The Commissioner: Expectations for the Forward View refresh

Bumpy ride

In a few weeks the NHS leadership will collectively turn its mind back to October 2014 and the publication of the Five Year Forward View.

Forward view Mark 1 was warmly welcomed by every interest group worth their salt, signed by the full set of NHS quangos, and showered with praise across the political divide.

The “Forward View delivery plan”, to be published late this month, might have a bumpier ride. We’ve seen two more years of performance decline, the finances are on a precipice, and Simon Stevens has been dipping into his political capital (not to mention the actual capital).

At the same time, a wedge has been driven between the task of reform – characterised by the Forward View vision – and the task of delivery.

Message to ministers

Many staff who are working flat out to keep their head above water – or, in the current euphemism, working on “sustainability” – have become increasingly irritated by alien ambitions of “transformation”: new care models, accountable care organisations, and national promises of dramatic service expansion and improvement.

The first thing this group wants to see in the Forward View refresh is a robust message to ministers that without significant extra funding, there will be severe limits on what the NHS can achieve – excluding, for example, headline access targets, seven day services and a big IT upgrade.

The difficulty is that this would be a clear up-yours to the government, which it presumably wouldn’t take well to, while Mr Stevens won’t be keen to drop any of his personal priorities either.

Instead, the document can be expected to fine tune the NHS’s existing “must dos” – homing in on specific improvement measures for cancer, mental health and emergency care, for example – rather than culling any of them.

The money

On the money, it will underline the NHS’s stark “hard choices”, in a nod to the pressure on the front line and an attempt to buy politicians into some controversial cost savings.

If next week’s budget delivers as hoped, the document will at least be able to point to some more resources for social care, targeted to help the NHS; while the centre is still working to secure some new capital for implementing STPs.

The second big demand of the document – particularly from providers – is for a sharp focus on helping with the daily challenge of keeping the show on the road. Many in NHS Improvement, the headquarters of delivery, will sympathise with this. It will be important to watch whether the full list of quangos has signed off on the refresh.

The publication, which is, after all, a “delivery plan”, will major on a new approach to trying to sort out the emergency care system, following on from the latest winter breakdown, and start new projects on elective performance.

It will take a more realistic tack on general practice reform by promoting GP networks, “hubs” and “primary care home” – representing more pragmatic alternatives to the 5YFV’s multispecialty community providers which have proved too difficult for most places.

A handbrake turn?

Will this be a handbrake turn away from the original reform vision? Perhaps not. The refresh will seek to persuade readers there are signs of light at the end of the transformation tunnel, citing evidence that new care models have started to make a dent in emergency admissions.

The NHS England chief executive told MPs on Monday, with conviction, that not only would STPs go on, but that their hand would be strengthened and a few will move quickly to “accountable care” structures.

That won’t be universally popular – confidence in STPs is low, many are blighted by local opposition, there is concern about their riding roughshod over statutory organisations, and a few leadership clashes too.

STPs will also, however, be asked for an “implementation plan” – a process to refine actions and match them to nailed down financial targets. Theoretically this will help eliminate make believe transformation savings, although there will also be pressure to propagate them to fill holes.

Finally, a substantial dollop of new capital funding announced in the budget would be a big help in getting some momentum behind STPs, and holding together the Forward View consensus. This is still seen as a possibility by national officials, who would target it to get the better STPs not just transforming care, but delivering quickly.