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Five‑year plan to transform NHS focuses on teamwork Strategy to create new models of care by 2020 will rely on strong joint working between commissioners and providers, writes Nick Triggle NHS ENGLAND is promising a new partnership between local and national leaders as part of its five-year plan to transform the health service. The NHS Five Year Forward View, published in October, sets out a new vision for how care should be provided by 2020. It was unveiled by NHS England chief executive Simon Stevens, and the following national bodies have signed up to support it: Public Health England, health service regulator Monitor, the Trust Development Authority, the Care Quality Commission and Health Education England. When the 39-page document was released, much of the focus was on its call for extra money to plug the NHS funding gap predicted for the end of the next parliament, in 2020. The report suggests that annual rises of 1.5% above inflation will be needed over the next five years, which is likely to 10 December 2014 | Volume 21 | Number 8

mean the budget will have to be £8 billion larger than it is now. But the plan estimates that more than two thirds of the shortfall can come from changing how NHS care is delivered. This is where joint working between national leadership and those leading local health economies will be central. England is ‘too diverse’ to pretend that a single model of care should apply everywhere, states the report. However, this does not imply that there will be an explosion in the number of new models. Instead, the document sets out a number of different approaches, mainly aimed at relieving pressure on hospitals. These include: ■ Multi-specialty community providers. Large GP practices or smaller ones working together in federations should be encouraged to expand and bring in senior nurses and hospital consultants to offer extra services in the community.

■ Primary and acute care systems. These could involve hospitals opening their own GP surgeries where there is an under-supply. The ‘vertical integration’ model could also be extended to mental health and community care services. ■ Viable smaller hospitals. As the move towards specialising complex care at larger sites continues, smaller hospitals will need to alter how they work. This could involve combining with other small hospitals in chains to share back-office functions, or partnering with larger hospitals to open ‘franchises’ such as the type that Moorfields Eye Hospital has established at several London sites. ■ Enhanced health in care homes. Hospitals, and other parts of the health service, should be encouraged to provide more support to residents in care homes to help reduce admissions to hospital. Mr Stevens says these ideas have been put forward as a guide to what needs to happen. ‘The answer is not simply to let a thousand flowers bloom, but to support local leaders to ensure the best solutions are found and shared,’ he says. ‘Our approach will be to identify the characteristics of similar health communities and then work with them to consider which options constitute a viable way forward.’ Strategy So how will this be done? The Five Year Forward View promises that the national bodies signed up to it will ensure that discretion is exercised regarding the application of payment rules and regulations to allow new models of care to flourish. Meanwhile, greater alignment between the work of groups such as strategic clinical networks, clinical senates and the NHS Leadership Academy will ensure there is regional and national expertise in place to support local leaders. And NHS England’s National Quality Board will be expanded with more clinical leaders acting as a forum to share intelligence and monitor progress. But the report also recognises the need to invest in the workforce. It states that, while in some areas staffing numbers have increased, such growth has been uneven. An example NURSING MANAGEMENT

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Analysis of this is the small increase, just 0.6% in ten years, in the number of nurses working in the community. Health Education England has been tasked with helping to identify and meet education and training needs, and greater flexibility to allow staff to work across organisational and sector boundaries will be explored. Meanwhile, a National Information Board has been established to set out ‘road maps’ showing how digital innovation can play a role. Elements of this are likely to include transparency of performance data, increased use of health apps and online facilities to make GP appointments. While these systems are being developed, the Five Year Forward View acknowledges that change is already underway. Next year will see the launch of the government’s Better Care Fund and the report states that this will need evaluating to see how it can be developed. Royal College of Nursing nurses in management and leadership forum member Judi Ingram says the proposals ‘make sense’. But she thinks their success will be down to whether nurses, and other front line leaders, have enough time and opportunity to develop them. ‘It has to be about building relationships and networking,’ she says. ‘Nurse leaders can’t do this on their own. It’s very easy, especially in a big hospital, to get your head down and not look up. Nurses and other staff need to be given the time to develop a vision for the future and then implement it. ‘It will require commissioners and providers to work together, and that is

sometimes difficult. On the one hand the relationship is about one party holding the other to account and keeping an eye on money, but then we need them to be working collaboratively. Changing between the two is not easy.’ To create the space and momentum leaders need to make change, the Five Year Forward View recognises that ‘pump priming’ will be needed; as a result, NHS England has confirmed that a transformation fund of some form will be set up. So far, however, it has refused to be drawn on the size of this, saying only that there is potential to unlock surpluses sitting with foundation trusts and to sell off surplus land. Nuffield Trust chief executive Nigel Edwards fears that this pot could be raided inappropriately. ‘There is a danger that any money from it will end up papering over the cracks caused by deficits. This is especially likely if a “pump-prime model” or transformation fund is centrally funded and administered.’ However, he praises the approach taken, suggesting its strength lies in the fact that it encourages transition to be driven by local clinicians and managers working closely with patients rather than by using ‘centrally imposed blueprints’. NHS Confederation chief executive Rob Webster agrees, saying the Five Year Forward View presents a ‘new burning ambition we can all get behind’. But he adds: ‘The contribution of significant parts of the service needs to be clearer. The document says little about the future

and role of mental health care, community care and ambulance providers. Their leaders can support the successful transition to the new world, alongside those in our hospitals and general practices. We cannot afford to ignore or underuse any type of provider.’ Healthier workplaces Alongside new models of care, the NHS Five Year Forward View is clear that preventing ill health must be a priority. It states that employers have an important role to play by encouraging their staff to become healthier, and it suggests the health service could take a lead in this. While three quarters of NHS trusts say they offer staff help to quit smoking, only about one third support them in keeping to a healthy weight, the report states. It recommends that trusts take a number of steps, including reducing the amount of unhealthy foods offered, which is a particular problem during night shifts, measuring staff wellbeing and promoting active travel such as cycling and walking. Research by NHS England suggests that, if the NHS reduces its sickness rate by one third, more than three million lost working days could be saved, which equates to an extra 15,000 staff. Nick Triggle is a freelance journalist

Find out more The Five Year Forward View can be viewed at tinyurl.com/kcjenmc

Case studies: how care could look in the future Case study 1: South Yorkshire In Rotherham, GPs and community matrons work with advisers who know which voluntary services are available for patients with long-term conditions. Their aim is to help address these patients’ non‑clinical needs. Since this ‘social prescribing’ programme was launched in April 2012, patients have been referred to services offering a range of activities, including craft classes, organised gardening and befriending. NURSING MANAGEMENT

A recent evaluation has shown that emergency department visits have been reduced by one fifth and admissions by one tenth. Case study 2: West Yorkshire Staff at Airedale General Hospital can communicate by secure video link with a number of residential homes in the area. This enables staff to carry out consultations on conditions ranging from bumps and bruises to diabetes and the onset of confusion. The number of emergency admissions from these homes has been

reduced by one third and emergency department attendances by one half. Case study 3: London In Greenwich, a team of nurses, social workers, occupational therapists and physiotherapists respond to emergencies in care homes, emergency departments and GP surgeries. The team cares for people at home or in community-based intermediate care beds. More than 2,000 admissions have been prevented in the past two and a half years. December 2014 | Volume 21 | Number 8 11

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Five-year plan to transform NHS focuses on teamwork.

NHS ENGLAND is promising a new partnership between local and national leaders as part of its five-year plan to transform the health service...
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