Four risks loom for the forward view

Halfway through what health economists have dubbed the NHS’s “decade of austerity”, the new models of care initiative passes as the bright side of health policy.

Simon Stevens and colleagues have pushed the work persistently, and more than 50 sites are now home to either a vanguard or another NHS Five Year Forward View local initiative, and the list still grows. Some headway has also been made in turning up the NHS voice on outside determinants like unhealthy eating and housing.

‘Northumberland’s experience highlights the challenges now faced elsewhere’

A few areas are moving very quickly and are set to make important breaks from longstanding financial and structural rules as early as next year.

Particularly significant is the example of Northumberland where, as we revealed yesterday, the CCG has agreed to pass virtually its entire role over to an accountable care organisation – shrugging off the current purchaser-provider split.

Northumberland’s experience also highlights the challenges now faced elsewhere. Its leaders are the first to point out that the foundations for their success were established in a much happier environment.

• First wedge of of £200m transformation funding allocated to vanguards
• Also this week: Why NICE must publish its safe staffing guidance

Things are harder

Funding growth helped pay for a purpose built emergency hospital, making the case for service centralisation easier, and made more palatable the risk of transferring social care responsibilities and staff. Clear direction from the now absent strategic health authority and a centrally run NHS meant it was easier to get on with change once approved. Staff weren’t watching pay fall behind other sectors as they soon will be.

In all these respects things are now much harder.

Efforts are being made nationally to try to smooth the process of major change, including the support teams and modest grants announced today.

But long term success for the forward view will require several bigger factors to come good. Four looming risks are particularly important.

‘Autumn spending review negotiations are keeping healthcare’s representatives in Whitehall perspiring through the summer’

First, the senior leadership crisis. The latest exodus of trust chief executives this summer should settle the case for urgent introduction of provider chains and NHS management franchise, to spread the influence of strong leaders and organisations.

Second, joining the two system regulators under the NHS Improvement banner. The new set up needs to move speedily, without distraction, into single teams and policies. Ministers should give it the clear task of supporting transition to sustainable services, rather than a secret agenda of cutting deficits at whatever cost.

Third, the government’s autumn spending review will have an enormous impact. Preparation and negotiations are keeping healthcare’s representatives in Whitehall perspiring through the summer.

The chances of securing a respectably sized transformation fund, as NHS England would like, are slim. There is a threat of further mandated transfer from the NHS to social care, and there is the issue of phasing the £8bn real terms growth - the NHS needs it front loaded, the opposite would help the Treasury’s books.

A final concern is the “single departmental plan” which has to be agreed as part of the review. To give the forward view a fighting chance, the Department of Health’s plan needs to renew its commitment to the strategy as the overriding agenda, and reject inevitable temptation to add new tasks, priorities and deadlines. These would add further cost and more importantly distraction.