I thought the Five Year Forward View (5YFV) had a lot of promise. It identified the key issues:
“we need to take our own health seriously, change the way services are provided, and yes ask the next government to support us financially”, source: press release)
It also pinpointed the key things to focus on:
- prevention: tackling the root causes of ill health
- co-production: giving patients more control over their care
- integration: breaking down the barriers between different parts of the health system, physical and mental health and health and social care
- innovation: investing in new models of care, the workforce and technology.
An implementation process was then set up with various multi-organisational working groups. Perhaps there wasn’t quite as much involvement of local government as might have been ideal, but generally it wasn’t bad.
Progress since then hasn’t been quite so steady.
Prevention is the number one priority, but what has actually come out of that? There have been initiatives on diabetes, cancer and mental health. PHE are quite vocal. But a truly system-wide blitz, which I suspect is what is needed to produce a radical change in lifestyles (especially activity, diet and unhealthy behaviours), is nowhere in sight. That requires a partnership between national and local levels, with constant learning from each other, so that national, regional and local actions complement and reinforce each other.
Integration, again, is on everyone’s radar, but while there are many good examples of joint working (e.g. better ways of accessing health care in nursing homes) the underlying problems are still there, as illustrated by the record number of delayed transfers from hospitals.
The innovation heading is another mixed bag.
There seems to be a steady plodding at technology, but perhaps fewer examples of success on the ground to match the paperless future slogans.
Workforce continues to be a struggle with the promise of 5,000 extra GPs having always looked unreachable, and shortages and unmanageable workloads a regular news item (only this week, a survey by NHS Providers of NHS trust bosses found 73% saying they did not have enough staff to function properly).
But most time seems to have been spent on new models of care, or reconfiguration, but with little evidence that that will save any money or even have much effect on service quality (at least according to leading think tanks such as the King’s Fund).
Which brings us to STPs. Really, what were they thinking? New imposed geographies to get partnerships working in limited time, without public engagement and for what purpose? To do what they thought Health and Wellbeing Boards were failing to do? Or was this mainly about reconfiguration, centralising specialist services and closing down wards and services? In other words, more re-organisation, with little or no evidence that it would improve services and save money.
So as for co-production, despite all the talk, and some good work, on engaging patients and the public, the STPs sent a very clear message: nice if you can manage it, but when things get desperate, resort to top down, pressurised deals behind closed doors and forget the public. And, perhaps unsurprisingly, the indications are that STPs will not achieve what they set out to, with 66% of respondents to an HSJ survey (£) saying they had low confidence their STP would have the desired impact.
So where have we got to with the 5YFV? A financial crisis, with the extra money for ‘transformation’ going instead to propping up the sector. And cuts elsewhere, particularly in social care but also in public health and in education and training, just making matters worse.
To be fair, it was always a huge challenge. It needs collaboration across the sectors and with the public and through all levels from central government, through the NHS to local areas. That needs vision and drive not just from NHS England and its immediate partners, but more widely. And the support from Government doesn’t seem to be there. In spite of assertions by the Prime Minister and Chancellor, they have not provided what was asked for in the 5YFV, which was predicated on continued support across the whole of healthcare including public health and social care. And they have not been properly playing their part in tackling ill-health, for instance, with a much delayed and then watered down childhood obesity strategy, no action (except in Scotland) on minimum unit pricing for alcohol and local government cuts impacting negatively on the social determinants of health, building up even further problems for the future.
Maybe, under the circumstances, what’s been done was all that could be managed; nibbling away at the edges? And yet the 5YFV seemed to promise so much more. Here was a coherent approach, getting to the fundamentals. Is it really just too hard? Or was it the common purpose which was just lacking? Certainly, it can’t be done by the NHS alone. It needs a national co-ordinated, coherent, commitment. As the review by the 5YFV partners in June 2015 said:
“The NHS cannot close these three gaps alone. If we are to close all three gaps, then we will need our partners across health and social care in Local and National Government, individuals and their communities, the corporate and charitable sectors to use their levers, unleashing local energies to help create the future we want.”
But it’s not happening. Instead, it looks as though health and social care will limp on until they trip over a pothole and need to be taken into emergency care. And for how long will systemic failure delay its discharge?
(This blog also appears here.)