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.