Two years on from the Forward View, is there hope for sustainability and transformation in the NHS?

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Part of The NHS five year forward view

In the two years since the NHS five year forward view was published, the need for change within the NHS has become more urgent. Pressures on health and social care have been growing year on year, with most providers now in deficit and key patient care targets being consistently missed.

The main challenge of implementing the Forward View is to balance the urgent need for change with the pace of implementation. The scope and scale of the changes set out in the Forward View are ambitious, and local systems cannot be rushed into transforming services if changes are to succeed.

Given enough time to develop, new care models set out in the Forward View may well hold the answer to these rising pressures with their focus on prevention, early intervention, avoiding unnecessary hospital admissions and supporting people to stay well at home. Local innovations in how care is delivered are beginning to show promise.

For example, in West Wakefield’s MCP vanguard, ‘care navigators’ are helping patients to access social prescribing and to connect with voluntary sector and preventive services, and pharmacists and physiotherapists are working in GP practices to allow GPs more time to spend with patients with complex health needs. In London and other areas, hospital trusts have begun working together in acute care collaboration (ACC) vanguards to try to reduce costs and variation in clinical services through collaboration.

There has also been encouraging progress in developing the organisational forms and contracting arrangements to support new care models, largely driven locally through the vanguard sites. With MCPs and PACS, providers and commissioners are beginning to work together in new ways – with the most advanced sites looking to put in place agreements on new contracting and funding models such as alliance contracts and capitated budgets.

However, despite these developments new care models are still a work in progress. Putting in place new organisational forms and associated contracting and governance arrangements to support this is proving challenging. There are legal uncertainties about procurement and tendering that have yet to be clarified, with even the most advanced vanguards yet to issue any contracts. Despite guidance issued by national bodies on payment approaches and key issues, local leaders are still unclear on some of the technical aspects of how new approaches to payment systems will work, such as how to determine the size of the budget and how risks and rewards can be shared.

The difficulty of the challenge facing local leaders should not be underestimated. Providers and commissioners are being asked to come together to make difficult decisions about the future of health care in their local areas in an uncertain climate. Meanwhile, providers still have a day job to do, and are understandably preoccupied with keeping services running under increasing pressures.

Even if local leaders manage to overcome these obstacles, it might all be for nothing. Almost all of the Sustainability and Transformation Fund is being spent on reducing acute trust deficits. With this trend set to continue over the next few years, there is precious little money left to fund much-needed transformation. And without adequate funding to support running an old system while introducing a new one, how can local leaders hope to be successful in transforming services at pace?

The transformation of mental health services that began in the 1970s showed that large-scale transformation is possible given enough time and investment. National bodies need to recognise that transformation is the key to the sustainability of the NHS and ensure that it is sufficiently funded.

Comments

Peter Brindle

Position
GP and Leader - Commissioning Evidence Informed Care,
Organisation
West of England AHSN
Comment date
27 October 2016
Clearly the FV has generated a lot of activity and reorganization in ways of working. People are very busy on their STPs.
How do we know what the impact on patients and budgets is and what are mechanisms for measuring this?
There are statements like "pharmacists and physiotherapists are working in GP practices to allow GPs more time to spend with patients with complex health needs" Sounds great, but how certain are we that it is working (and for whom?)?
What is the evidence that the new care models are beginning to be the "answer to these rising pressures with their focus on prevention, early intervention, avoiding unnecessary hospital admissions and supporting people to stay well at home"?
Activity is no substitute for impact.

Terry

Position
Member of the publuic,
Comment date
27 October 2016
I should be a little embarrassed, to say the least, if this is all that can be reported as progress after so long. What has it been now - 10 years since collaboration was the buzz word?
You say 'given enough time' and 'beginning to work together in new ways' as if it was really noteworthy.
The quality of management and leadership in many areas is not strong and unfortunately for the public, they are being recruited with such qualities with individuals being allowed to keep their heads low and often getting promoted as a result.
Those that are now bringing about change of course are to be congratulated but there is such a long way to go to get to where we should have been all those years ago.

kevin riley

Position
Retired Public Sector Solicitor and User and active Supporter of Doctors and Nurses working in the NHS,
Organisation
N/a
Comment date
29 October 2016
All this discussion ignores the elephant in the room namely that,since the Health and Social Care Act 2012 removed the NHS from democratic control, there is nothing that NHS England, Jeremy Hunt or the Department of Health can do to force the now free from Democratic control "independent" 175 NHS Trusts to provide health services in accordance with any centripetally devised "plan".
The above can now only "recommend and or advise" but can do nothing if the independent and free from democratic control NHS Trusts choose to ignore that advice and/or recommendation.
The reality of the above was made perfectly clear in the White Paper published before the Health and Social Care Act 2012 was placed before Parliament for approval.
The reality of the above is that any five year plan is not enforceable in any way and each and every Trust can ignore all of its contents should they so wish and there is nothing that NHS England, Jeremy Hunt or the DOH can do about that decision.
Unfortunately all of the above are intent on concealing the above legal reality, not only from employees of the now "independent and free from democratic control NHS Trusts" but also employees of the Kings Fund and the general public

kevin riley

Position
Retired Public Sector Solicitor and User and active Supporter of Doctors and Nurses working in the NHS,
Organisation
N/a
Comment date
29 October 2016
Re last post - the word "centripetally" in the last line of the first paragraph should have read "centrally"!!

