisation of care), and the accountability model we choose (e.g. personalised information about my care to hold my care givers to account).
Javid is right that more of the same will not suffice this time given the opportunities and challenges we are facing. Incremental reform disguised as radical is a symptom of what is currently lacking: honesty that no one should expect him to have all the answers.
Acknowledging this would be radical. The road from an episodic sickness model conceived for communicable diseases to a continuous healthcare model that focuses on keeping people healthy is unchartered. Weaning policy makers off the instinct that complex public services such as health can be planned and controlled centrally by sprinkling selective policy ideas is step one. Step two is focusing relentlessly on setting out a clear change model that clarifies the respective roles of the centre, healthcare providers, and citizens.