New approaches to the design and operation of NHS bodies following the five year forward view

Part 1: the organic shift to a system approach

‘You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.’ R. Buckminster Fuller

The Health and Social Care Act (the Act) was intended to be the final stage in setting up a new competitive market in health. It set out clear arm’s length divisions between the roles of provider and commissioner organisations as well as a key role for competition in health.

Subsequently there have been many changes both within the health and social care sector and from outside which have impacted upon the implementation of the Act and have redirected the path of the health and care system away from its original vision as reflected in the legislation.

The advent of the ‘five year forward view’ (FYFV) with the development of new care models and increased focus on care pathways and populations has been a step change away from the division of provision and commissioning and competition, which has required the system to review and adjust its approach (i.e. through sustainability and transformation plans and partnerships (STPs)) to collaborate and develop different commercial and risk-based relationships to a degree that was not envisaged in the Act. These changes have also been supported centrally by NHS England and NHS Improvement and there have even been direct statements from Simon Stevens at NHS England around the use of accountable care systems and STPs to effectively end the purchaser provider split.

The risks that come into play in this are clear; the gap between policy and legislation is now widening and the threat of legal challenge (e.g. judicial review) is increasingly present for health bodies. The confusion caused often contributes to delays in progress as organisations seek to find a route to deliver the wider collaborative approach with more regional control within the framework of an act which did not envisage it.

The simplest solution would seem to be for a new Health and Care Bill and reform to accommodate the changes – this was the previous approach in the US under the Affordable Care Act (described as ‘ObamaCare’) which was followed in subsequent years by a huge upsurge in the numbers of accountable care organisations. Unfortunately in the pre-Brexit environment without a clear mandate there appears to be very little appetite to introduce new legislation (and any new legislation would not be delivered in line with the FYFV ambition or the growing shorter term efficiency targets now facing the system).

Therefore the NHS has and will continue to seek to reinvent itself through wider planning under STPs, developing new models of population based healthcare – redefining the roles of providers and commissioners within accountable care organisations/systems and new forms of collaboration such as alliances. The question then becomes how far and how quickly the NHS can evolve in this way without substantive changes to the legislation?