Make change local: a transformation fund for the NHS

The Five Year Forward View paints an inspiring picture of a brighter future for the NHS. One in which the barriers have been torn down between primary care and acute services, between health and social care and between physical and mental health. This is what many of us have been talking about across the NHS for many years, but in that lies the problem. There has been a lot of talking about it but not a great deal of doing it. 

That's why a new report from the Health Foundation and the Kings Fund, Making Change Possible: A Transformation Fund for the NHS raises important questions. It recognises that without clear goals, strong leadership and dedicated resourcing of the change the Five Year Forward View may never become a reality.

Drawing on experience from other major transformations, the report concludes that significant resources in the order of £1.5bn - £.2.1bn per annum will be needed to support transition. This would fund protected time for staff away from the day job to learn and develop new ways of working, to invest in physical infrastructure including the use of IT technology, for double running costs and for programme infrastructure on a national and local level. 

There is much in this diagnosis with which to agree. Certainly the existing £200m transformation fund attached to the Vanguard Programme will not be able to support change at scale across the NHS as a whole. However, I believe that there are aspects of the Report’s recommendations which should be either modified or strengthened. The following five steps would increase the chances of the fund having the impact we all want to see:

1. Establish a blended central/local transformation fund: the central transformation fund could be much smaller than envisaged in the report if local health economies (commissioners and providers working together) were required to match fund it from their own resources. This would be challenging given the mounting scale of provider deficits, but it is essential that local NHS leaders should have some skin in the game if they are to be committed to making transformation work.
    
2. Avoid creating another new national body: the Report holds out the prospect of yet another new national agency being created to administer the fund, whilst also acknowledging that one of the existing bodies could take on the role. This second option is far more preferable. Right now the last thing that the service needs is yet another national agency vying for position. It would only increase the confusion of an already befuddled NHS. Monitor and the NHS Trust Development Authority, as they come together as the new NHS Improvement, will be best placed to take on this role.
    
3. Regionalise it: This may not be the report’s intention, but it reads as though the fund should be allocated and administered in a highly centralised way. Transformation will not be sustainable unless it secures the active engagement of local communities. This can't be done by a team administering the fund from Whitehall or indeed anywhere else within the orbit of the M25. Critical to its success will be a regional presence and understanding, which has been sadly lacking since the demise of SHA's.
    
4. Invest in QI Capability at local level: the board of every NHS organisation should be required through the regulatory and inspection framework to invest in developing quality improvement capability across their institutions and health economies. The success of organisations such as Salford Royal and Wrightington, Wigan and Leigh in the North West has been based on these kinds of local investments in staff skills and protected time. Unless deep local roots are put down so that local systems and cultures of improvement are created there will be no fertile ground into which successful innovations can be spread.
    
5. Engage everyone in innovation: The proposed development phase of the fund, which envisages 20% of the NHS working on innovations over the next five years and a roll out phase in the five years following, is too slow and too narrowly focused on a small number of innovative communities.  We need everyone to be unleashing their creative energies to transform services not just a chosen few. 

The report is right to conclude that ‘business as usual is not sustainable.’ We need locally owned transformation plans with dedicated local resources to implement them; strategic direction and support organised on a regional basis; and a step increase in the investment in quality improvement and change management skills right across the NHS. If we do this then the Forward View might yet be an exciting vision that this time we do actually implement.  

David is Chief Executive AQuA (the Advancing Quality Alliance)