Two years after NHS England unveiled the Five Year Forward View (pdf) – its blueprint for community-based, integrated healthcare able to cope with the pressures of a growing and ageing population – the central bodies are still not doing enough to make it happen.
The King’s Fund is about to publish analysis of progress in reforming the way the NHS works to allow the new care models outlined in the Forward View to flourish. Speaking to the Guardian’s Healthcare Professionals Network, chief executive Chris Ham identified four ways in which the system is hampering local reforms – a shortage of cash to kickstart change, too little progress on a payment system which encourages collaboration, the need to sort out the debacle of the contracting rules which emerged from the Lansley reforms, and rushing change.
“The big concern we’ve got is the importance of a transformation fund to prime new care models. Virtually all the money in the Sustainability and Transformation Fund is going into sustainability and deficit reduction. It leaves precious little left over to support transformation,” he says.
“It is difficult to see how you stem rising demand unless there is the resource to invest in the out of hospital services. More money has to be found to prime those services, which are creaking at the seams. The NHS and its leadership need to explore other avenues [to raise cash], such as the work going on in relation to the NHS estate to generate income.”
Ham wants the central bodies to move faster in shifting from the old payment by results system to population-based funding, which encourages organisations to collaborate around prevention, helping patients manage long-term conditions at home, and avoiding unnecessary hospital admissions.
So far local areas have largely been left to design population-based funding systems on their own. Ham warns that the collapse of the £800m UnitingCare Partnership scheme in Cambridgeshire and Peterborough shows “there are opportunities but massive risks in some of these innovative contracting and funding arrangements, so the centre needs to provide more hands-on support to local leaders in working through the detail”.
The contracting rules imposed by the 2012 reforms create the ludicrous situation whereby, with some of the new approaches to running services, commissioners and hospital managers are tied up in a long and expensive tendering process when it is obvious that the contract will go to the local hospital. “But it’s not clear to commissioners whether they can go ahead in that way or whether they have to test the market before they decide,” says Ham. Guidance would clear away some of the legal thicket which is holding back change.
Finally, Ham is adamant that rushing change could wreck it: “There is a real impatience among the national bodies to accelerate what’s happening, but we know that if you are going to build these new care models on a sustainable basis you have got to allow time in terms of building the relationships between clinicians and between leaders so they are built on strong foundations. The worst of all worlds would be to go too quickly and for them to fall over.”
But despite all these difficulties, Ham believes local teams have made considerable progress in developing new ways of working, and recognises the efforts NHS England and NHS Improvement are making to ensure they are giving the system clear and consistent messages about what is expected.
Ham believes that on balance the Sustainability and Transformation Plan (STP) process is helping deliver the Forward View: “STPs are not perfect; they are the least bad option for trying to plan in a more coherent way in an NHS that is more complex than at any time in my 40-year career. STPs are a workaround of the Lansley legacy. Nobody wants another top-down reorganisation, nobody thinks the current system works well, so the answer is STPs.”
Article originally published by The Guardian
