Open Forum Events conference – 26th March 2015

The need for change and the Five

Year Forward View

Kieran Walshe

Manchester Business School, University of Manchester

kieran.walshe@mbs.ac.uk @kieran_walshe

After Lansley: the next five years

• How not to do health reform: £3 billion and five years

wasted, and much collateral damage to NHS

infrastructure

• Making it up: extra-legislative reform – CSUs, voluntary

tariff, co-commissioning primary care

• Financial pressures – short term crisis in 2013/14 and

2014/15, medium term funding gap of £30 billion by

2020

• QIPP: delivered savings 2010-2014 thru tariff

reductions, pay freeze and reduced staffing – cannot

be sustained

• Something has to change…

NHS productivity in England 1995-2020 (Kings Fund 2014)

QIPP savings by method 2012-13 (Kings Fund 2014)

The five year forward view: new models of care

• Multispecialty community providers

• Primary and acute care systems

• Urgent and emergency care networks

• Viable smaller hospitals

• Specialised care

• Modern maternity services

• Enhanced care in care homes

Five Year Forward View: new thinking

• “Many of the innovation gains we should be aiming for over the

next five or so years probably won’t come from new standalone

diagnostic technologies or treatments - the number of these

blockbuster ‘silver bullets’ is inevitably limited.”

• “But we do have an arguably larger unexploited opportunity to

combine different technologies and changed ways of working in

order to transform care delivery.”

• “In practice, our track record has been decidedly mixed. Too often

single elements have been ‘piloted’ without other needed

components. Even where ‘whole system’ innovations have been

tested, the design has sometimes been weak, with an absence of

control groups plus inadequate and rushed implementation. As a

result they have produced limited empirical insight”

The five year forward view: new models of care

• Models not new – founded on some long established

but hard to realise ideas – particularly service

integration (mainly in healthcare)

• Primary outcomes and mechanisms for new models of

care are not defined and need to be articulated

• Horses for courses – means understanding

mechanism and context to transfer learning

• History of new care model rollout not encouraging –

pace, scale, ambition, limited ex post facto evaluation,

modest and variable effects and sustainability

Building a logic model of the intended service

redesign is essential and often neglected

Logic model: pathways for referral management

(Baxter et al 2014)

Implementation timescale and process

• £200m fund for investment in new care models in 2015/16

• Focus on four models – MCP, PACS, viable smaller

hospitals, enhanced health in care homes

• Selection of vanguard sites able to move fast to implement

new care models – act as successful prototypes for later

cohorts

• New national Models of Care Board and structured support

programme for implementation sites; and new operational

research and evaluation capability to support this activity

• Potential scale and contribution of evaluation/research –

from upstream design/development through process and

outcome evaluation to successful spread and sustainability

New Models of

Care Board

29 vanguard

sites chosen:

9 PACS

14 MCP

6 ECCH

Five Year Forward View: some issues

• Scale and pace ambitious – serious transitional funding

available and high policy priority

• Basic ideas – integration, coordination – have been shown

to work elsewhere with caveats

• Doing this is extraordinarily challenging – needs careful

design and modelling of changes to systems of care

• Organisational capacity to innovate and implement is very

limited

• Scope for financial savings very limited - already low-

spending and constrained utilisation by international

standards

• Organisational infrastructure to “hold the ring” removed and

having to be reinvented bottom up – will it be robust enough

Likely financial impact of new models of care

• Some cost savings through reduced duplication and substitution of

services – but only if services are or can be taken out

• Some cost increases through uncovering and meeting unmet

need/demand and improving access

• Large effects of small changes to self-care/professional care boundary and

care seeking behaviour

• Transfers of service from hospital to community/closer to home unlikely to

produce savings

Conclusions

• Huge expectations resting on the shoulders of Five

Year Forward View – in part unrealistic

• Major opportunity for service redesign and

reconfiguration at scale with resources to match

• Need much more detailed upfront work on service

design, mechanism and intended outcomes

• Need to get researchers to work alongside managers

and clinical leaders upstream, on using evidence to

design new models, and on formative and summative

evaluation