Karen

Position
Quality Manager,
Organisation
HEE
Comment date
29 October 2016
Kevin, does this mean that the groups of CCGs forming geographical footprints do not have to work together to produce STPs if they choose not to?

kevin riley

Position
Retired Public Sector Solicitor and User and active Supporter of Doctors and Nurses working in the NHS,
Organisation
N/a
Comment date
29 October 2016
Yes - the legal reality means that CCGs are as independent and free from democratic control as NHS Trusts.
I would suggest you access the White Paper published in 2012 which makes the position post Health and Social Care Act 2012 abundantly clear..
Any cooperation is entirely voluntary and beyond the control of NHS England, the Department of Health and Jeremy Hunt who as with NHS Truts can now only advise and/or recommend..

kevin riley

Position
Retired Public Sector Solicitor and User and active Supporter of Doctors and Nurses working in the NHS,
Organisation
N/a
Comment date
29 October 2016
EXTRACT FROM WEBSITE OF NHS ENGLAND

STPs footprints are not statutory bodies, but collective discussion forums which aim to bring together health and care leaders to support the delivery of improved health and care based on the needs of local populations. They do not replace existing local bodies, or change local accountabilities.

kevin riley

Position
Retired Public Sector Solicitor and User and active Supporter of Doctors and Nurses working in the NHS,
Organisation
N/a
Comment date
29 October 2016
Realistically the most immediate and practical way to improve patient throughout the now fragmented NHS is for the individual Chief Executives "in charge" of each and every independent NHS Trust to be forced to accept personal responsibility for identified failures (usually by the CQC ) fin patient outcomes (particularly preventable/avoidable deaths) that have occurred in the organisation for which they are legally responsible.

In addition to the above warranting dismissal under employment law for breach of a fundamentaL requirement in their individual employment contracts (express or implied) each Chief Executive ALSO owes a legally enforceable (under criminal law) "duty of care" to every patient which "duty of care" can not be delegated to subordinate staff.

At the moment these Chief Executives are being effectively rewarded for failure - and also escaping crimial liability entirely..

kevin riley

Position
Retired Public Sector Solicitor and User and active Supporter of Doctors and Nurses working in the NHS,
Organisation
N/a
Comment date
29 October 2016
Apologies - the word "outcomes" was omitted from the end of the first line of my last "post"

Sue Vaughan

Position
retired GP,
Comment date
30 October 2016
The hospital trust in my arra is about to run out of cash, having used up its capital reserves. It is negotiating a loan from NHSE so it will be able to pay the staff. The £14m transformation pot that was earmarked for them "will never be paid" they have been told and their plans to expand services to meet increasing demand have been cancelled by the NHSI team - they are in finacial special measures.
They may be independent legally but are totally controlled financially. Responsibility without financial power is a bad combination. The suspicion is that they will be forced to look for other funding streams ie expand the provision of private care.
What is the legal framework that justifies the upheaval in control that is at tne heart of the 5YFV? What is to stop the handing over of the accountable care organisations that may be created to private sector control?

James Bunt

Position
Management Consultant,
Organisation
Gordian Management
Comment date
31 October 2016
Interesting article. I am hearing noises from within a local Trust that the STP is just another "game to play". What we learn from this is, I think, that the Trusts have a logical interest in sustaining themselves as individual organisations whereas the level of collaboration needed to fulfil the 5 Year Plan requires sacrifice of services, income and status. This is something Trusts will find difficult, if not impossible, to do.

In addition there is little meaningful sanction if co-operation is not taken forward and the STPs fail. Even removal of senior Execs merely hands them a pension pot/severance windfall in many cases. There needs to be more "hearts and minds" work leading to willing participation but the timescale makes this hard.

john clarke

Position
Social care,
Comment date
16 November 2016
Kevin Riley the real elephant in the room is the political dogma which fails to truely invest in the NHS but want to take us down the road to a privitised and insurance based health service. We need to increase expenditure from 6.9 % GDP to between 7.6 to 8.3 this would then equate to 67billion at lowest level. Additional moneys which are then used to address deficits is true false economy and in effect sets trusts and other up to fail. O and then it can be said this is not working we need a new way and that is open market!

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