Last reviewed 24 January 2017
In this feature, Thoreya Swage, Healthcare Consultant, provides an update on the changes to the NHS landscape in England that have been implemented over the past two years following the publication of the Five Year Forward View.
It is now two years since the publication of the Five Year Forward View in October 2014 which signalled a change in the direction in the way the NHS was to develop its services, driven by the need to close the health and wellbeing, quality and financial gaps that it was facing.
Since then changes have been made swiftly with the formation and publication of the Sustainability and Transformation Plans (STPs) in October 2016 and experiments with various new models of care across the country.
In the interim, the pace was accelerated further in September 2016 with the publication of the Planning Guidance from NHS England, which required NHS organisations within their STP areas to agree two-year contracts, three months earlier than in previous years together with a plan to reach a “system control total”. This timetable was to enable organisations to prepare in time and properly for the new financial year beginning April 2017.
So what is the progress so far?
1. Sustainability and Transformation Plans
STPs cover defined geographical areas and are population-based. Forty-four STPs have been published covering the whole of England (and can be accessed through the NHS England website) but not all are at the same stage of development. An analysis by NHS England has indicated that the STPs had a number of different forms with some highlighting proposals or outlines that required further development using contracting as the mechanism, and needed more engagement and consultation locally before becoming fully formed plans, while others were better formed.
It was envisaged that the next stage of development would be a partnership of the relevant statutory bodies, managed by a clear governance structure with a few becoming integrated organisations.
The STPs were required to clarify their first active steps in the implementation of their plans in their submissions of their two-year (2017–2019) operational plans on 23 December 2016. Following on from this NHS England is planning to strengthen the ability of STP areas to carry out these intentions with a number of supportive actions.
Helping STPs to identify the resources and people that are working within their area to achieve change — this includes Clinical Commissioning Groups, Commissioning Support Units and the improvement teams of NHS England and NHS Improvement. For the STPs that have greater clarity on their proposals for change, they will be granted the opportunity to go ahead and begin the redesign of the services in their locality together with the ability to have control over these resources and people.
To support this, NHS England plans to shift more of their resources away from assurance and monitoring activities to facilitating the implementation of STPs and other national change programmes.
These resources will initially be focussed on the STPs that appear likely to achieve change over the following 18–24 months in order to maximise success of the change process.
Identifying possible different STP governance models which span across many organisations with the intention of clarifying the roles of individual bodies within the STP, as well as what is required with regard to shared working across a health economy. This is a key issue as currently each NHS organisation has a statutory responsibility and accountability for its own budget. However, the STP requires the organisations within its area to share financial risk across the statutory boundaries and may require transfers of funding from one body to another to support a system-wide pathway of care. Furthermore, the STP model implies a collective financial risk across the whole area with the system control total required to be achieved which may mean that some organisations may be in surplus and others in deficit as a result of the changes in service delivery in a system.
Although all STPs have identified senior managers to lead the local programme, these positions are being carried out in addition to their regular roles. In recognition of this, NHS England plans to provide part-funding for the salary of STP leaders.
Encouraging STP areas to learn from each other and to accelerate the engagement and consultation with staff, patients and the public.
Establishing programmes of support nationally with a focus on system development such as primary care provider development and urgent and emergency care, rather than individual bodies; and promoting clinical standardisation and improvement in productivity programmes.
Where STPs have identified capital projects that are in advanced stage of development and have the potential to have an impact over the next two years and yield savings, NHS England and NHS Improvement will prioritise these for funding.
NHS England is planning to publish in spring 2017 an update on the Five Year Forward View covering the above points.
The ultimate aim of this work is to develop STPs that have combined the commissioning and provider functions and within that, develop and embed the new models of care that have been maturing in parallel to the STP work.
2. New models of care
A key plank of the Five Year Forward View is the development of new models of care covering:
primary and acute care systems (PACS) — whereby many organisations, including general practice, hospital, mental health and community services, come together to provide care for their populations
multispecialty community providers (MCPs) — when a number of practices join together into single entities where GPs and other primary care professionals proactively manage patients with complex and continuing needs utilising digital technologies, as well as developing new skills
enhanced health in care homes — different models such as in-reach support, provided jointly by the NHS and care home sector, including medical and medication reviews and better rehabilitation are tested. The aim is to reduce the need for hospital admissions
urgent and emergency care — urgent and emergency care services include care not just in but also outside of the hospital setting such as general practices, community teams, pharmacists, ambulances, NHS 111, social care and the voluntary sector. In addition, the networks aim to remove the barriers between physical and mental health to enhance the quality of care and to support patients to manage their own conditions through education and other initiatives
acute care collaborations — where local hospitals join together to reduce the variation in clinical care and enhance their financial viability.
