Three key factors for making NHS England’s Forward View a success on the frontline

In my clinic last Friday I was shocked: four out of sixteen appointments were taken by patients who were unable to gain access to the hospital services they had been told they needed. Having each tried to contact the hospital several times, they came to me to ask for help in navigating hospital booking systems, for interim pain relief, and reassurance. GP appointments that should have been available for clinical problems were used for administrative support, alongside clinical advice on the symptoms that arose from delays in care.

There are other insights about the state of the NHS available to GPs. Responding to requests for medical certificates for NHS staff experiencing work stress allows us to explore the underlying problems they face. Nurses are increasingly struggling with work pressures, sometimes working on a full ward with only two permanent staff and additional agency nurses. Other nurses have given up permanent posts to do agency work, saying they feel more in control of their lives this way.

Experienced administrative staff are throwing in the towel because staff numbers have been cut. Temps are brought in when the backlog of work builds up too much. The temps often don’t know the systems, so more work is diverted to the permanent staff who remain. Permanent staff are overwhelmed and some are either signing off sick or resigning – saying that temping seems more attractive.

So, people are increasingly spinning around a stressed health system, frustrated by delays in care and swallowing up GP appointments that cannot then be accessed by people with acute physical problems. The administrative burden in practices is rising and frustration levels are growing.

It is against this background that we received confirmation in the Forward View that financial pressures on the NHS are set to remain for the next five years, hopefully mitigated by an £8b increase in funding. Further improvements in efficiency and fundamental system transformation through new models of care have been proposed to address the remaining £22b funding gap.

Importantly, the Forward View promises the ‘resources and support’ for the introduction of new models of care, and the emphasis on local flexibility in payment and regulation will also help system leaders to achieve change. It also warns against further staff cuts and wage freezes as the route to financial balance. 

So, how can this promise translate into helping front-line staff?

First: Time

The new models of care proposed in the Forward View will require staff to work in new ways; to re-cast their professional roles and build new working relationships. This transformation cannot be based on discretionary effort - squeezed into lunchtimes and early evenings as is often the case now. People will need time out of their day jobs to understand new models of care, to influence their design and to develop a commitment to success. The capacity of NHS staff to work just a little bit harder is running out and proper investment in the time for staff engagement and training is essential.

Second: Realistic expectations about performance during transition

Giving staff the time described above may well affect performance levels and ‘backfilling’ absences may not be possible given current workforce shortages. Agency or temporary staff are unlikely to work as efficiently as permanent staff, so performance may dip and targets may be missed. Without some tolerance for such effects, the price of transformation may be too high. Or corners may be cut in staff engagement and success will be harder to achieve.

Third: Substantial support for local leaders

In terms of training and development; time to fulfil leadership roles and tolerance of (well-planned) risk taking and failure, leaders will need to make it clear to staff that they will be supported not penalised if their efforts to transform care cause them to temporarily de-prioritise other activities.

Efforts at my practice in Greenwich to transform care through integration have been illuminating. They have required a sustained, long term focus on involving staff and service users in understanding the problems with existing services and imagining new ways of working. We’ve made real progress across community health and social care and are now extending the approach to include general practice and hospital teams. The above list is far from exhaustive, but it would be a good start for the front line professionals who transform paper plans into everyday reality. It won’t be cheap, but should be seen as an essential investment in the future.

The Forward View sets out a coherent vision for the NHS and describes innovative services models through which to transform the provision of health care. But there is no doubt that this level of transformation needs staff who are willing to make the effort to learn new ways of working at the same time as delivering high quality, empathic, patient-focused care.