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The Five Year Forward Look – A not insurmountable challenge

October 24, 2014


NHS England’s 5 year Forward View is, in general, a bold, grounded and salutary document which sets out clearly the challenges which we all face in ensuring that a thriving system of publicly funded universal health care is in place in 2020, despite the economic and other pressures which face us as a society. It is a document helpfully devoid of political spin which does not attempt to set out detailed prescriptions for how those challenges are met but rather provides a sense of permission for the actions which all of us involved in the system need to take to reshape the way in which healthcare is delivered in this country. It strikes the right balance in pervading a sense of optimism that these challenges can be overcome while arguing for realistic decisions about funding if that optimism is to be justified. The document is the most tangible sign so far of NHS England staking its claim as the leader of the new system and it is creditable that it has decided to do so, working together with the other major players in the post-Lansley NHS.

There were a number of things in the document I wanted to comment on, some where I support what has been said, some where I feel it could have gone further, some where I feel an important ingredient for change has been left out.

First I applaud the strength of statement supporting a commitment to delivering genuine parity of esteem to mental health. Recent announcements around waiting times for mental health have been a welcome first step towards trying to close the gap between rhetoric and reality in this respect and I am pleased to see there is recognition that this must go much further. However I am concerned that behind this promising start there may be a failure to realise the enormity of the task to ensure that people with mental ill health receive the same response at those with physical conditions. It is inconceivable, for instance, that we can close the treatment gap for the 75% of people with depression and severe anxiety who do not receive any form of treatment without a major rebalancing of resources.

In addition it is crucial that, across the NHS, we take a more psychologically informed view of health and health behaviours. There is no artificial boundary between our minds and bodies. Our psychological condition impacts crucially on our ability to recover but these insights are often far removed from how health professionals are trained and from how we organise services to care for patients. While I welcome the emphasis in the document on a more assertive engagement with public health and on earlier intervention to prevent or postpone chronic illness such an approach must also be informed by an understanding of the psychological and social environment in which people are motivated to look after their health. Exhortation and lecturing on their own will do little to persuade people to reduce their weight, drink less or take more exercise.

The document says some important and helpful things about the need to reshape the landscape of care away from the paradigm of the District General Hospital to a world where more care is delivered closer to home in the community but where, at the same time, specialist care is concentrated in a smaller number of centres of excellence. Sensibly in 2014, compared to 1962 when the last blueprint for hospital care was published, it indicates that how transformation is achieved must be a matter for local determination. It is also sensible to suggest that while it is self-evident that we will need, as a result of these changes, less hospital care it may be better, in some cases, to find ways of finding new approaches for existing facilities rather than always entering a toxic debate about closure. As was clearly illustrated to me when my elderly mother was recently hospitalised patients can understand why treatment, especially specialist treatment, may have to be remote but do not understand why care, especially more routine care, cannot be delivered locally in a way which keeps patients connected to their networks of family and social support. A particularly strong point was made in the document about the value of working with the nursing and residential sector to strengthen their ability to care for patients with complex needs.

The shift to out of hospital care clearly needs us to crack the delivery of integrated care. The vision document says some helpful things about the structural options which might help to facilitate this and again rightly stresses that “one size will not fit all”. It is important however that the NHS does not, as its default position, focus solely on structure while ignoring the issues of how it facilitates different models of collaboration between practitioners in the community and the underlying issues of behaviours and relationship which underpin this. It is one of the most abiding lessons of the closure of the long stay mental health hospitals that you cannot just take staff out of an institutional setting of care and expect them to behave in a different way. These questions as much as structural and financial ones need attention.

Finally I welcomed the recognition in the document of the need for the NHS to be working not just in the community but to be of the community. So there was an important reference to the role of the NHS as a local employer and of its responsibility to look after the health and wellbeing of its workforce. There was a healthy message about the opportunity to work more closely with the voluntary sector who can, at times, have a reach and impact which the NHS cannot replicate and I welcomed the emphasis on volunteering and working with carers and families. A greater emphasis on public health and early intervention should also see the NHS concerned not just about what it does itself but how it can support other organisations such as schools and employers to manage health issues.

It seems a feature of our digital age that the lifespan of reports and strategy documents seems to be shrinking and it will be interesting to see how frequently this document is quoted in 5 years’ time. It is, today, a welcome contribution to the debate, running with the grain of debate about the nature of the problems facing us, encouraging innovation, not over promising delivery and setting rather than following the tone of political debate.

There is no doubt a challenge ahead of us to save the NHS but I accept the premise of the document statement that it is one that with the right effort and encouragements we can meet.


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