No alternative – next steps on the Five Year Forward View
The refresh of the Five Year Forward View, published on Friday, gave all of us in the NHS our marching orders for the priorities in navigating the next two crucial years in the service’s history. The original 5 Year Forward View was one of those rare genuinely strategic moments, inevitably Friday’s publication was tactics. Like most of the key pronouncements in the Stevens’ era it was worth reading and, in my view, made the most of a difficult hand.
The abiding message was more of the same and quite right too. The original Five Year Forward View prompted an unprecedented level of consensus on what needed to change if we were to deliver a sustainable health and care system which could withstand the demographic and other pressure of the next 20 years. Some progress has been made in delivering that vision and, however difficult the current circumstances, now is not the time to draw back. However, given the scale of financial and workforce pressure in the system, delivery is not straightforward.
The Refresh is clear about the givens. Brexit is Brexit and the money is the money. Whatever happens will happen within the funding committed in the Comprehensive Spending Review and the next two years are the toughest ones in the settlement. There is little room for investment in the double running of services and activities which would smooth the process of transforming services, very little room to deal with anything new or unexpected such as a genuine flu epidemic, very little scope to address the financial pressure on NHS staff, especially at the time when Brexit will exacerbate staffing pressures, and very little room to get anything wrong. It’s not impossible but the margins are immensely tight, as anyone of us involved in driving a STP delivery plan is more than aware.
However that is the hand which Simon Stevens has been dealt and which he, in turn, has to get the NHS to operate within. Unless political pressure plays out with a different dynamic than it has over the last 6 months, and something did shift on social care, then the chances of new money remain very low. There are, though, some important commitments which might make a difference.
First there is a clear and consistent set of priorities: finance, A&E, primary care, mental health and cancer. In the circumstances these make sense and I am pleased to see the commitment to mental health followed through again although there is still much to do to make the funding flows required to deliver the Mental Health Five Year Forward View objectives clear and transparent.
Second there is a recognition that something else has to give in the form of waiting time targets for some routine surgery and treatment. This will not be without cost for individuals who will face longer periods of distress and anxiety as they wait for treatment, something which in mental health, without historic waiting time guarantees, we are all too familiar with. There must also be a concern that this is the beginning of a process by which the NHS consolidates as a universal service around urgent care. Nonetheless in the circumstances it may be the least bad thing to do.
Third there is the commitment for budget flexibility in relation to the rollout of new drug treatments. This will again not be without cost but I have long felt that it was unjust that new drug treatments and the commercial interests of the pharmaceutical industry trumped basic access to care in areas such as psychological therapies. Unless we see substantial new growth in future funding for the NHS we will need, in any case, to see a radical overhaul of thresholds for approving new drugs and treatments with a much greater emphasis on those with a genuinely transformational impact and less space for “Me toos”.
Finally it was interesting to read the intention to put the nail in the coffin of QoF which the Refresh describes tactfully “as an approach which has run its course”. As I remember from the time, its intentions were well meant but as a mechanism for driving genuinely health improvement it has become discredited. Hopefully there will be better ways of spending £700 million.
It takes until Chapter 8 until we reach the issue of Workforce and yet nothing could be more significant, both to managing short term pressures and to longer term hopes of transformation. Workforce pressures and issues have been central to some of the biggest financial and quality challenges over the last couple of years, epitomised by agency staffing. They perhaps have a bigger profile in the Refresh than they did in the original Five Year Forward View but the NHS has a consistent record of not giving workforce the attention it is due. That cannot be the case over the next couple of years.
There are three challenges. Keeping the numbers on track at a time when retention may be difficult with ongoing pay restraint and the impact of Brexit. Reskilling the existing workforce to work in the very different ways required by new models of care, perhaps the part of service transformation which mental health took longest to get right in respect of the closure of the long stay hospitals. Finally the challenge of maintaining staff morale and wellbeing when anxiety is high, pressures are increasing and pay restraint likely to continue.
As we enter the new financial year it is a good time to take stock on where we’ve got to. The Refresh deliberately accentuates the positives and, despite the pressures which most of us can feel trying to manage the system, it is right to celebrate some of the significant achievements of the last year including the introduction of the first waiting time targets for mental health. In the last year the NHS and its staff have shown great strength, commitment and resilience to achieve what they have in such difficult times. While the direction of travel still remains the right one it will take a lot more hard work and resilience to get to the final destination.