SUSTAINABILITY AND TRANSFORMATION PLANS: PART ONE. Recently shadow health secretary Jonathan Ashworth said his first job in government would be to launch an independent review of every single Sustainability and Transformation Plan (STP) and to halt service closures. Labour’s proposed moratorium on the plans followed consultation with patients and campaigners around the country who were “pleading with the government to hear their concerns about their local services”. According to Mr Ashworth, STP plans for service changes had caused “widespread concern and confusion”. He added: “What is more, these decisions have been decided behind closed doors, with no genuine involvement of local people. It’s a disgrace”. In response Health Secretary Jeremy Hunt said, ‘These local plans are developed by local doctors and communities, backed by the top doctors and nurses of the NHS, and will improve patient care. This is all underpinned by an extra £10bn for the NHS, which we can only afford thanks to our strong economy”.
At this juncture we won’t offer another retread of the STP construct – more will follow in the second part of this series – though suffice to say that the plans offer a concrete embodiment of the analysis presented in Simon Stevens’ Five Year Forward View as to how the NHS can retain fiscal stability until 2020 whilst coping with the growing pressures on health and social care services. Instead we’d like to examine some of the questions raised by both Ashworth and Hunt as to where the plans come from. Both can’t be right, and indeed casting the net a bit wider offers a distinctly, shall we say, transnational view. And where better to look than the World Economic Forum, home to the Fortune 1000 and their faithful retainers in governments and other associated fora.
SUSTAINABLE HEALTH SYSTEMS
The jury seems to be still out on the concept of a transnational capitalist class. Its advocates insist that a breed now exists which owes its primary allegiance to ensuring global circuits of accumulation, assisted, and largely controlled, by the processes of financialisation. Critics on the other hand point to logistical inconsistencies in the idea, arguing instead that a more nuanced, empirically grounded formulation is required, and one that pays greater fealty to the hegemonic role of the US. Even so it’s still worth a look at the pages of the World Economic Forum (WEF) to see who Davos Man is and what he’s up to, particularly in healthcare, and particularly with regard to increased productivity within new place-based health economies.
In 2012 the WEF turned out a series of reports, co-scripted with McKinsey & Co, on sustainable health systems, which aimed to examine the growing tension between fiscal pressures and maintaining qualitative healthcare for populations, and offering various visions and strategies which could address this. As usual the triple threat, as it’s known, of ageing populations, growing consumer expectations, and more expensive technology was dragged out as the main drivers of cost pressures, though increasingly compounded by the wider economic context of drastic public debt, non-existent revenues, and severe austerity programmes.
The first document in the series, ‘The Financial Sustainability of Health Systems’, considered ways that governments could attempt to resolve this tension. These included the “blunt but effective” forms of rationing and shifting the burden of cost to individuals and employers, through for example, mandatory private insurance, and at the other end of the spectrum. The Forum considered increased tax revenue. A third option, that of raising healthcare productivity through delivering more services with fewer resources would, it was argued, “go a long way to ensuring their financial sustainability” while avoiding the “fierce political contest” inherent in both the previous choices.
Such productivity improvements would however prove “challenging”, not least the public resistance that blocks radical change with the result that inefficient providers remain. Similarly health systems can’t outsource to low cost venues, though the digital revolution may alter this, and the labour intensive nature of healthcare in general makes it difficult to replace labour with capital. Sustainability therefore must be achieved through transforming supply. And the Forum considers various levers with which to accomplish this. These included: payment innovations related to value rather than volume with financial incentives aligned to performance; such innovations to span both health and social care; boosting clinician productivity through greater use of digital technology; and an emphasis on preventative care and on more integrated care pathways.
Critically the Forum advocates a complete reinvention of the delivery system via new models of care. These would be in “capital-light settings” using leveraged talent models and low-cost channels, such as home-based, patient-driven models. However these “must be accompanied by capacity reductions in higher-cost channels” (such as hospitals) and new systems “must become more agile in leveraging the opportunities for more self-care”.
Keen eyed observers will of course recognise that NHS England’s Five Year Forward View of 2014 is a more or less verbatim transcript of the Forum’s diagnosis of the healthcare crisis, as well as reproducing the Forum’s prescription for supply side change and the various levers available to policy makers. It’s worth adding that ‘leveraged talent models’ can be translated as more flexible roles carried out by less qualified, cheaper staff, with weaker rules about pay and conditions. Similarly, capacity reductions entail not simply acute bed cutting but also a fairly comprehensive sell off of the NHS estate.
