NHS England and NHS Improvement have published Next steps on the NHS five year forward view which outlines progress on the ambitions set out in the Five year forward view since its original publication in October 2014, defines what still needs to be achieved over the next two years, and how this will be achieved.
Here, Chris Hopson shares his reflections on the document.
- A difficult balancing act
Who’d be an arm's length body chief executive writing a very public document, subject to intense scrutiny, trying to balance multiple different stakeholder views, in a very challenging strategic context? A far from easy task.
- Combining very different perspectives
A good example of the conflicting tensions at play here are the different perspectives of the government and NHS frontline leaders. The government, as all governments do, will want a plan that sets out how well the NHS is doing and how much improvement is going to be delivered for the extra investment they have made. NHS frontline leaders will be looking for acknowledgement of how difficult the strategic context is and realism on what can be delivered on lower funding increases.
- Once bitten, twice shy
This context is further complicated by the legacy left by the “£22bn savings work” that followed the Spending Review. Parts of the government clearly think the NHS has taken the extra funding but failed, in return, to deliver what it promised. They need to be reassured that the NHS can and does deliver what it commits to. The NHS frontline believes that a set of impossible to deliver, over-optimistic, promises were made in the £22bn savings work. They want to ensure that they are not over committed again. A thin tightrope on which Next steps has to balance.
- The 2017/18 ask has been reduced from what is in the planning guidance
A fortnight ago, NHS Providers’ Mission impossible? report set out how the provider ask in the 2017/18 planning guidance was impossible to deliver. We called for greater realism. We therefore welcome the more realistic performance trajectories against the four hour A&E wait and 18-week elective surgery targets. But, as we also pointed out in Mission impossible?, there will be a significant adverse impact on patients and trusts would much prefer to be funded at the levels required to meet the NHS constitutional standards.
- But there is still very significant delivery risk here
There’s a danger that Next steps underplays the level of delivery risk to even these reduced performance trajectories. Take the A&E trajectories. We must not forget how difficult this winter was. We need to ensure patient safety risk is better managed next winter. That needs extra capacity (it should be up to local systems to decide what kind of capacity). That’s why we have been strongly focused on the NHS being able to free up between 2,000 and 3,000 beds as a result of the extra £1bn social care funding allocated in the Budget. Without this, or other extra capacity, the plan’s A&E performance trajectories in the second half of 2017/18 look very difficult indeed.
- And there are some important missing bits of the jigsaw
Next steps has also been unable, for good reason, to provide a full picture. We don’t, for example, know what the financial targets look like in 2017/18. There still appears to be a £1bn gap in next year’s numbers at the national system level. How will this gap be closed? Next steps also doesn’t set out how 2018/19 is going to be delivered on funding increases that drop from +3.6% in 2016/17 to +1.3% in 2017/18 and then to +0.4% in 2018/19. These important pieces need to be filled in.
- Local plans show the size of the challenge
It’s also instructive to match this national level perspective on the 2017 to 2019 task to the local plans that have been produced. The Next steps press release trumpets the changes to be made to improve cancer care, boost mental health services, give better access to GP services, provide better care for older people, drive efficiency and tackle waste. These are all important. And, given that lots of focus has unsurprisingly been on winter pressures and A&E, the focus on improving mental health and cancer performance is welcome. But trusts have produced local 2017 to 2019 plans that talk about the pressure on performance, workforce shortages, staff overload, the difficulty of achieving financial targets and the rapidly escalating maintenance backlog as we rob the capital budget to meet day to day running costs. Two strongly contrasting perspectives on the same topic.
- Next steps on sustainability and transformation plans…or is it partnerships now
There’s been much debate on how STPs will develop. Lots of trust leaders have told us that they were concerned that NHS England was rushing precipitately to creating a 'one size fits all' mid-level STP tier with statutory powers that was incompatible with current legislation. We welcome the way Next steps recognises the importance of existing governance and accountability structures focussed on trusts, but also the opportunity for shared decision-making at the STP level. We also like the way it allows different STPs to move at different speeds: enabling the fastest to progress without delay but not forcing others to adopt a single uniform approach they neither want nor are ready for.
- Do the workforce solutions stack up?
One part of Next steps where we’ll be particularly interested to get member feedback is chapter eight – Strengthening Our Workforce. Trust leaders tell us that workforce concerns are now top of their worry list. For example, Brexit pressures are clearly beginning to bite as the flow of those wanting to join the NHS from the EU slows down. We want to see if the solutions proposed in Next steps do credibly, realistically and sustainably answer those concerns.
- A tin of Quality Street?
In summary, I suspect that Next steps is a bit like a tin of Quality Street. Everyone can take what they want from it. And, to extend the analogy, what’s the Orange Cream, the one that no one likes and is always left at the bottom of the tin? The difficulty of actually delivering everything in Next steps with the resource available. It looks a big ask.