2017 promises to be another challenging year for the health and care system, with demand for care increasing faster than the supply of resources.
A system already stretched to its limits will have to work even harder to maintain current standards of care and to balance budgets. This requires a continuing focus on operational performance and renewed efforts to transform the delivery of care at a time when frontline staff are working under intense pressure.
The NHS five year forward view (Forward View) will be tested to its limits as leaders work to improve performance and transform care. The NHS locally has to deliver £15 billion of the £22 billion efficiency improvements required under the Forward View, with the remaining £7 billion to be delivered nationally. It also has to provide evidence that new care models are delivering benefits. Failure to do so will raise serious questions about the assumptions on which the Forward View was based and on the ability of leaders to deliver their plans.
Against this background, we have identified five main priorities for 2017.
Supporting new care models centred on the needs of patients
We have argued that the growing and ageing population and changing patterns of disease call for fundamental changes in the delivery of care.
People should be much more involved in their own health and care and be offered the information and support to manage their medical conditions. More care should be delivered in people’s homes or closer to home, with greater investment in district nursing, general practice and social care. Plans to integrate care – encompassing health and social care, primary and secondary care, and physical and mental health services – should be accelerated.
Much greater priority should be given to public health and prevention through partnerships between local government, the NHS and other organisations working in population health systems. The aim should be to ‘fully engage’ the public in tackling the causes of ill health and supporting people to remain in good health for as long as possible. Action by government is also needed to reverse the rising tide of obesity and other major risk factors.
The vanguards set up to implement the Forward View are establishing a range of new care models. The most advanced, in areas such as Northumberland, Salford, Nottingham and Tower Hamlets, are demonstrating progress in integrating care and are evolving into accountable care organisations and systems. A few are beginning to pay attention to public health and prevention.
The priority now is for national bodies to signal their continuing support for the vanguards, help to spread the learning from the most advanced areas as rapidly as possible, and provide the funding needed to mainstream their work. The vanguards themselves need to produce evidence of early impact, acknowledging the time needed to transform care. This process cannot be rushed, and sustainable change needs patience and commitment.
Strengthening and implementing sustainability and transformation plans
Sustainability and transformation plans (STPs) are a practical expression of the ‘place-based systems of care’ that we have argued offer the best opportunity for the NHS and its partners to work together to transform the delivery of care. After a difficult start, the challenge is to achieve much deeper and more meaningful engagement with stakeholders. STPs must also strengthen their leadership and staffing as they move from planning to implementation.
The proposals set out in STPs envisage major changes in how health and care are delivered in hospitals and the community. Used wisely, they could be the means by which new care models are supported and spread across England. For this to happen, every STP needs to be stress tested to ensure that the service changes they envisage and the financial plans that underpin them are credible.
STPs are a ‘workaround’ of the complex and fragmented organisational arrangements that resulted from the Health and Social Care Act 2012, and they have no basis in statute. It is all the more important therefore that their governance is formalised to align their work with the responsibilities of the boards running NHS organisations and to avoid legal challenges. In due course, given the emphasis now being placed on collaboration rather than competition, the 2012 Act will need to be amended.
Improving productivity and delivering better value
As an organisation with an annual budget of more than £100 billion, the NHS has plenty of scope to be more productive. Increasing productivity has become more urgent as funding increases have fallen and deficits among NHS providers have risen. The Carter review identified many ways of improving productivity, including through changes in clinical practice. In doing so, it echoed our work on how the NHS can deliver better value to patients and taxpayers.
Supporting clinical teams to reduce unwarranted variations in care and to improve care should be the priority for every NHS organisation. The use of tried and tested quality improvement methods has been shown to deliver results; staff need training in these methods and time to realise the benefits. The boards of NHS organisations have a key role in leading this work, ensuring that resources are made available to support implementation and developing the cultures in which improvement is supported and valued.
An important way of delivering better value is to act on evidence that medical care is sometimes used inappropriately. Work in Wales to promote prudent health care and in Scotland on realistic medicine exemplify efforts in the UK to act on this evidence. The Choosing Wisely initiative similarly seeks to ensure better use of care by engaging patients in decision-making and sharing information about the risks and benefits of treatment options.
Developing and strengthening leadership at all levels
Improving care depends in large part on the quality of leadership throughout the NHS and the ability of leaders to engage and support staff to improve care. There is evidence that it is becoming more difficult to fill leadership vacancies in the NHS, partly as a result of the intense pressures on leaders to improve performance and to cope with the burden of regulation. Much more needs to be done to support the compassionate and inclusive styles of leadership advocated in the national framework for action on improvement and leadership development and to tackle the cycle of fear and bullying behaviours evident in some parts of the NHS.
Our work has highlighted the crucial role of clinical leaders working with experienced operational managers to deliver high-quality care. This is where many of the productivity opportunities arising from changes in clinical practice can be realised, for example, reducing delayed transfers of care by improving the flow of patients through hospitals. High-performing NHS organisations like Frimley Park NHS Foundation Trust, East London NHS Foundation Trust and Western Sussex NHS Foundation Trust are examples of where this is already happening.
The success of STPs and the new care models hinges on experienced organisational leaders developing into system leaders who are able to work across boundaries to negotiate and implement improvements in care. Our work has argued that this requires leaders who are ‘comfortable with chaos’ because they are able to work within fluid and often rapidly changing organisational arrangements. The NHS can learn from local government, where these skills are more common.
Securing adequate funding for health and social care
In April the NHS will enter the eighth year of unprecedented constraints on funding while adult social care is rapidly becoming little more than a threadbare safety net for the poorest and most needy older and disabled people. The prospects for the remainder of this parliament remain bleak, with limited scope for raising more funds for social care and the NHS having to plan for infinitesimal growth in 2018/19 and 2019/20.
The government must choose between finding additional resources for health and care or being honest with the public about the consequences of continuing austerity for patients and users of publicly funded social care. Finding additional resources means being willing either to increase taxation or to reallocate funds from other areas of spending. Being honest about the consequences of continuing austerity requires acknowledgement that current performance standards and new commitments like seven-day working cannot be delivered within available funding.
The more important challenge is to initiate a debate about a new settlement for health and social care, building on the work of the Barker Commission. This would go beyond the short-term interventions that have sought to shore up the current creaking system and would instead reform fundamentally the funding of health and care. An equitable and sustainable system would be one in which public funding is increased and entitlements to social care are aligned more closely with those in health care, paid for by increases in taxes and National Insurance and changes to some existing benefits.
Our work in 2017
The Fund will continue to analyse the impact of government policies on health and care and to support leaders to make the changes needed to sustain and transform services. We will make the case for changes in policy and practice that hold out the possibility of improving the outcome and experience of patients and service users based on evidence drawn from our research. This includes highlighting innovations in care that are possible within the constraints of current arrangements. We will also use our expertise to speak truth to power where we believe politicians are avoiding difficult but necessary choices about taxation and spending.