The recently-published five year forward view (the “View”) represents a serious attempt to highlight the steps that the NHS as a whole needs to take in order to meet the grave challenges it faces. Although it does not express the message that the NHS is running out of time, there is clearly a need for change. Without fresh approaches to the way it operates, the forecast funding gap by 2020/21 of £8bn (which assumes the achievement of greater productivity) is likely to be much wider. This could require forced change which could threaten the continuation of the NHS in its current form.
Models of care
The view gives a clear message about the need for prevention and highlights the problems that the NHS currently has from having to deal with diseases which are largely self-inflicted through lifestyle choices. One in five adults still smoke, two thirds of adults are overweight or obese and there are 3,000 alcohol-related admissions to A&E every day. It also points out that previous messages about the importance of taking personal responsibility for avoidable illnesses have not been heeded and that differing approaches to smoking, obesity and alcohol are required through adopting hard-hitting national action and workplace incentives to promote employee health.
Recognising the adverse impact of these three key pillars of chronic disease is, of course, not new. However, it is helpful that a more innovative approach to mitigating their impact is being considered and that employers as well as local authorities are being involved to share not only in developing a solution but also in the benefits that will arise as a result. Sickness absences to employers and taxpayers are estimated at £22bn a year.
Perhaps the most significant message is that the traditional divide between primary care, community services and hospitals is increasingly a barrier to the personalisation and coordination of care that patients need. The View suggests the need to dissolve traditional boundaries by fostering greater collaboration between providers across health networks, in short, managing systems not organisations
The significance of greater integration is not new. Indeed, it is a central theme of the Procurement, Choice and Competition Regulations and one of the objectives of greater integration of commissioning has been that the provider market would respond through greater collaboration. However, the emphasis in the View on provider integration perhaps acknowledges that too little progress has been made and that there is much greater need to encourage new models of integrated care without the need for collaborations to either be led or dictated by commissioning decisions.
In addition to requiring greater coordination across emergency care networks; concentrating the provision of specialised care; considering how to make smaller hospitals more viable; and reviewing the model for maternity care, there are three models of care which merit specific comment:
Multispecialty Community Providers (“MCPs”)
This envisages that GP practices will employ more specialist clinicians (e.g. consultant physicians, geriatricians, paediatricians) to work alongside nurse, therapists, and community-based professionals with a view to shifting the provision of outpatient consultations and ambulatory care away from hospital to community settings.
Primary and Acute Care Systems (“PACs”)
This model would see the vertical integration between primary and acute providers facilitating the provision of GP and acute hospital services as well as mental health and community care services. This model could be either GP or acute trust-led. The View acknowledges the complexities that are involved in putting PACs together. Although not specifically mentioned, one of these issues will be dealing with the anticompetitive elements. This issue is alluded to by the View, and is referred to as being “potential unintended side effects which will need to be managed.”
Enhanced Care in Care Homes
The View highlights the benefits of establishing closer links between social and primary care, particularly in relation to more active health management and rehabilitation support. The aim of a collaboration like this would be to improve quality of life and avoid hospital admissions, thereby delivering greater savings than the initiative would itself cost.
The View recognises that locally-developed models represent only part of the story and that, although nationally-imposed solutions are not part of the plan, there are steps which the centre and/or others need to take in order to make the overall objectives achievable. For example, movement is required on the availability of social care services and central government needs to make additional funding available.
These can be summarised as:
There is a promise to work with ambitious local areas to define and champion joint commissioning models, including integrated personal commissioning and better care fund-style pooling.
Aligned National NHS Leadership
Although the View points out that the various national bodies (NHS England, Monitor, the TDS, the CQC, Health Education England, NICE and Public Health England) have differing responsibilities and duties, they do need to be aligned and seen as acting in concert in dealing with issues which are being proposed following the View.
Developing a Modern Workforce
The View acknowledges the important role that all those engaged in the provision of care as well as in supporting roles will play in delivering successful care models. With this in mind, NHS England is committed to ensuring the NHS becomes a better employer and has access to sufficient numbers of properly trained and flexible staff.
The Importance of IT
The View recognises the importance of IT and information in the provision of care but also accepts that the NHS strategy in delivering IT either by centrally-planned projects or exclusively local procurements has failed.
NHS England will adopt an approach which recognises the need for a wider approach to systems which allow the system as a whole to function whilst acknowledging the need for the local NGS to decide on systems for each organisation. It will also provide a road map that will allow NHS organisations to see who needs to do what in order to transform digital care.
Speeding up Health Innovation
NHS England points out that steps will need to be taken to speed up innovation in new treatments and diagnostics. It promises to play its role in this by continuing to support the work of the National Institute for Health Research as well as specialist clinical research by the NHS. It will also work to shorten the time between discovery and use in clinical practice and to encourage the piloting off combining different health technologies to transform care delivery.
NHS England points out that by 2020/21, there is likely to be a financial shortfall across the NHS. Depending on a number of factors (the delivery of increased productivity and the extent of funding increments between 2015/16 and 2020/21) the estimates for this shortfall range from zero to £30bn.
Opportunities and Challenges
Providers are already collaborating to respond to integrated clinical procurements but these have thus far tended to revolve around service consolidation, as opposed to commissioning through pathways, which is still in its infancy. As a result, providers often struggle to deal with the issues they face in establishing these collaborations with organisations with which they are often in direct competition, particularly in relation to the disclosure of sensitive information as well as operating models.
The models of care proposed highlight the importance of pathway integration and, in doing so encourage the development of a market for both commissioners and providers, which removes, to an extent at least, the difficulties of competitor collaboration. There are a number of different models of care which are proposed, but the View is at pains to point out that one of the most important changes will be to expand and strengthen primary and out of hospital care with a view to addressing the considerable impact of long-term conditions and stretching the scarce resources of the NHS.
Providers need to consider the opportunities afforded by the View and to establish relationships and structures that will help them to respond. One of the most important messages conveyed by the View is that there is little room for nationally-imposed “one size fits all” models. It recognises that to stand the greatest prospect of success, solutions need to be tailored to address local issues. As such the View provides an apparently flexible framework within which it should be possible to achieve improvements in care whilst avoiding avoid national structural reorganisations and the resulting distractions. However, as it acknowledges, locally developed models must be supported not only by national leadership and central initiatives but also by commissioning decisions so that change is encouraged and takes place at a realistic pace which can be met by providers.This information is intended as a general discussion surrounding the topics covered and is for guidance purposes only. It does not constitute legal advice and should not be regarded as a substitute for taking legal advice. DWF is not responsible for any activity undertaken based on this information.