One of the things that the Health and Social Care Act (2012) did was to set up NHS England (initially called the NHS Commissioning Board) to run the NHS. Supposedly independent from the Department of Health, its responsibilities include making sure that the NHS has an efficient system of commissioning (planning and buying healthcare services), and supervising clinical commissioning groups (CCGs). In practice, this seems to mean that NHS England, an unelected body, can set out radical proposals to change the NHS without any discussion in parliament and without any explicit political mandate.
The Five Year Forward View (FYFV) is just such a proposal, and it’s already in the early stages of being implemented. NHS England’s Director, Simon Stevens, published the FYFV in October 2014, six months after his return from the USA where he worked for the health insurance giant, UnitedHealth. He was also a founder member of The Alliance for Healthcare Competitiveness that lobbies for the inclusion of health services in the Transatlantic Trade and Investment Partnership.
The FYFV claims that for a number of reasons, such as growing pressure on health services, the NHS needs to undergo fundamental change. It argues that continuing with a comprehensive, tax-funded NHS is possible, but only if action is taken on prevention and new ways of delivering care that improve efficiency. The emphasis is on integrated care and ‘new care models’ that allow dismantling of the traditional boundaries between the NHS and social care, between physical and mental health, and between GP services and hospital care through developing new ‘networks of care’.
The FYFV also refers to vague ‘wider system improvements’ (such as ensuring a ‘modern workforce’) and the need for the NHS to become a more active agent of ‘health-related social change’. It calls for the NHS to learn from international developments, such as developments in Spain (e.g. the ‘Alzira’ model), where publicly funded, ‘integrative’ health care facilities are provided by private companies on the basis of a fixed fee per registered patient, or the Accountable Care Organisations developed in the US. Although it doesn’t make obvious reference to it, the FYFV seems to draw heavily on a report from the King’s Fund, Accountable Care Organisations in the United States and England.
Besides NHS England, a number of organisations involved in running and overseeing health and care services helped to develop the FYFV, including Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority (see Explanation of terms for details of these different bodies). Unspecified patient groups and clinicians were also involved, as were unnamed ‘independent experts’, possibly representatives of the private sector or think tanks such as the Kings Fund.
So far, the FYFV has received a fairly uncritical response. For example, while the Labour Party thought that FYFV left some important questions unanswered (e.g. about competition), it seemed on the whole to support the proposals (http://www.lgcplus.com/news/election-2015/exclusive-forward-view-leaves-big-questions-unanswered-says-burnham/5084169.article). The British Medical Association said it was ‘encouraged’ by the plan and its recognition of the current strain on GPs. The Royal College of Nursing made little comment on the proposed changes but expressed concerned that these could not be achieved without more NHS funding and improved pay for the nursing workforce.
And at first sight, the FYFV does seem fairly NHS-friendly: it sings the praises of the NHS and the values that underpin it. The FYFV says that it wants the radical change that it calls for to be driven by local clinicians and managers, rather than being centrally imposed. It also appears to call on the government to increase NHS funding. There is certainly very little in the plan that obviously suggests any intention to dismantle the NHS.
However, the FYFV can also be seen as part of a long-term strategy, dating back to the early Thatcher years, aimed at gradually restructuring the NHS so that it can become an insurance-based health care system similar to that of the US (see our webpage A long term plan). Different governments over the past 20 or so years have already implemented many of the key stages of this strategy: now the FYFV allows some of its final steps.
In our opinion, the FYFV is carefully written so that the extent of the radical changes it proposes is hidden in plain sight. In what follows, some of the main proposals of FYFV are set out in three sections relating to the main issues that the FYFV says need to be addressed, namely:
- The demand on services,
- The efficiency of services and the workforce, and
- How services are funded.
- THE DEMAND ON SERVICES
The FYFV argues that one of the ways of reducing demand on services is to introduce ‘targeted health support’ to cut sickness-related employment. Although it doesn’t mention it, this dovetails with an initiative on the part of the Department of Work and Pensions (DWP) called Fit to Work.
Fit to 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 will 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 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 ‘intensive lifestyle intervention programmes’ consisting 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 incentives for employers to provide approved workplace health programmes for their employees. It’s unclear what happens if someone 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 through taking advantage of new forms of technology, such as mobile phone apps, to get health care advice. These developments are described as ’empowering patients’, but they run in tandem with changes being demanded in the workforce, such as new roles, new payment patterns, and probably fewer qualified staff, in order to cut costs.
