Comment / No magic solution

Transformation is probably an overused word. It sometimes just seems like the intangible ‘something’ that will bridge the financial gap that more traditional efficiency savings can’t breach on their own. Easy to say, not so easy to put into cash-releasing practice.

It is about much more than money. It’s about the right care and support in the right place. So, patients taking more control of their own conditions. More prevention – avoiding the need for care in the first place. Or more proactive support and earlier intervention, avoiding more serious interventions downstream. 

There are real patient benefits in all that. But money is also a huge part of why we need to transform services. 

Demand is being driven by an ageing population, rising expectations and growing levels of long-term conditions. 

Simply trying to meet that demand in the same way as we have done would require increases in funding that would soon become unaffordable to parties of any political persuasion. The US health system is probably the closest to being in that position of unaffordability already.

So transformation of the sort set out in the Five-year forward view involving new models of care is absolutely the right direction of travel – the only viable direction of travel.

But there is a danger that it becomes viewed as an almost magic solution that will fill the affordability gap, no matter what size that gap becomes. 

The real debate should be around timing. How quickly can we realistically expect
new models of care to be having an impact at scale? Is current funding sufficient to see the service through the transition period – allowing health economies to meet existing demand while developing new pathways in parallel?

It has been three years this month since the Forward view was published. And soon after that, 50 national vanguards started to be selected to test out new models in five areas – integrated primary and acute care systems; multispecialty community providers; enhanced health in care homes; urgent and emergency care; and acute care collaborations. 

Other systems are pursuing similar change programmes and the whole transformation agenda has become wrapped up with sensible attempts to take a system-wide approach to transformation through sustainability and transformation partnerships and moves to accountable care systems.

There are some early signs that new models are already delivering improvements – moving care into the community, being more proactive and reducing costs. But it is a slow process. Even where areas are borrowing ideas from elsewhere, there is no quick fix. Transformation needs to be from the bottom up, clinically driven and taking account of local infrastructure and context.

Some aspects of transformation will need communities to understand why the changes are necessary. 

Consolidating some services in regional locations rather than in every community
can be as much about safety and quality – needing sufficient numbers of appropriately qualified staff seeing enough cases to keep their skills honed – as it is about financial affordability, although that should be a legitimate factor as well.

So, three years on from setting out on the vanguard movement, let’s not expect too much too soon. Yes, keep the pressure on to drive reform as quickly as sensibly possible. But it is the right approach and localities need to be given time and sufficient resources to make a success of system working. This then needs to be underpinned by the right payment mechanisms.

The choice is not between more funds or transformation. Instead we should be talking about how much funding is needed to enable the NHS to achieve transformation over a realistic timeframe.