Last reviewed 24 March 2015
NHS England’s “Five Year Forward View” sets out some of the new initiatives designed to allow health care providers to deliver fully integrated services. Dr Thoreya Swage examines some of the document’s main goals and the strategies adopted in order to achieve them.
In October 2014, NHS England (NHSE) published a strategy for the next five years called “Five Year Forward View”. This document set out its vision for the NHS, described a range of models that could deliver better care, identified targets areas for transformation and outlined the actions to be taken to achieve these improvements.
This strategy was supported by detailed planning guidance which was published jointly by NHSE, Monitor, the NHS Trust Development Authority (NTDA), the Care Quality Commission (CQC), Public Health England (PHE) and Health Education England (HEE) in January 2015.
The guidance is backed by additional funding announced by the Government, including £200 million earmarked for the development of new care models, as described in the Five Year Forward View, plus an additional £250 million for investment in primary care.
For the first time, the six bodies that produced the Five Year Forward View have committed themselves to working together by establishing a single group to provide leadership at the national level, enabling a joined-up approach to working with commissioners, providers and their local authority partners at the local level.
Creating the new models of care
The Five Year Forward View document describes possible new models of care which are better suited to allow for the smooth implementation of integrated care. Four such models include:
Multispecialty Community Providers (MCPs) in which a number of practices join together to form federations, networks or single entities to provide more rounded care with other professionals for people with complex and continuing needs.
Primary and Acute Care Systems (PACS) in which many organisations, including general practice, hospital, mental health and community services, come together to provide care for their populations
Small, viable hospitals where non specialist care is delivered to local communities. This may include different organisational forms where there are chains or franchises.
Enhanced health services delivered in care homes.
In March 2015, following a selection process based primarily workshops involving key partners and patient representative groups, 29 areas were chosen to lead the development of these new care models. They comprise 14 MCPs, nine PACS and six localities piloting enhanced health in care homes. It is anticipated that the MCPs and PACS sites will be ready to use a single capitated budget to pay for health services in their locality by the end of 2015–16.
For these sites, which have generally begun to make some progress towards implementing the new models of care, a programme of support will be developed, funded by a £200 million Transformation Fund.
The aim of having a few sites test out the new models of care is to establish successful prototypes which can be replicated elsewhere. It is anticipated that the programme will be rolled out later in the year to other areas using the lessons learned by these “vanguard” sites. The support programmes will be co-ordinated by a national New Models of Care Board.
Greater Manchester leading the way to an integrated approach to Health and social care commissioning
In February 2015, 12 Clinical Commissioning Groups (CCGs), 15 providers and 10 local authorities in Greater Manchester agreed a framework with NHSE on a joint approach to decision-making on the commissioning of integrated care for their population. This has brought together a combined health and social care budget of £6 billion.
The scope of the agreement includes the whole health and social care system in Greater Manchester, building on the work of the Greater Manchester Combined Authority to achieve the ambition of full devolution of public spending. It also means no reorganising of the NHS locally or a change in its principles need take place.
The first part of the agreement brings together adult, primary and social care, mental health, public health and community services in Greater Manchester, while the second part of the agreement sets out a combined framework for the strategies on governance, regulation, finance, resources, property, workforce, education and the sharing of information.
The agreement enables Greater Manchester to start making its own decisions and developing a map for the transition to the new arrangements from April 2015, with full devolution of health and social care services from 1 April 2016.
Health economies facing significant difficulties
For a small number of health economies that are facing significant financial challenges, NHSE, the NTDA and Monitor will work with the local players in applying a new “success regime” that will create the conditions for improvement. The intervention will be supportive in its nature - for example, addressing current performance and creating an environment for future transformational change, rather than supplementing the local capacity. The range of actions will include:
an accountability mechanism to enable the national bodies to oversee the recovery process and to ensure that all the key players are held to account
the agreement of a single short-term plan for the health economy, stating the actions that need to be achieved during the intervention period
extra support, including clinical, financial or performance expertise to deal with the specific issues facing the health economy
support from health economies that are performing well to enable the building up of capacity and progress in the challenged area
development and agreement of a medium-term plan for transformational change across the health economy
clear conditions for the agreement of any financial support that may be required.
Enabling change to be implemented locally
The national bodies will make it easier to implement change locally for the remaining health economies. It may be that some of the sites that will be developing the new care models in the scenario described above may be involved in the local areas that are dealing with the significant challenges.
