Sustainability and transformation plans and new care models must be backed up by resources, time and leadership and not become lost in the huge drive to get performance back on track, writes Chris Ham

An epic struggle is occurring within the NHS to sustain current services and at the same time transform how care is delivered to better meet changing needs.

This struggle is being played out in an uncertain political and economic context. Brexit and its consequences mean that public finances remain are tighter than ever and domestic issues like health and social care are receiving much less attention than usual at the heart of government.

The resignations of David Cameron and George Osborne have removed the two members of the Cabinet – apart from Jeremy Hunt – who had a personal commitment to the Five Year Forward View. Theresa May and Philip Hammond have much less understanding of the NHS and social care and unlike their predecessors they lack access to advisers who do.

May and Hammond are also known to be unsympathetic to the claims being made for extra funding for health and care, having previously run government departments whose budgets were not protected.

Against this background, 2017 promises to be another testing year. Leaders at all levels have focused on achieving financial control totals and getting back on track in meeting waiting time targets. They have done so under intense political and media scrutiny and scepticism in some parts of Whitehall about their ability to deliver their plans.

Work to transform care through new care models has been less visible but progress is being made. This is evident in the primary and acute care systems and multispecialty community provider vanguards in Northumberland, Salford, Wakefield, Nottingham and Birmingham, as well as in work on enhanced care homes in Sutton and Sunderland.

Alongside new care models, STPs have emerged as a potentially powerful force for service transformation. The challenge for STP leaders is to engage stakeholders more effectively, undertake meaningful consultation on their plans, and ensure that these plans are robust and credible.

Great pressure

The struggle to sustain and transform the NHS is taking place in an extremely challenging environment. Hospital activity continues to increase faster than NHS funding, resulting in high levels of bed occupancy and staff working at their limits.

The forward view was based on an ambition to reduce long term growth in hospital activity but in fact it has accelerated. Part of the reason may be that the services delivered by GPs, district nurses and social care are also under great pressure, resulting in patients being displaced to hospitals.

Under pressure to show that their plans are working, national leaders need to be patient, recognising that worthwhile innovations in care cannot be rushed

All the more important therefore that new care models designed to strengthen services in the community are adequately supported and funded. The difficulty is where to find new resources when most of the extra funding for the NHS is being used to reduce deficits, leaving very little for transformation.

The pressure on the new care models to demonstrate results is understandable in the face of these challenges. All the evidence from the NHS and other systems is that it takes five to 10 years for service transformation to become established and deliver improvements in care. Under pressure to show that their plans are working, national leaders need to be patient, recognising that worthwhile innovations in care cannot be rushed.

Spreading the work of the vanguards to other areas is a work in progress. In some parts of England, STPs could be an effective means of achieving spread, as in the example of Frimley Health, which plans to expand the coverage of its PACS in this way. Channelling additional funds through STPs will in any case require greater alignment between STPs and new care models if these models are to be extended.

Spread could be facilitated by drawing on the experience of leaders in the most advanced vanguards and making it available to others. There are precedents in the work of the intensive support team, which uses experienced clinicians and managers to offer advice to trusts facing challenges in the delivery of urgent and emergency care. Peer to peer support of this kind can be a powerful force for improvement.

Herculean efforts

Transformation undoubtedly has the potential to offer the solution to sustainability in the medium term if it is allowed time to evolve and has visible support from ministers and national leaders. All the more important therefore that resources, time and leadership are aligned behind STPs and new care models and are not consumed by the herculean efforts being made to get performance back on track.

April marks the mid-point of the forward view and the spotlight is bound to turn back on NHS England, NHS Improvement and their partners. They will want to demonstrate that finances and performance are improving significantly and that new care models are delivering results. Neither will be easy and failure will carry consequences.

2017 really does promise to be a make or break year for the forward view.

Chris Ham is chief executive of The King’s Fund.