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.