The planning guidance emphasizes the continued focus on the multi-agency approach to prevention, including identifying the behavioural interventions, as described in the NICE guidance, in relation to smoking, alcohol and obesity. CCGs, local authorities and their partners are expected to identify appropriate measures to monitor progress.
A key prevention action is the co-design and implementation of a national evidence-based diabetes prevention programme, linked where appropriate to the NHS Health Check. An agreed approach led by PHE, NHSE and Diabetes UK will be published in the spring of 2015 and implemented through local organisations from 2016–17 onwards. This programme will be overseen by a National Prevention Board, chaired by PHE and including the NHS, local authorities and other key partners.
Managing long-term conditions and empowering patients
An essential aspect of improving the management of people with long-term conditions is to empower them through allowing them to make their own choices of what care they receive. This is the basis of personal health budgets.
Integrated Personalised Commissioning (IPC), where personal health budgets can be used to support either individual choices for personalised support or through a “year of care” model, are seen as one of the ways to realise the goal of empowering long-term patients.
In April of this year, eight sites across the country will go live implementing their models of IPC, covering 10,000 people who have complex needs. This ranges from supporting people who have diabetes to people with learning disabilities and those with dementia.
Another area where patient empowerment is expected to be enhanced is the choice pregnant women will have as to which maternity services they would prefer to use, thereby making it easier for the setting up of NHS funded midwifery services.
Investment in primary care
The Five Year Forward View recognised the need to invest more in primary care services in order to achieve the vision of better and integrated care. NHSE has made £1 billion available over the next four years for the development of primary care infrastructure, including improving premises and technology and enabling practices to offer more appointments and improved care for older people, with the aim of reducing the need for hospital admissions.
A workforce plan is being developed by NHSE, HEE, the Royal College of General Practitioners and the General Practitioners’ Committee to address the shortfall of doctors in general practice, and to attract more doctors into the area. In addition, the plan will include proposals for how other clinical professionals could be deployed in primary care, measures to support retention of current general practitioners, and means to encourage doctors who have left general practice to return.
The 150 (out of 211) CCGs that have been approved to take on co-commissioning on 1 April will have greater freedom to take local action to improve primary care services. Improved access to primary care through the Prime Ministers’ Challenge Fund has seen an extra £100 million allocated in order to implement this.
A number of initiatives have been proposed to improve electronic communication and access to records, including:
everyone having online access to their GP records from April 2015
the NHS number becoming the primary identifier in instances where information is to be shared
an expectation that at least 60% of surgeries will be transmitting prescriptions electronically to the pharmacy by March 2016
online appointments to primary care being made available to patients
at least 80% of elective referrals being made electronically.
Improving patient safety
The strategy also seeks to place a greater focus on patient safety in general practice, with a drive for practices and CCGs to join the “Sign up to Safety” campaign and align their plans to the local Patient Safety Collaborative.
“Sign up to Safety” is a three year national campaign, which started in June 2014, with the aim of having the NHS become the safest healthcare system globally by helping all staff involved to create a safer environment and tackle the issue of unsafe care and avoidable harm.
An electronic form developed by NHSE has been launched to make the reporting of patient safety incidents to the National Reporting and Learning System (NRLS) more straightforward for primary care staff. The NRLS is a national database which holds information on patient safety incidents and near misses, whether they result in harm or not.
Antibiotic resistance is becoming a widespread concern and is becoming a threat to the delivery of effective healthcare. It is recognised that antibiotic resistance and prescribing are very closely linked, with incorrect and overuse of antibiotic drugs a key cause of resistance. CCGs and providers are required to develop plans to improve antibiotic prescribing in primary and secondary care.
Parity for people with mental health conditions
In 2015–16 there will, for the first time, be access and waiting time standards in place relating to people requiring mental health care. This means that by April 2016 more than 50% of people having a first episode of psychosis will expect to receive treatment within two weeks. To support this, a further £40 million will be made available to help specialist mental health providers develop dedicated “early intervention-in-psychosis” services with other agencies.
Furthermore, there will be a new waiting time standard for Improving Access to Psychological Therapies services (IAPT) for adults. This includes at least 75% of adults receiving their first treatment session within six weeks of referral, and a minimum of 95% of people to be treated within 18 weeks. An extra £10 million is being made available to implement this waiting time standard.
For more details on the Five Year Forward View, see www.england.nhs.uk/ourwork/futurenhs/