The above have been spearheaded by 50 “Vanguard” projects across the country which have been permitted to develop their models to suit local relationships and population needs. The essential approach has been to allow experimentation with the possibility of failure together with learning arising from this experience.
Although there are officially 50 Vanguards which cover a small percentage of the country (for example, currently MCPs and PACS Vanguards cover about eight percent of England), there are other such projects being tried and tested that are following the same principles. Many of these are identified in their local STPs.
In order to promote the development of new models of care, national guidance has been published to support the Vanguards and similar initiatives including the following.
The Multispecialty Community Provider (MCP) Emerging Care Model and Contract Framework (published in July 2016) — Three versions of the MCP contract (which is based on the GP registered population and covers primary, community, mental health and social care) and the MCP Care Model are described.
Integrated Primary and Acute Care Systems (PACS) — Describing the Care Model and the Business Model (published in September 2016) — This framework or contract is similar to the MCP model and includes, in addition, hospital services.
New Care Models: Vanguards — Developing a Blueprint for the Future of NHS and Care Services (published in September 2016) — This describes the different emerging care models that have been tried and tested across the country which provide a “blueprint” for other similar initiatives.
National Support Package for All 50 Vanguards covering:
integrated commissioning and provision
monitoring and evaluation
making the most of technology
redesigning the workforce
engagement and communication.
3. Other models of care
Although the focus has largely been on the new models of care described above, other care models, some predating the Five Year Forward View, are currently underway including the integrated care pioneers and test sites for the primary care home model.
Integrated care pioneers
Two years prior to the publication of the Five Year Forward View, in 2013 NHS and local government partners were asked to express an interest in developing better ways of joint working through combining health and social care together with the voluntary sector in order to improve the effectiveness of services being provided. Twenty-five integrated care pioneers were selected to act as exemplars of driving health and social care improvement in a locality.
The key features of an integrated method of working that have been identified include:
joint assessment and care planning
accountability placed with a lead professional
a single point of access
use of technology.
An essential element of the integrated care model is the shift of care from the hospital setting to nearer to people’s homes, a key feature of which is the establishment of community hubs centred around primary care practices. These hubs are designed to provide a broader range of services than primary care involving greater input from community and social care services, thereby reducing the need for hospital care. It also encourages greater self-care approaches.
The integrated care models have also delivered enhanced discharge from hospital through the development of integrated arrangements for discharge and improved re-ablement for patients leaving hospital.
The pioneers have developed various programmes of self-care for their populations, as well as improved signposting for the full range of services within their communities, the latter usually facilitated by the voluntary sector.
Integrated mental health assessment and liaison services have been developed as part of the integrated care offering.
The early outcomes of the integrated care pioneers have informed the thinking of subsequent national policy such as the Five Year Forward View and are now anticipated to be developed within STP localities.
An added outcome is the development of patient-centred care, with the pioneers ensuring that patient choice is built in their models of care through the use of integrated personalised commissioning.
Primary care home model
Launched in October 2015 jointly by the National Association of Primary Care and the NHS Confederation, the primary care home model is a type of MCP that delivers primary care services according to the needs of the local population (rather than the registered GP population).
Fifteen sites across the country are testing this model covering populations between 30,000–50,000 in size. The model focuses on aligning healthcare teams from all disciplines and social care professionals working together to provide personalised care to patients. The essential element is that every member of this team knows everyone else thereby improving the consistency of care to patients.
The model has four main features.
A first point of contact — for the new patients requiring this care.
Holistic (person-centred) care rather than disease focused.
Care that is comprehensive.
Co-ordination and integration such that if a person needs specialist care this can be arranged.
Aligning the clinical and financial risk under one body (ie the Primary Care Home model ) is made possible through the NHS Act (Primary Care) 1997 which permits the flexibility for primary care to reshape services to meet local needs.
It is clear that many models of care are being tested across England and the key action for STPs areas is to identify the most appropriate for their populations and ensure that these are embedded as part of the day-to-day service for their communities.
For more information about Sustainability and Transformation Plans, see www.england.nhs.uk.
For more information about Vanguards, see www.england.nhs.uk.
For more information about Integrated Care Pioneers, see www.england.nhs.uk.
For more information about Primary Care Home, see www.napc.co.uk.