The 5 Year Forward View Next Steps – Back to the Future?

In this week’s view, John Tacchi explains the path that the new installment of the 5 Year Forward View sets out for local services. Make sure to keep up to date with our views in the upcoming weeks, as next time he will be looking at practical steps to take now to prepare for the journey ahead.

The latest installment of the 5 Year Forward View is out and it looks like the direction of travel is set. Simon Stevens has been particularly clever continuing the ‘permission’ narrative and we all just have to get on with making it happen. I think that this is authority enough for those who want to make a change. 

So what impact will this new installment have on general practice? Actually, quite a lot. Here are the headlines:

  • The law won’t change so don’t wait around to be told to do things.
  • STPs become Strategic Transformation Partnerships and they are the authority vehicle for change. GPs must be part of this.
  • Reasonably quickly, we will be moving towards whole population budgets and Accountable Care Systems (ACS) are step 1 of the journey towards this.
  • Current STP boundaries can be changed if there is a good argument for it.

Specific changes for GPs

The good news is that funding will continue to rise – by 2020/1 it will be at £2.4bn or a 14% increase in real terms. There will be a targeted national investment to expand the number of clinical pharmacists and mental health therapists embedded in primary care. GPs will be ‘encouraged to work in clusters of 30-50,000 patients’ but it is not clear how this encouragement will be handled. QOF will be going and something new will replace it.

STPs transformed

The new STPs are not going to take on statutory powers but there is an interesting ‘stick’ mentioned. From April all NHS organisations will form a part of one of the new STPs and a board will be drawn up from all relevant constituent organisations (including GPs and local government). A chair will then be re-appointed or appointed and CCGs will form Committees in Common to allow for strategic commissioning on the STP level. At this point, CCGs will be able to begin aligning (reducing?) their management structures and/or governing bodies. Current boundaries for STPs might then be re-drawn if thought appropriate by local bodies in consultation with NHSE.

Overall STPs will be judged by what they actually achieve and an interesting line is: ‘the way to judge STPs  – and their constituent organisations – is by results’. The ‘stick’ is this: ‘In the unlikely event that it is apparent to NHS England and NHS Improvement that an individual organisation is standing in the way of needed local change and failing to meet their duties of collaboration we will – on the recommendation of the STP as appropriate – take action to unblock progress, using the full range of interventions at our disposal’. You have been warned!

How will Accountable Care Systems work?

The general idea is that an ACS will represent an ‘evolved’ version of an STP in a bid to establish a new provider-led model. Or in fact a new version of an ‘old’ model. I am new enough to the NHS not to remember it but plenty of you will recall fundholding. For those of you whose memories don’t stretch that far back, GPs held real budgets with which they purchased primarily non-urgent elective and community care for patients; they had the right to keep any savings and had the freedom to deliver new services. This proposal is simply a system-wide version of that. It should mean that providers now will have an incentive to work together as it is certainly envisaged that there will be risk transfer to the single provider that represents an ACS. As Charles Dickens so famously said:

Annual income twenty pounds, annual expenditure nineteen pounds nineteen shillings and six pence, result happiness. Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery.”

On the money front, an ACS will have to agree an accountable performance contract with NHSE and NHSI that will credibly lead to faster improvements for 2017/8 and 2018/9.The various providers (and indeed CCGs) within the ACS will then have to manage funding for a defined population committing to shared performance goals and a ‘control total’ across the entire health system.

This is new (or old if you have a long memory!) and eliminates at one fell swoop existing barriers between providers. The ACS must have a collective decision making and governance structure and within it individual providers must operate on a horizontally integrated basis whether virtually or through mergers, and an example of that is ‘one hospital on several sites’ through clinically networked service delivery. However, at the same time providers must operate as a vertically integrated care system and GPs must work on the basis of 30-50,000 patient lists. Additionally, ‘in every case this will also mean a new relationship with local and community and mental health providers as well as social services’.

Within this is the ability for local commissioners in the ACS to have delegated decision rights in respect of primary care and specialised services and from 2018 a devolved funding package for GPFV, mental health and cancer. The ACS will also have the ability to redeploy staff and related funding from NHSE and NHSI to support its work and free up local administration cost. Over time ACS should become Accountable Care organisations. How much time? I would suggest be ready to do it by 2019/20.

Let me know what you make of these upcoming changes in the comments below. 

John Tacchi hails from a medical family but had a career as a barrister and investment banker before a brush with cancer persuaded him to re-evaluate life priorities. A graduate of the NHS Executive Fast Track Programme, he began his career in the NHS as CEO of BIG Practice Ltd, a large 86 practice GP Provider company in Birmingham. Now in the acute sector, he continues to have a strong interest in the future of General Practice and is a firm believer that if the NHS is to be saved then the direction of travel must be towards Accountable Care Organisations.

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