Five Year Forward View: survival is optional

29 October 2014

Simon Stevens’ prescription for the NHS, expressed in the NHS Five Year Forward View published last week, is significant for what it includes and for what it leaves out.

Inevitably there is a strong focus on finance. The document proposes a deal with government under which the NHS will seek productivity and efficiency gains of £22bn between now and 2020 to close the main part of the £30bn funding gap. For its part, government is asked to find an extra £1.5bn a year over the life of the next parliament.

As a joint production by six NHS organisations (NHS England, Public Health England, Trust Development Authority, Monitor, Care Quality Commission, Health Education England), the document signals consensus among NHS bodies while acknowledging that no single organisation is in charge. (Few people seem to have noticed that the Health and Social Care Act abolished the position of NHS chief executive.)

What might be seen as a failing of command and control is presented in the Five Year Forward View as a strength of the new system. The document describes several potential “new models of care”, some arising from federations of general practice, others led by hospitals or formed by coalitions of health professionals.

In describing a limited range of new models, the authors attempt to avoid one-size-fits-all solutions without being seen to licence a free-for-all.

England is too diverse for a ‘one size fits all’ care model to apply everywhere. But nor is the answer simply to let ‘a thousand flowers bloom’.

This controlled pluralism appears to have taken some of the political heat out of the debate. The document, deliberately presented as independent of government and notably missing the Department of Health logo, has succeeded in winning the backing of the main parties, all of which can find something in it to agree with and little to object to.

Particularly noteworthy is the lack of any reference to privatisation or competition – neither word appears once in the 40-page document.

The document reserves some of its strongest language for public health, underscoring that the biggest challenge to the NHS, beyond debates about money and models, is the behaviour that fuels rising demand.

…the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.

The NHS will therefore now back hard-hitting national action on obesity, smoking, alcohol and other major health risks. We will help develop and support new workplace incentives to promote employee health and cut sickness-related unemployment.

Implications for primary care

The Five Year Forward View uses a wide-angle lens but acknowledges the problems facing primary care, particularly the “severe strain” on general practice.

Most of the remedies described under the heading “a new deal for primary care” are general and long-term, including the promise to “expand as fast as possible the number of GPs in training”.

GPs are unlikely to be satisfied by the promise to “stabilise core funding for general practice nationally over the next two years” without further detail.

There are few surprises in the statement that “CCGs will have more influence over the wider NHS budget”, a reference to the progressive devolution of responsibility for commissioning primary care and specialised services to CCGs – policies that recognise that shifting investment from acute to primary and community services can only happen if commissioners can reach all the funding levers.

Hints that new funding may find its way into general practice through the expansion of the Prime Minister’s Challenge Fund and similar schemes were followed less than a week later by the announcement of a second wave of funding worth £100m.  A single line is devoted to the issue of premises, with a pledge to “expand funding to upgrade primary care infrastructure and scope of services”.

The “new deal” is focused on general practice both because GPs have the strongest voice of the primary care professions but also because the crisis in general practice appears real and urgent.

Apart from the promise to stabilise core funding, other pledges to GPs come with strings attached. Any new money will not be used to pump up the core contract but selectively to pump-prime initiatives where there are signs of innovation and willingness to change.

The Five Year Forward View is clear that none of the solutions to the problems faced by the NHS will be solved in the traditional way.

It is implausible to think that over this period NHS spending growth could return to the 6%-7% real annual increases seen in the first decade of this century.

The document strikes an optimistic note that the NHS can meet the challenges it faces, even the financial challenge, but leaves no doubt that this will depend on the rate at which clinicians and managers on all sides embrace new ways of working and new organisational forms.   

“The foundation of NHS care will remain list-based primary care”, the document says, but not by way of stay-as-you-are reassurance to anxious GPs. Of the two models of new organisation proposed in the Five Year Forward View, only one will put GPs in the driving seat.

One new option will permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care - the Multispecialty Community Provider.

The other will see hospitals running the show.

A further new option will be the integrated hospital and primary care provider - Primary and Acute Care Systems - combining for the first time general practice and hospital services, similar to the Accountable Care Organisations now developing in other countries too.

The Five Year Forward View suggests that NHS leadership is agnostic about the options, but has firmly ruled out the default option of doing nothing.

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