Collective leadership will keep forward view ambitions on track

The forward view has been widely welcomed, but it risks gathering dust on the shelves without fundamental changes in how services are commissioned, paid for and regulated.

‘Commissioning needs to be much more integrated than at present’

Its ambitious aims also require much more support being provided to NHS organisations in improving care and developing new styles of leadership.

Here, we set out the main changes needed to ensure national policies are aligned behind the plan.

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Commissioning

Making a reality of multispecialty community providers and primary and acute care systems requires commissioning to be much more integrated than at present.

This means pooling budgets currently controlled by NHS England, clinical commissioning groups and local authorities.

It also means much more rapid implementation of innovations in commissioning such as alliance and prime provider contracts, recognising the scale of the challenges involved in so doing.

Payment systems

The new care models described in the forward view will not be supported through continued use of payment by results.

‘The CQC needs to focus on the performance of local systems’

Capitated budgets in which commissioners agree with providers on the resources needed to deliver integrated care are required, linked to the achievement of defined outcomes of care.

In turn, providers must agree on how these budgets will be shared and how risks will be managed in the alliances and supply chains that will be required in these care models.

Role of regulation

The Care Quality Commission needs to focus on the performance of local systems of care rather than the performance of individual organisations.

‘Monitor must ensure market regulation does not unintentionally create barriers’

It also needs to work with Monitor, the NHS Trust Development Authority and NHS England on a whole system intervention regime in challenged health economies.

Monitor must ensure market regulation does not unintentionally create barriers to integrated care through rigid enforcement of rules on procurement, tendering and mergers.

Improvement support

NHS organisations need support to bring about improvements in care and implement new care models.

‘Networks could play a part by helping to spread expertise in improvement’

Some of the resources controlled by NHS Improving Quality should be made available to areas chosen to fast track implementation to acquire the improvement support they need.

Academic health sciences networks, and networks such as the Advancing Quality Alliance in the north west of England, could play a part by helping to spread expertise in improvement more widely.

Leadership development

The same applies to leadership development; most NHS Leadership Academy resources would be better deployed by NHS organisations, rather than used to deliver national programmes.

‘Financial deficits, A&E pressures and waiting times are crowding the forward view’

This is likely to entail NHS organisations collaborating with each other through local and regional networks to develop the system and clinical leadership on which the success of new care models depends.

National support should focus only on those functions that cannot be delivered locally.

Developing a national strategy

If the NHS is to become the learning organisation described in Don Berwick’s report on patient safety, there needs to be a national strategy setting out how this aspiration will be realised.

‘National leadership of the highest order is needed to align policies with the plan’

The strategy must link work on quality improvement and leadership development through a small, expert body combining the roles of NHS Improving Quality and the Leadership Academy.

It should be developed jointly with the NHS, drawing on the work of leading edge organisations such as Salford Royal Foundation Trust, as well as experience in the NHS in Scotland.

Where next?

The difficulties of acting on these ideas should not be underestimated. Each of the policy changes discussed presents its own challenges, and working on them all, and at the same time, is daunting to say the least.

National leadership of the highest order is needed to align policies with the plan.

This is particularly the case in the context of an NHS in which operational pressures around finance and performance are increasing.

The focus of leaders within the NHS on dealing with financial deficits, A&E pressures and performance against waiting time targets is understandable, but it’s crowding out the time and space needed to attend to the opportunities offered by the forward view.

‘Improving operational performance and implementing new care models are two sides of the same coin’

The reality is that improving operational performance and implementing new care models are two sides of the same coin, and both need to be priorities.

Leaders within the NHS have a responsibility to release key staff, including clinicians, to work on the development of new care models and to provide them with the support and skills they need to convert plans into practice.

National leaders also need to maintain the unity shown during the development of the forward view as attention shifts to implementation.

If the centre cannot hold together, then the risk, to borrow from Yeats, is that everything will fall apart. Collective leadership is needed to deliver the ambitious aims set out by NHS England and its partners.

Chris Ham is chief executive, and Richard Murray is director of policy, both at the King’s Fund