One of the central aims of the Five Year Forward View (FYFV), NHS England’s five year plan for 2015-2020, is to reduce patients’ use of health services. The intention is to achieve this by:
- making people more responsible for their own health, and
- encouraging patients to manage their own healthcare, e.g. through the increased use of information technology, and to ‘self care’.
Notably, the FYFV fails to acknowledge that increasing pressure on the NHS arises in large part from government policies. For example, ‘austerity’ measures affecting housing, the environment, welfare benefits, and cuts in the money made available to local governments for public health services and social care will have a serious knock on effect on NHS healthcare services.
Making people more responsible for their health
The FYFV states that the NHS has done too little in the past to act on the broader influences on health and well being, and “has not fully harnessed the renewable energy represented by patients and communities, or the potential positive health impacts of employers and national and local governments.” One way in which it aims to address this is through introducing “targeted health support” to keep people in work. Although the FYFV doesn’t mention it, it neatly dovetails with an initiative on the part of the Department of Work and Pensions (DWP) called Fit for Work.
Fit for Work aims to save costs through the use of a health and work assessment and advisory service, currently outsourced to Health Management Ltd (a UK company owned by US corporation Maximus), to “better manage sickness absence” and get people back to work. In essence, after someone in work has had (or is expected to have) four weeks of sickness absence, their GP is expected to refer them to Health Management Ltd for assessment and a Return to Work Plan. The Plan will then be made available to the employer, the employee and their GP. Significantly, after issuing a Return to Work Plan, the GP will no longer be responsible for providing a fit to work note: instead, the employer will be responsible for decisions about fitness to work. This shift in the care of the sick employee from GP to employer is justified on the grounds that ‘work is good for health’.
Alongside Fit to Work, the FYFV’s proposal for targeted health support includes plans to involve employers in changing the health behaviours of their staff through, for example, ‘intensive lifestyle intervention programmes’. These consist of group sessions focusing on issues such as diet or exercise, together with annual assessments, in order to change behaviour that might lead to conditions like obesity or diabetes. Plans include tax incentives for employers to provide approved workplace health programmes for their employees. It’s unclear what happens if an employee fails to follow these programmes or fails to get the desired results – i.e. whether they will face punitive measures as an employee, or perhaps as a patient. There are already signs of NHS care being denied to those apparently following less healthy lifestyles: one CCG in Devon, for example, in response to limited funding, has announced all routine surgery is being denied to patients who are obese or who smoke (see article below under ‘Sources’).
Besides attempting to regulate the health behaviours of individuals, the FYFV also wants to make patients responsible for managing their own healthcare and use of health services. According to NHS Choices, “self care means knowing how to keep fit and healthy, how to deal with medicines appropriately, manage self-treatable conditions and when to seek appropriate clinical help”, and it provides advice about how to deal with minor illnesses on its website (http://www.nhs.uk/selfcare/Pages/self-care-week.aspx).
The shift towards self care is described as ’empowering patients’, but it’s very much in tandem with changes being demanded in the NHS workforce, such as fewer qualified staff, new roles based on less qualifications, and new payment patterns, in order to cut costs. For example, NHS England recently announced a new “Sore Throat Test and Treat service” where people will be able to go to a pharmacist and get a swab test to see if a course of antibiotics is needed. Based on a small study by Boots the Chemist, the test will cost £7.50 and any antibiotics prescribed will cost £10. The service is due to be available some time in 2017. However, the scheme has been widely criticised on the basis that it will encourage more people to seek antibiotic treatment when many sore throats get better without treatment, and that the for-profit prescribing of antibiotics by pharmacists is likely to increase antibiotic use (despite growing concern about their over-use and the rising risk of antibiotic resistance), with little evidence of benefit. The initiative also comes just as the Department of Health has announced proposals to cut funding for pharmacies by 12%.
The self care initiative also relies heavily on new forms of technology to get health care advice – technology that of course is not available to everyone. A significant part of this initiative appears to be new ‘apps’ for mobile phones that are said to ‘put a doctor in your pocket’ (such as ‘Babylon’, already accredited by the NHS and available for a monthly fee of £4.99 per month: consultation fees additional). This new mobile health (or ‘mhealth’) market – expected to be worth $23 billion to the private sector by 2017 – raises serious concerns. These include
- how the information on offer is going to be regulated,
- who has access to the data patients provide,
- whether this development is going to increase the privatisation of healthcare advice,
- whether this development will offer a way of introducing fees for services (see https://opendemocracy.net/ournhs/shibley-rahman/247-transparent-nhs-–-or-rise-of-planet-of-apps, and
- given that this type of service will be aimed at younger and presumably fitter people, will it remove funding from GP practices that will then have to cope with a higher proportion of patients with complex conditions and requiring more care.
Some employers are offering to subsidise phone apps, on the grounds that this saves staff from taking time off work to see a GP, but it raises concerns that employers may have access to the data provided by their employees using these apps.
In 2013 the NHS set up a pilot scheme for a Health Apps Library, a website that reviewed and recommended commercial apps against a defined set of criteria. It was closed down after a 2015 study raised concerns about some of the software used. It found, for example, one app that could potentially provide inappropriate insulin doses for people with diabetes. The study also showed that a significant number of the apps in the Library ignored privacy standards and had been sending patient (or ‘customer’) data to a third party. Of 79 apps checked, nearly a third were sending personal and health data without using encryption. NHS England was put under scrutiny because of the weakness of the criteria it used to review apps, and because some apps even appeared in the Library without meeting these criteria.
In 2016 the Health Apps Library was replaced by a new “endorsement model” (developed by the National Institute for Health and Care Excellence, Public Health England and the Health and Social Care Information Centre ) that will kite-mark approved health apps. However, a new national director for operations and information at NHSE did not believe in kite marking for all health apps on the grounds that it stifled innovation. Instead, apps could be written by those with specific experience (eg the most appropriate app for a person with HIV could be written by the Terrence Higgins Trust rather than the government or a corporation). In addition, he suggested that there should be ‘open data systems’ where patients had the right to give app access to their data to whoever they wanted.
A further way in which the FYFV wants patients to manage their own care is by opting for an integrated personal budget to pay for health and social care. However, there are serious concerns that these kinds of personal budgets are less about increasing choice and control for individual patients and more about laying the foundations of a health care system based on an annual, fixed-sum voucher that provides a minimum level of healthcare, with any additional care having to be funded out of patients’ own pockets. This can also be seen as a step towards reconstructing the NHS as a US style, insurance-based form of health care (see our page on personal health budgets). And there are fears that as integrated personal budgets can cover social care (which is means-tested) as well as healthcare (which is not) their introduction could lead to NHS care becoming means-tested too.
In emphasising the need to make people responsible for their own health and health care the FYFV makes no mention of the social causes of ill health, such as the particular conditions that individuals are born into and that shape their daily life, or the influence of social or economic policies on people’s health. And given the lack of commitment to the proper funding of a comprehensive healthcare system, the new emphasis on self care can be seen as an excuse for reducing the amount of care that patients are entitled to receive on the NHS.
The Five Year Forward Plan
Fit for Work
For information on how work is work being reframed as cure https://opendemocracy.net/ournhs/dr-lynne-friedli-robert-stern/why-we-re-opposed-to-jobs-on-prescription