The NHS Five Year Forward View – Summary

The NHS Five Year Forward View was published on 23 October 2014 and sets out a new shared vision for the future of the NHS based around the new models of care. It has been developed by the partner organisations that deliver and oversee health and care services including Care Quality Commission, Public Health England and NHS Improvement (previously Monitor and National Trust Development Authority).

Summary

  1. The NHS has dramatically improved over the past fifteen years. Cancer and cardiac outcomes are better; waits are shorter; patient satisfaction much higher. Progress has continued even during global recession and austerity thanks to protected funding and the commitment of NHS staff. But quality of care can be variable, preventable illness is widespread, health inequalities deep-rooted. Our patients’ needs are changing, new treatment options are emerging, and we face particular challenges in areas such as mental health, cancer and support for frail older patients. Service pressures are building.
  2. Fortunately there is now quite broad consensus on what a better future should be. This ‘Forward View’ sets out a clear direction for the NHS – showing why change is needed and what it will look like. Some of what is needed can be brought about by the NHS itself. Other actions require new  partnerships with local communities, local authorities and employers. Some critical decisions – for example on investment, on various public health measures, and on local service changes – will need explicit support from the next government.
  3. The first argument we make in this Forward View is that the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgradein prevention and public health. Twelve years ago Derek Wanless’ health review warned that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. That warning has not been heeded – and the NHS is on the hook for the consequences.
  4. 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. And we will advocate for stronger public health-related powers for local government and elected mayors.
  5. Second, when people do need health services, patients will gain far greater control of their own care – including the option of shared budgets combining health and social care. The 1.4 million full time unpaid carers in England will get new support, and the NHS will become a better partner with voluntary organisations and local communities.
  6. Third, the NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases.
  7. 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’. Different local health communities will instead be supported by the NHS’ national leadership to choose from amongst a small number of radical new care delivery options, and then given the resources and support to implement them where that makes sense.
  8. 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. Early versions of these models are emerging in different parts of the country, but they generally do not yet employ hospital consultants, have admitting rights to hospital beds, run community hospitals or take delegated control of the NHS budget.
  9. 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.
  10. Across the NHS, urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services. Smaller hospitals will have new options to help them remain viable, including forming partnerships with other hospitals further afield, and partnering with specialist hospitals to provide more local services. Midwives will have new options to take charge of the maternity services they offer. The NHS will provide more support for frail older people living in care homes.
  11. The foundation of NHS care will remain list-based primary care. Given the pressures they are under, we need a ‘new deal’ for GPs. Over the next five years the NHS will invest more in primary care, while stabilising core funding for general practice nationally over the next two years. GP-led Clinical Commissioning Groups will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services. The number of GPs in training needs to be increased as fast as possible, with new options to encourage retention.
  12. In order to support these changes, the national leadership of the NHS will need to act coherently together, and provide meaningful local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied. We will back diverse solutions and local leadership, in place of the distraction of further national structural reorganisation. We will invest in new options for our workforce, and raise our game on health technology – radically improving patients’ experience of interacting with the NHS. We will improve the NHS’ ability to undertake research and apply innovation – including by developing new ‘test bed’ sites for worldwide innovators, and new ‘green field’ sites where completely new NHS services will be designed from scratch.
  13. In order to provide the comprehensive and high quality care the people of England clearly want, Monitor, NHS England and independent analysts have previously calculated that a combination of growing demand if met by no further annual efficiencies and flat real terms funding would produce a mismatch between resources and patient needs of nearly £30 billion a year by 2020/21. So to sustain a comprehensive high-quality NHS, action will be needed on all three fronts – demand, efficiency and funding. Less impact on any one of them will require compensating action on the other two.
  14. The NHS’ long run performance has been efficiency of 0.8% annually, but nearer to 1.5%-2% in recent years. For the NHS repeatedly to achieve an extra 2% net efficiency/demand saving across its whole funding base each year for the rest of the decade would represent a strong performance – compared with the NHS’ own past, compared with the wider UK economy, and with other countries’ health systems. We believe it is possible – perhaps rising to as high as 3% by the end of the period – provided we take action on prevention, invest in new care models, sustain social care services, and over time see a bigger share of the efficiency coming from wider system improvements.
  15. On funding scenarios, flat real terms NHS spending overall would represent a continuation of current budget protection. Flat real terms NHS spending per person would take account of population growth. Flat NHS spending as a share of GDP would differ from the long term trend in which health spending in industrialised countries tends to rise as a share of national income.
  16. Depending on the combined efficiency and funding option pursued, the effect is to close the £30 billion gap by one third, one half, or all the way. Delivering on the transformational changes set out in this Forward View and the resulting annual efficiencies could – if matched by staged funding increases as the economy allows – close the £30 billion gap by 2020/21. Decisions on these options will be for the next Parliament and government, and will need to be updated and adjusted over the course of the five year period. However nothing in the analysis above suggests that continuing with a comprehensive taxfunded NHS is intrinsically un-doable. Instead it suggests that there are viable options for sustaining and improving the NHS over the next five years, provided that the NHS does its part, allied with the support of government, and of our other partners, both national and local.

“It suggests there are winners and losers using NHS services. We can only hope the new models of care makes more winners”


 

Care home deaths – Why were warnings ignored?

Melanie Newman and Oliver Wright writing in The Independent (03/08/2015) – The lives of vulnerable care home residents were put at risk because the country’s healthcare regulators failed to act promptly on official warnings about fatally negligent standards, an investigation for The Independent reveals.

Coroners’ courts have identified over 20 deaths of care home residents in the last two years that could happen again without changes in practice.

Yet in more than half the cases, research by the Bureau of Investigative Journalism has found, these reports failed to trigger inspections by the Care Quality Commission (CQC).

Care Quality Commission

Last night England’s health care regulator admitted its response to the warnings had “not always been consistent” and was working to improve the situation. Charities working in the sector claimed the regulator “loses vital information in its systems all the time”.

“I am not going to defend the indefensible,” said David Behan, Chief Executive of the CQC. “We have got more to do.”

The investigation by the bureau examined 23 cases where an individual had died unexpectedly in a care home since July 2013. In every case and inquest was held and the coroner went on to advise a care home or agency in England to take action to prevent another death occurring. But in nine out of the 23 cases, however, the homes and agencies involved were last inspected by the CQC before the deaths occurred up to two years ago.

In a further two cases the homes were not inspected until long after the deaths, and six months after the coroner’s report was completed. In another case, the CQC inspected the home in the two months between the unexpected death in September 2014 and the coroner completing a formal report in November.

The CQC did not mention the recent deaths in its review and there is nothing in its findings to show that inspectors had checked whether issues subsequently raised by the coroner had been addressed. The inspectors have not returned to the home after the coroners report.

The bureau found four further cases where the homes were inspected within a few months of the coroner’s report. But in none of these cases did the CQC reports mention either the inquest or whether the inspection had checked to see if the coroner’s concerns had been addressed.

In the remaining seven cases, providers had been inspected promptly after the coroners’ warnings and it is clear in the CQC reports that the issue raised had been looked into.

The CQC  is not obliged to inspect in every case, but has a range of options in responding to a coroner’s warning notice, such as reviewing any proposed action plans from the care home and meeting with them to discuss action taken.

Mr Behan said that since the cases had arisen the CQC had reviewed its procedures and was now working with coroners to ensure that all warnings were promptly acted on.

“It’s not good by any stretch of the imagination. Our social care systems are and will continually be shown to be lacking, especially as financial input is squeezed”