Local leaders and MPs must embrace NHS England vision

Nigel Edwards responds to the unveiling of NHS England's Five Year Forward view.

Blog post

Published: 23/10/2014

It’s the report the NHS has been waiting for. 

Simon Stevens’ vision for the future of how care will be organised and delivered in England is set out in the Five Year Forward View – the first time the arm’s length bodies in the NHS have come together to produce such a report. 

Just as he did when creating The NHS Plan at the turn of the century, Simon Stevens has produced a commendable effort this time round. 

Working outside some of the constraints he would have faced while in government, this report takes an interesting position on a number of issues which it would have been difficult for the Department of Health or NHS to have taken before Andrew Lansley’s structural changes that gave more independence to NHS England.

The report not only makes crystal clear that the NHS cannot continue with ‘business as usual’ if it is to meet the needs of a diverse and ageing population, but it also sets out a radical vision of the different approaches that local areas can take to adapt for the future. 

The Forward View therefore offers the potential for a break from the past. 

These approaches could range from hospitals running GP surgeries to groups of medical professionals, therapists and social workers buying health services for patients in their area.

 I was particularly pleased to see the healthcare available in nursing and residential homes being given much more attention and a range of interesting ideas for primary care and small hospitals, having advocated for these approaches in the advice I gave to NHS England as it developed the report.   

And the report helpfully attempts to reset the relationship between the NHS and public by not only encouraging people to take more responsibility for their own health, but also by recognising the critical role the NHS as an employer should be playing in offering incentives to staff to become healthier.

But there is one significant difference from The NHS Plan and other centrally-imposed blueprints from the NHS’ past: this time we are seeing a move away from top-down diktat and an over-reliance on micro-incentives to deliver much-needed change. 

Decades of top-down targets, financial incentives and punitive approaches have left the NHS hooked on being told what to do. Directives and requirements enforced by regulation have also been overused. Coupled with politicians’ desire to adopt eye-catching initiatives that work well on the campaign trail but melt away when enacted, patients and practitioners alike have been disempowered by this top down approach. 

And far from driving lasting and effective improvements, these micro-incentives have languished precisely because there is no clearly understood model for how services can adapt to changing population needs. 

These approaches have instead become an attempt to continue to try and manage services in detail. Often they have resembled lengthy tasks lists accompanied by billions of pounds in extra funding – a luxury not afforded to Mr Stevens this time round.  

We have seen another example of this approach this week with GPs set to be paid £55 for every case of dementia they identify. 

Earlier diagnosis of dementia is an important goal. But offering cash to do it assumes that the best way to effect change is through thousands of small financial incentives when we really should be aiming to empowering GPs and other health care professionals to manage the care system more effectively.

And far from driving lasting and effective improvements, these micro-incentives have languished precisely because there is no clearly understood model for how services can adapt to changing population needs.

The Forward View therefore offers the potential for a break from the past. 

After years of top down rhetoric about the ‘N’ in the NHS, Simon Stevens rightly recognises that in a country as large and diverse as England, it is simply not possible for someone in an office in London or Leeds to know the right solutions for populations in Cornwall or Cumbria. 

But although I think this more nuanced approach is right, it is risky because it requires one of the hardest changes of all: culture change. 

In adopting this approach, local clinicians and managers – working closely with patients – will be expected to drive the transition the NHS needs to make. NHS leaders who have grown used to a system in which national plans are issued from on-high will need to step up to the plate and lose the habit of following a centrally imposed blueprint.

The approach to change in the Forward View requires more organic and locally tailored approaches. This requires experiment, risk taking and the time and space to do the work. It also requires the long promised mind-set change away from central control.

In return, politicians will need to step back from the desire to ‘fix’ problems with one-size fits all solutions. 

One important feature of the report is the way it seems to put politicians on the spot.

Claiming that a flat real settlement will protect the NHS will not wash; it is the spending per person – adjusted for age – that really matters.

Simply keeping a flat real total spend represents a cut. It also sets out what can be reasonably expected in terms of efficiency, and will make it harder to claim that there is a magic bullet solution somewhere, whether that is integration, improved safety or better procurement.

So, if we can get this right, this new more sophisticated approach promises to be more effective than past attempts to reform the NHS. 

But adapting to this approach requires high quality leadership at all levels of the NHS – from clinicians right through to political leaders. It also requires there to be the spare cash in the system to help services transition to this brave new world. 

With NHS providers going into the red, and social care cut to the bone, the road ahead is not going to be easy. But the prize of a health service that works effectively to meet the needs of people inside and outside of hospital is too important to miss.  

Suggested citation

Edwards N (2014) 'Local leaders and MPs must embrace NHS England vision' Nuffield Trust comment, 23 October 2014. https://www.nuffieldtrust.org.uk/news-item/local-leaders-and-mps-must-embrace-nhs-england-vision