The FYFV’s use of the Forum’s tenets shouldn’t come as too much of a surprise as Stevens himself acted as Project Steward of the Steering Board for the first WEF report, working with chief executives of leading healthcare companies such as Apax Partners, Novartis, Merck, Medtronic and Kaiser Permanente, as well as the Directors of Health at the World Bank, the WHO, and the European Commission. At the time Stevens was head of UnitedHealth’s Global Division, rather than chief executive of the NHS, though some might argue the roles are interchangeable.
Stevens was naturally enough on the Steering Board for the Forum’s second report, ‘Sustainable Health Systems’. This was produced in early 2013 after a series of roundtable events in England, China, Spain, Germany and the Netherlands, and comprising some 200 interested stakeholders from all three levels of the WEF membership strata, namely transnational business, governments, and media/intelligentsia. Again various visions and strategies were assessed, culminating in three likely scenarios, which as the report argued were “not forecasts or preferences, but plausible stories about the future”, and which could provide “a rich context for improving decision-making in the present”.
An analysis of these scenarios will follow in part two, with some form of adjudication of the Forum’s preferences, particularly with reference to the STP programme. But at this point a closer look at the participants in the reports produced by the Forum can be rather revealing, especially with regard to transnational capitalist class formation, and equally to the notion of ‘leadership’ as disseminated throughout the STP programme and within NHS transformation as a whole.
As already pointed out, the WEF pursued a consistent approach to the problems of sustainability throughout their investigations, notably in terms of the composition of the various groups assigned to the process. As mentioned, the Steering Board comprised “eminent health systems leaders and experts (who) provided overall direction”, although closer examination reveals these were predominantly from healthcare corporations. Such a breakdown was also mirrored in the Working Group of experts who “supported the projects approach and methodology”. Interestingly in the latter group we find Michael MacDonnell, then Senior Fellow from Imperial College’s Centre for Global Health Innovation, but who is now acting as head of policy for the STP framework as a whole.
Indeed among the workshop participants who supported the project we can identify at least two, Amanda Doyle and Ron Webster, who are leading individual STPs in Cumbria and West Yorkshire. However it’s safe to assume the WEF agenda is effectively disseminated among other STP ‘leaders’, and they can always update the curriculum at the various leadership academies offered by global consultancies, domestic think tanks and privately partnered government agencies.
The list of other UK participants reads almost as a who’s who of the various personnel who regularly win leadership awards from healthcare management journals in England and extolled for their ability to take brave and tough decisions and other euphemisms for service cuts. It also includes ex-health ministers and leading participants in government reviews, as well as Treasury officials and former members of health committees. Such high level privateers include Alan Milburn, Dame Julie, Mark Newbold, Sir Robert Naylor, Bruce Keogh, Niti Pall, Paul Bate, Nick Seddon, various members from the NHS Confederation, not to mention the unfortunate Katrina Percy and selected bods from UK private healthcare such as Jill Watts and David Mobbs. We have to say it would have been nice to see David Dalton among the list to offer a sense of completeness but he can be found with the others in global consultancy outings.
Interestingly only two English MPs are among the contributors: Stephen Dorrell then in his guise as chair of the Parliamentary Health Committee, and now working for KPMG; and former Blairite leadership candidate Liz Kendall. Even more reason, one would imagine, for Labour leader Jeremy Corbyn to distance himself from such a bunch.
That said, the various groups in the project do appear to offer a chain of command within the transnational class, certainly as exemplified by the WEF and its efforts to extend the influence of global corporations as a whole. And as mentioned such a chain can clearly be seen in the policy framework of STPs. Jeremy Hunt’s assertion that local communities and doctors and nurses developed STPs does seem a trifle far-fetched, not to say radically inconsistent with the aims and influence of Davos Man whose footprints can be seen all over FYFV and, as we’ll see, the STPs. As Klaus Schwab, the WEF’s billionaire Executive Chairman, said in his preface to the second report, “sustainability is unlikely to be achieved through incremental changes. Instead transformative solutions will be needed”.