Matched with this, the FYFV says it wants patients to have greater control over their own care, including the option of integrated personal budgets to pay for health and social care. 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 on which to reconstruct the NHS as US style, insurance-based form of health care (see our page on personal health budgets). And there are fears that integrating social care (which is means-tested) with healthcare (which is not) 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.
- THE EFFICIENCY OF SERVICES
The FYFV calls for ‘sometimes controversial system efficiencies’, some of which are given more prominence than others. According to the FYFV, the main ways of achieving these efficiencies will be through a radical restructuring of both the NHS and its workforce.
- Restructuring the NHS
In line with dissolving the traditional boundaries of the NHS, the FYFV wants to see services integrated around the patient, the development of new roles and skills, and out-of-hospital care becoming a much larger part of what the NHS does.
To this effect, the FVFV calls for stronger ‘health-related powers’ to be given to local government and elected mayors to allow “local democratic decisions on public health policy that go further and faster than prevailing national law” on issues that affect physical and mental health. There are no further details on the nature of these extended powers, and how they might be regulated, although the FYFV seems to be referring to the recent government strategy to devolve powers (including the control of pooled health and social care budgets) to local areas (as with Greater Manchester).
Radical new ways of delivering care will be developed, such as ‘new care models’, to provide best value for money while improving patients’ experience. These new models are to be developed rapidly and extensively – in fact, implementation is already under way with a number of ‘vanguard sites’. According to NHS England, “Through the New Care Models programme, complete redesign of whole health and care systems are being considered”. While the FYFV emphasises that there is no one size that fits all and that the exact nature of the models used will be decided on locally, the choice of model will be ‘guided’ by NHS England.
There are already examples of GP practices forming federations or networks to help them survive in a competitive market, either sharing ‘back room’ administration, staff or occasionally premises. The FYFV encourages such initiatives but is really pushing for more extensive forms of ‘integration’. Here we give just two examples of the kinds of models outlined by the FYFV: these are the ones that, so far, seem to have caught the most attention.
A) Multispecialty Community Provider (MCPs)
According to the British Medical Association, there are different versions of this model. These can range from:
– little more than an extension of what is already happening in some areas, where federations of GPs extend the services they currently provide, to
– versions where a CCG reorganises services around different GP practices, to
– the large-scale version described in the FYFW.
In the FYFV version, a group of GP practices comes together with a variety of health practitioners to form an organisation providing the majority of out-of-hospital care for a registered list, probably of 30 – 50,000 patients. The MCP is funded through a capitated contract – i.e. on the basis of a flat fee for each patient registered, irrespective of how many visits a patient makes or how many treatments are given.
The MCP will combine GP care with community-based services such as district nursing, health visiting, dentistry, and pharmacy, and -potentially – mental health services and social care. It could provide many of the specialist services currently provided by hospitals, such as chemotherapy and dialysis, on an outpatient basis. Over time, MCPs may employ hospital consultants, have admitting rights to hospital beds and/or manage the health service budget (or even the combined health and social care budget) of their registered patients. (MCPs are described as providing ‘horizontal integration’.)
B) Primary and Acute Care Systems (PACS)
PACS are single organisations contracted to integrate GP, hospital, community and mental health services for a registered list of patients, on the basis of a fixed budget per head and on a long-term basis. They are similar in some ways to MCPs but extend further, incorporating all core hospital services and ‘redesigned’ emergency care and urgent care services. PACS are also likely to cover wider geographical areas, serving a population similar to that covered by a small District General Hospital (about 200 – 250,000 patients), if not more. Some PACS may provide new GP-based services. There will also be a requirement for PACS to offer personal health budgets. In time, PACs might become accountable for the entire health needs of a registered list of patients across different care settings. (PACS are described as providing vertical integration.)
[For details of other care models referred to, see http://www.england.nhs.uk/ourwork/futurenhs/5yfv-ch3/].
Both of these care models are similar to the Accountable Care Organisations found in other countries like the US.
Despite acknowledging that there is no appetite for wholesale reorganisation, this is nonetheless what the FYFV wants to bring about. What’s more, it’s reorganisation coming on top of the massive change that followed the HSC Act (2012) that has already led to chaos and poor staff morale.
The FYFV says that the changes it calls for will be different and less disruptive than after the Act because they will be locally driven: NHS England will be backing ‘local leadership’ in place of the ‘distraction of further national reorganisation’. However, it’s hard to see how a series of radical, local changes taking place across the whole of the NHS in England is anything other than a national reorganisation, especially when strongly steered or ‘co-developed’ by a central organisation like NHS England.
