Is five a good number for the forward view?

There has been one word in the Five Year Forward View that hasn’t felt right – the word five.

It’s understandable why Simon Stevens chose it and aligned the programme change in the delivery of health and care he advocated with the term of a Parliament. Five years convey a sense of urgency and can seize the attention of politicians concerned with the electoral cycle but, as is already emerging, is too short a period for the kind of fundamental change in the culture and behaviour of our health and care services, which the forward view advocates.

Relationships matter

If we have learnt anything from our experience of integrated care pilots, vanguard sites and now Sustainability and Transformation Plans it is that the quality of relationships, both at senior and operational level, are absolutely crucial to the success of the endeavour. Good relationships for the most part do not happen overnight.

There are lots of different levels to why relationships matter if we are to deliver a different system of care.

Good relationships for the most part do not happen overnight, they are the product of hard work and time spent together building trust and working out differences

First, we are asking leaders to work together in different ways. In ways which expect them to put the interests of the care system ahead of the interests of the organisations they represent. In ways which expect them to trust to accept the impact which decisions taken by their peers will have on the issues for which they are personally accountable.

That we are asking for a change in leadership behaviour is entirely right and proper and all across my sector I see leaders who are trying to rise to the challenge. But we would be foolish to imagine that does not come at a price. Trust is a precious commodity. Where it exists it can work miracles but is hard won and easily lost.

Good relationships and trust between system leaders is only part of the picture. Genuinely integrated care needs trust between practitioners on the ground.

Such trust is not always straightforward especially when individual practitioners will inevitably be held to account if something goes wrong and when individual professional traditions of training and practice reinforce particular ways of looking at the world. A critical area is differences in perceptions of the management of risk which will be central to decisions about whether or not patients are admitted to hospital.

Such differences need an investment in the time and resources for shared training and development focused on delivering integrated care which works across organisational and professional boundaries. Our own organisation, the Tavistock and Portman, has been involved in the delivery of such programmes focused on reflective practice about shared cases and they should be essential component of what we need to do to transform care.

Whether they have the profile they should do across STP plans is another question.

The role of different sectors

New models of care also require new relationships between sectors. Any hope to reduce significantly the inexorable increase in the use of secondary care must attach equal importance to the wider psychological and social factors as well as clinical ones. The role of social care and housing providers are crucial as is the ability of the voluntary sector to provide interventions which keep people well and safe at home.

We have a wonderfully rich and diverse voluntary sector but the links between it and formal health and care services are underdeveloped. Our experience has been that front line clinicians often have a limited understanding of what services exist and what the voluntary sector may be able to offer for their patients.

There is a need to recognise that the essence of these changes is not new structures but changed relationships across a complex system working under considerable pressure

Just as significantly, constrained in thinking by a clinical model, they may not always trust the competence and skills of voluntary sector providers to manage risk and complexity. Good models of integrated care have brought the voluntary sector in as equal partners and have identified mechanisms to make it easier for clinicians to identify and refer to the voluntary sector resources which could make a crucial difference to keeping a patient out of hospital.

Across the piece, however, the dialogue through the STP process with the voluntary sector and other community based resources is still at first base.

The final relationship which matters is, of course, that with patients and carers. New models of care rely just as much on different behaviours from patients and carers as they do on changes in what clinicians do.

New models must be based on the principles of co-production.

When the forward view was published two years ago we like many other leaders in the NHS and beyond saw it as an essential prescription for creating a health and care service which would be sustainable in 20 years. It would be an awful pity if the integrity of that vision was compromised because in the short time we cannot deliver the time and financial turning space to do things properly.

At the heart of that dilemma is the need to recognise that the essence of these changes is not new structures but changed relationships across a complex system working under considerable pressure.

The current financial challenges we all face increases the urgency to get on with the task but cannot fundamentally shorten the time it takes to complete the journey. After all you can’t hurry love.

Paul Burstow is chair and Paul Jenkins chief executive officer at The Tavistock and Portman  Foundation Trust