As the good book notes ‘Without a vision the people perish. While not on a biblical scale, the Five Year Forward View published in 2014 set out what was a broad road for the NHS in England. Last week saw the latest report on progress.

The Five Year Forward View pithily summarised a common view of what change is needed and why. It acknowledged that NHS care had ‘dramatically’ improved over the previous 15 years but identified three big opportunities: a health gap; a quality of care gap; and a financial sustainability gap. It suggested radical action on the major health risks, new ways of delivering services to be more integrated, effective, streamlined, and empowering for patients, a boost to primary care including more investment, and coherent national leadership acting permissively to encourage local initiative. All this while acknowledging that since 2010 the NHS was experiencing the harshest funding settlement in its history.

What’s happened since then? Funding constraints, the majority of NHS trusts in deficit, waits increasing, social care cut with knock on impacts on older patients whose discharge is delayed, planned care cancelled as hospitals are full, providers struggling to cope with demand especially for urgent care.

The headlines paint a lurid picture, but not the full story. Next Steps on the NHS Five Year Forward View provides a more balanced assessment, while clearly acknowledging the intense pressure the NHS is under. It draws on a wider set of facts to show progress in priority areas - cancer care, urgent and emergency care, general practice, new models of care, and efficiency.  And it brings perspective too – waiting times historically low, cancer survival improving, heart attack and stroke deaths down and public satisfaction with care high. There is honesty about the scale of challenge and trade-offs in a funding squeeze. And clarity about next steps, what support is available to help, and more than a glint of teeth reserved for the recalcitrant eg for NHS trusts that persistently overspend. The report is upbeat, yet wrapped in lupine charm.

The hand dealt to the current set of national leaders was truly appalling: a funding slowdown on a scale never seen in the NHS and a distracting and expensive set of reforms, which reorganised most of the NHS’s administrative anatomy, lost many experienced managers, and baffled and turned off clinical staff. Now the dust has almost settled, one result has been space for the NHS itself to set out an agenda for the future, beyond the two year attention span of the political class. At national level it has done this with verve and aplomb, without victimhood and can’t do.

The task now is delivery – in particular to relieve demand pressures on hospitals and general practices, continue to improve the effectiveness of care across the major disease areas, and get more serious about prevention and population health. Despite the mess of recent reforms, across the NHS staff have got on with the day job, in many cases at great personal cost in the face of intense demands on time. Many bet on technology to save the day, but a far surer place to look for salvation must be the NHS’s staff. The NHS is the most complex, risky and expensive single industry in Europe with the most educated (and intrinsically motivated) staff. Working out what will be the most effective blend of support, incentive, and stick to make progress is going to need constant reflective intelligence, over sporadic reactive power, when the going gets tougher. The blend used in the past won’t do: as vision turns to delivery the temptation to use brawn over brain to speed change will be a mistake.

And it will get tougher. The stormclouds are all there to see: real capita spend on the NHS declining over 2018/19 and 2019/20; social care, in the words of the CQC, at ‘tipping point’; Brexit threatening more staff shortages; inflation pushing up costs – to name a few. The trade-offs to the public will also be very visible: longer waits for non-urgent surgery or faster treatment in A&E?; delayed access to the latest NICE approved drugs, or investment in community services? Time will tell if public concern on this pierces other political distractions.

And if it does, what then? A benign hope will be the chancellor will reach for his cheque book. A more malignant analysis would have a resurfacing of ‘zombie’  solutions which may be simple elegant, but wrong and out of tune with public opinion. User fees, tax breaks for private insurance… let’s not go there. As the Five Year Forward View noted that there was nothing in its analysis which ‘suggests that continuing with a comprehensive tax-funded NHS is intrinsically undoable… provided that the NHS does its part, together with the support of government’. Praise be, and game on.

Jennifer is Chief Executive at the Health Foundation

This post was originally published in the BMJ on 3 April 2017.


Dr Umesh Prabhu

Very well said Jennifer. But as they say success of any organisation is due to its wonderful staff and failure of an organisation is due to its poor leadership! Unless NHS gets leadership, governance, accountability for leaders right and stops working in silos and takes transformation agenda seriously, nothing will change! NHS has to save money to invest and save more. Sad reality is NHS wastes nearly £20 Billion a year and with duty of candour (If it works) the potential medico-legal bill for NHS is around £10 to £20 Billion!

NHS must get values, value based leadership, staff and patient engagement right and use excellent IT and I am convinced India can help NHS and we can help India. I saw some fantastic IT in India which can save million of pounds from chronic disease management! Indian doctors and nurses coming to UK and returning to India after working here for 2 to 3 years can help NHS, India and also UK. With Brexit we need all the friends we can get and India is ready to help NHS in a big-way and we can spread NHS values to all over the world.

New world order under Brexit means we need common wealth friends and we can help them and they can help us and together we can be great nation again. Simon Stevens has the right vision and plan and now we got to help him to implement it.

Aana Thomas

Very good thought Jennifer, nice view regarding the health, NHS and other companies should plan according to human welfare and their safety, I like your post, Keep sharing.

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