June 2, 2015, by Public Social Policy

Thoughts on the NHS Five Year Forward View


Professor Ian Shaw

Back in March I blogged about how the Five Year Forward View (FYFW) introduced by NHS Chief Exec Simon Stevens was effectively `Reforming the 2012 NHS Reforms’  . This blueprint for the future of the NHS, to be delivered within one parliament, was signed up to by the Conservative Party and they have pledged the increased funding of £8 billion a year requested by Simon Stevens. As outlined in my earlier blog, the FYFW involves moving health services out of the hospitals and into the community and there are a number of models suggested for doing that. The NHS budget as a percentage of GDP is set to fall from its high of 8% in 2009 to just 6% of GDP in 2021. Against this the projected demographic related demand points to a £30billion funding gap by 2021 . In a real sense FYFW was the NHS’s response to this funding reality with the government putting up £8 billion a year and the NHS finding the rest via reforming services.  These reform models  have very recently been put into operation as `Vanguard sites’  .


There are, however, a number of obstacles that the NHS has to overcome if it is to make the FYFW a reality:

The first is productivity.  Hospital Trusts in particular are not performing as well as anticipated. The Kings Fund highlights that the Hospital sector has only made a 0.5% increase in productivity over the last 5 years  . This won’t `cut the mustard’ and threatens the projections within the FYFW.  What’s more these productivity gains have been made on the back of massive overspending by Hospital Trusts – up to £822m million deficit in the last financial year which is 8 times that posted in the previous year .  Even in the primary care sector `lean working techniques’ which may allow GPs to see more patients in a day (and reduce the number of A&E attendances in a PWC projection) are sometimes viewed suspiciously by overworked GPs as wanting them to work harder for the same money… magnify this right across the health sector and a `what’s in it for me’ attitude may arise…

NHS Trusts are between a rock and a hard place with regards Care Quality Commission (CQC) and their financial regulator Monitor.  They can’t rationalise staffing too much as this this gets them into trouble with CQC and they need to break even or this gets them into trouble with Monitor. The situation was highlighted at United Lincoln Hospitals Trust. Over the last year United Lincolns management team and staff have successfully improved quality of service to get themselves out of CQC special measures, but the cost of doing so may have been highlighted in their end of year financial report (made public on the 2nd June) when the Trust reported a £75 million pound deficit . Such incidences are the  main reason why the NHS recently announced a curb on locum agency use ,which is itself a result of poor workforce planning over the previous 5 years on the part of the NHS.

Another strand to productivity and innovation relates to the current contracting round. CCGs have to submit their service commissioning intentions to NHS England for approval. I know that many of the Vanguard CCGs have planned on the grounds of building up community resource and funding that through commissioning less from hospital services. Simon Stevens himself directly intervened to `command’ CCGs to commission on average around 3% more services than their plans.  Essentially this means that CCGs are restricted in the amount of innovation they can undertake this year because the planned innovation money is now being put aside for use by hospitals. Only if actual take is less than the commanded plan (known towards the end of the financial year), will the CCGs be able to utilise that unused resource for community innovation work.  There is a `cart and horse’ issue here, but it’s one that may delay planned innovations unless the CCGs have an appetite for risk…

The second is ownership.  Simon Stevens may have a plan for the NHS but it’s by no means `owned’ by all of the NHS’s component parts. Change is uncomfortable:  There has to be a sense within the NHS that the status quo is unacceptable, that there is a shared vision of the correct direction of travel and the pain of the journey is worth the outcome.  I am not convinced myself that all trusts have yet progressed passed the first stage… Also many of the `Vanguard’ CCGs have not as yet discussed the consequences of the FYFW and the adopted Vanguard model with its GP members. Those members will be crucial to the success of the model and it’s important that they `own it’ or it will be just another reform that’s `been forced upon them’.  I recall back in 2002 as a relatively new Non-Executive Director in a PCT being at a workshop organised between the local GPs and the new PCT Board. I vividly recall a respected local GP standing up and saying “Ive been working as a GP in the NHS for the last 20 years and in that time I’ve seen 15+ reforms and not one of them has had any impact upon my practice. If I ignore you long enough you will go away with the next reform”.  He was of course right, with the Clinical Commissioning Groups replacing the PCTs in 2013. But my thought at the time was “ yes, these reforms have not impacted on your practice because you’ve not `owned’ it”. GPs and other consultants have a degree of `reform fatigue’ and the default is to carry on as usual… That won’t be possible if the FYFW is to become a reality. The negotiations around the GP contract will be interesting to monitor in this respect.

The third is collaboration. The FYFW envisages new models of community working, with specialist services within the community instead of within hospitals. This is to promote more treatment within the community and less hospital bed stay.  I can claim to have some knowledge on collaboration within the NHS ( having written a PhD thesis on it and several papers since) and the key question to be asked is `why should this organisation collaborate’? Collaboration involves sharing scarce resources and must demonstrably have the potential to help that organisation meet its own goals to be successful.  The NHS isn’t really one organisation any more – its comprised of hundreds of Trusts – and I expect the Acute Hospital Sector to be resistant to the core elements of the FYFW.  The reason is their large deficits and (for many) their PFI overheads.  Parkinson’s law  is appropriately applied to hospitals. If there is bed space then those beds will be filled.  More community services means less hospital services, so wards will have to close to make productivity a reality. NHS Trusts are charged for `void space’   so the wards can’t just remain empty on the current funding model – they may have to be bulldozed.  Envisage huge public reaction if its suggested and you can bet your bottom dollar that the Hospital Trusts will be resistant to it.

The fourth is Local Authorities. If funding within the NHS is challenging, it’s many times worse in the social care sector and there are no additional funds heading in that direction – officially. However… With the announcement that Local Authorities in some areas can take over the local NHS budget as part of the Governments `devolution settlement’ the prospect is raised of the Local Authorities being able to raid the NHS budget to fund social care. Roy Lilley has also raised the likelihood of this possibility  There is already experience of the Public Health Budget (devolved to Local Authorities from 2013) being raided to fund core Local Authority services as long as some `health impact’ can be demonstrated . I’d expect to see this intensified once Councils have their hands on the whole of the local NHS budget for their area. More certainly needs to be done to protect social care services and there is an impact on length of hospital stay if a social care package takes time to be put in place prior to discharge, as well as preventing falls etc amongst the elderly in the community – but this won’t be `shared budgets’ this will be raiding the NHS budgets in ways I don’t think envisioned by Simon Stevens.

So the Five Year Forward View has to work – there is no plan B – but it won’t happen easily, if indeed it happens at all within the 5 year period…







Image courtesy of Tony Roberts


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