NHS Five Year Forward View
The NHS Five Year Forward View was published on 23 October 2014, setting out the shared vision for how the health service needed to change to promote health and wellbeing, improve care and quality, and meet financial and efficiency challenges.
Developed at arm's length from the Department of Health, in NHS England, the Forward View made the case for additional funding and described a new vision that marked a substantial departure from the NHS reforms outlined by the coalition government in 2010.
The need for a radical upgrade in prevention and public health was identified, and as such the NHS pledged to support hard-hitting national action on obesity, alcohol and other major health risks. There were commitments to allowing patients far greater control of their own care, including the option of combining health and social care budgets.
The Forward View highlighted the importance of investing more in primary care, through shifting investment from acute to primary and community services. In order to implement these changes, NHS England emphasised the need for strong national leadership of the NHS to provide meaningful local flexibility in the way payment and regulatory requirements were applied. The Forward View also pledged to promote innovation and research to improve health technology.
The Forward View acknowledged the development of the NHS over the past 15 years, citing examples of patient satisfaction increasing and cancer and cardiac outcomes improving. However, NHS England also acknowledged the increasing challenges faced by the health service, including health inequalities, variable quality of care and funding pressures with a predicted annual funding gap of £30bn.
Through a more joined-up approach between primary and acute care providers, and through more efficient ways of working, the Forward View suggested £22bn of the funding gap could be addressed by the NHS – but £8bn of the funding gap would need to be met by the government.
Integrated care and new models of care
The Forward View focused on integrating services – both within the NHS and across health and social care – through ‘new partnerships with local communities, local authorities and employers’.
The NHS set out actions to break down the barriers in how care is provided between various health services, including between family doctors and hospitals, physical and mental health, and health and social care. In particular, local health communities would be supported to choose from amongst a number of new care delivery options.
The Forward View outlined six new care models:
- Multispecialty Community Providers (MCPs)
- Primary and Acute Care Systems (PACS)
- viable smaller hospitals
- specialised care
- modern maternity services
- enhanced health in care homes.
The new models of care all involved better integration of services. For example, the MCP model promoted the integration of primary and community care and the PACs model advocated integrating general practice with acute hospital services. The urgent and emergency care networks model sought to promote integration between A&E departments, GP out-of-hours services, urgent care centres, NHS 111 and ambulance services.
NHS England pledged to work with Monitor to deliver the new models of care. NHS England also committed to working more closely with Monitor and the Trust Development Authority (TDA) to develop a 'success regime' intervention programme, which aimed to create conditions for success in challenged health economies in foundation trusts, NHS trusts and clinical commissioning groups.
The publication of the Forward View was a significant moment, and the response of external organisations to the report was generally positive – although most highlighted the scale of the financial challenge facing the NHS and the need for additional funding regardless of which plan of action was employed.
There were accusations that the Forward View deprioritised patient choice and in a Health Service Journal (HSJ) article published in November 2014, the Secretary of State for Health, Jeremy Hunt, announced that choice was not the key to improving NHS performance. Hunt suggested that patient choice cannot always drive change within the NHS, as there were natural monopolies in health care. Hunt also added that patient choice would be relevant for some services such as residential care, but would be particularly irrelevant when considering emergency care. Hunt added that he did not believe 'the market' would ever be able to deliver satisfactorily in the area of integrated out-of-hospital care.
Instead, Hunt put forward the idea that greater transparency through Care Quality Commission (CQC) performance and access to additional data would drive improvement. Hunt suggested that commissioning could be a more important factor in improving NHS performance than patient choice, and emphasised the need to prioritise commissioners having patient-level cost data to achieve effective commissioning.
Concerns from the Opposition
In the run-up to the 2015 general election, the Shadow Secretary of State Andy Burnham voiced his concerns regarding the Forward View, suggesting that it had left 'big questions unanswered'. He suggested that questions remained around the competition regime in the NHS and the integration of health and social care.
Labour were the only major political party not to commit to the £8bn spending pledge for the NHS and the party suggested an alternative plan for NHS funding, which included committing to a £2.5bn 'time to care fund'. Burnham added that if Labour were to win the general election they would not adopt the Forward View without making 'fundamental changes', because, although he agreed with the principles of the forward view on the whole, its assumptions were based in part on the Coalition government's policies, which a Labour administration would have sought to change.
Five Year Forward View.
The Health Foundation.
Health Foundation's response to NHS Five Year Forward View.
The Health Foundation; 2014.
The King's Fund.
No escaping the financial challenge facing the NHS; our response to NHS England's Five Year Forward View.
The King's Fund; 2014.
Patient choice is not key to improving performance, says Hunt.
Health Service Journal; 2014.
Exclusive; Forward view leaves 'big questions unanswered', says Burnham.
Health Service Journal; 2014.