The FYFV prompts many concerns about how such reorganisation will affect NHS services, such as the possibility that patients will have to travel further for in-patient and emergency services. New models of care based on a fixed budget for each registered patient and designed with cost containment in mind could lead to pressures on staff to minimise hospital referrals or other treatments. Plus there is no evidence that what’s being proposed will save money, and little to no detail (given the sell off of NHS property or the acknowledged shortage of GPs and nurses) about where the new buildings, equipment and staff required will come from.
However, one of the biggest concerns is about the future of the NHS itself. The FYFV calls for the use of new models of care (such as MCPs or PACs) that have not been developed for a universal, publicly funded health service like the NHS but, instead, evolved in the US to meet the needs of an insurance based system. It’s only a short step from setting up a structure for the NHS that is compatible with an insurance-based health care system to turning the NHS into a system based on insurance.
And in line with the thinking behind the development of current models of care in the US, the FYFV suggests that its plan depends on not prescribing any specific model, but on innovation and adaptation to the local context. This suggests that while individual organisations like MultiSpecialty Providers may integrate care for their registered patients across organisational boundaries, the NHS more broadly will become increasingly fragmented.
- Restructuring of the NHS workforce
The FYFV calls for substantial changes to the NHS workforce, saying that new care models won’t be effective unless there is a ‘modern workforce’ with the right numbers, skills, values and behaviours. So, according to the FYFV, this means
- There needs to be local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied;
- More support should be available for employers to increase productivity and reduce the waste of skills and money: consideration needs to be given to the most appropriate employment arrangements to allow staff to work across organisational and sector boundaries;
- Health Education England will commission and expand new health and care roles, to ensure a flexible workforce;
- Working patterns and pay and terms and conditions will be looked at, in order to work towards rewarding high performance, supporting job and service redesign and encouraging recruitment and retention of staff across the country.
- A dramatic increase in the use of volunteers: the new models will “draw on the ‘renewable energy’ of carers, volunteers and patients themselves”.
The proposals for workforce efficiencies depend on disregarding the current, nationally agreed system called Agenda for Change (AfC) that assesses jobs and determines the appropriate pay for most NHS staff. Since 2004, this system has ensured that pay and conditions of employment have been consistent across the NHS and meet the requirements of equal pay law. In contrast, the FVFV proposals support the introduction of local agreements that are likely to drive down pay, and risk pay becoming a source of industrial relations conflict. Local pay agreements may also introduce damaging competition for staff between NHS organisations. The FYFV expects NHS employees to accept new roles, working patterns and skill mixes that will support service ‘redesign’ but that will probably also mean downgrading staff (expecting them to do the same job for less pay); getting less qualified staff to take on nursing and medical work; reducing or ending pay for working unsocial hours; and reducing the number of staff per patient.
This is a recipe for a poorly paid workforce with low morale. It is highly unlikely that such a workforce will be able to deliver quality patient care.
3. FUTURE FUNDING
Both Monitor and NHS England have calculated that, without radical change, by 20120/20 there will be a gap of almost £30 billion a year between the demand on services and NHS funding. The FYFV calls for
- £22 billion to be found from within the NHS through efficiency savings as a result of ‘wider system improvements’, reduced demand on services, new care models, and ‘new options’ for the NHS workforce.
- ‘Unlocking’ NHS assets (e.g. selling land or buildings ripe for development);
- Increased government funding of the NHS in flat real terms (taking account of population growth), amounting to £8 billion above inflation.
The FYFV claims that £22 billion can be saved by efficiencies of 2 to 3% by 2020. This is highly ambitious compared with the kind of efficiencies achieved by the wider UK economy or other countries’ health care systems. These savings are also sought on top of those already wrung from the NHS over the past five years through the Nicholson Challenge: every ounce of fat has already been trimmed.
At the same time, no consideration is given to how savings can be made by ending the highly costly business of running the NHS as a competitive market, or preventing money being wasted on exorbitant PFI debt repayments.
The long –term plan
Letwin, J Redwood (1988) Britain’s biggest enterprise: Ideas for radical reform of the NHS. Written for the Centre for Policy Studies. http://www.cps.org.uk/files/reports/original/111027171245-BritainsBiggestEnterprise1988.pdf
Madsen Pirie, Eamonn Butler, 1988, The health of nations. The Adam Smith Institute, http://www.adamsmith.org/sites/default/files/images/stories/The%20Health%20Of%20Nations.pdf
The Five Year Forward Plan
Fit for Work
Accountable Care Organisations
How routine surgery is being denied to those who are overweight or smoke
Updated July 2015