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 be responsible for the day-to-day running of the NHS.
NHS England (NHSE) is the largest public body, with a budget of £95.6 billion (2014). It’s relationship to the Department of Health has been described as ‘opaque’, and its accountability to the public unclear (see Sources: House of Commons Report “Whose Accountable?” below). 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 NHSE, 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 set of proposals, and it’s already in the process of being implemented. NHSE’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. During that time he led a project for the World Economic Forum apparently concerned about the financial sustainability of government-provided health services: a major part of its solution was to reduce publicly provided care while increasing private corporations’ access to services like the NHS. Simon Stevens is 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.
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 (now Health Improvement), 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 and think tanks such as the Kings Fund.
The FYFV claims that for a number of reasons, including growing pressure on health services, the NHS needs to undergo further fundamental change. It argues that continuing with a comprehensive, tax-funded NHS is possible, but only if swift and wide-scale action is taken to
- improve the prevention of ill-health;
- turn the NHS into a more active agent of ‘health-related social change’ – for instance, making people take greater responsibility for their own health and healthcare;
- harness the potential of new technologies;
- develop new ways of delivering care, including ‘new care models’ that improve productivity and allow ‘integrated care‘ and the dismantling of traditional boundaries between the NHS and social care, and between GP and hospital services;
- a shift in investment, from acute settings such as hospitals, to primary and community services;
- make ‘system improvements’, such as restructuring the NHS workforce, and ensuring patients’ access to services seven days a week (where this makes a difference to clinical outcome) to improve efficiency;
- save £7.5 billion by selling NHS assets;
- increase government funding; and
- find efficiency savings of £22 billion in the NHS over the five years of the plan.
At heart, the FYFV seems to believe that the NHS can care for a growing population not only without any matching growth in services but with reduced services that are provided in a different way.
For more information on these measures, see our pages on
In our opinion, the FYFV is carefully written so that the extent of the radical changes it proposes is hidden in plain sight. These initiatives also tend to go unseen because they happen without public debate or scrutiny. In the past, significant changes to the NHS would have needed to be introduced through primary legislation, government White Papers, formal public consultation and the like. Now, however, sweeping change can be rapidly introduced by the Secretary of State for Health because of the extraordinary powers handed over to him by the Health and Social Care Act (2012) – powers that also allow him to disregard the content of this same Act!
Even some of those most likely to support NHS England’s initiative are highly sceptical about aspects of the FYFV. For example, Chris Ham, Chief Exec of the Kings Fund, has said that there is no prospect that efficiencies of the scale being sought can be achieved by 2020/21, and that much of the new money intended to cover the costs of adopting new ways of delivering services (new ‘models of care’) will be used up to pay off existing deficits. It is also unlikely that proposed measures to prevent ill-health or to encourage people to ‘take more responsibility for their health’ can have a meaningful impact on the need for health care by 2021.
In addition, the ‘new models of care’ which form the cornerstone of the FYFV and which were to be trialled by 50 ‘vanguard’ sites have not been independently evaluated, so it’s unknown whether they are really able to improve patient care within five years at the same time as saving substantial costs. (See our page on STPs to see how ‘new models of care’ are now being rolled out across the country without the results of testing or evaluation.)
The ‘new care models’ proposed in the FYFV share many of the features of Accountable Care Organisations (ACOs) developed in other health care systems. For instance, the FYFV calls for the NHS to learn from international initiatives, such as the ‘Alzira’ model, a type of ACO developed in Spain. Under this model, the ACO receives a fixed annual sum per local resident (a capitation budget) from the government, for the length of a contract. In return, the ACO has to provide access to a specified range of primary, acute and specialist health services. Success depends on a highly integrated clinical and business model, stretching across primary and secondary care. There may also be incentives for the different providers involved to ensure that work is carried out in the most cost effective way: for instance, clinicians may receive a percentage of savings accrued by lowering the threshold at which treatment is offered. Notably, ACOs both plan and provide services across a wide area, and so are attractive to the private sector while, in the UK context, raise questions about the future of CCGs. The structure of ACOs, including their financial independence, makes it easier for ACOs to be run or controlled by private insurance companies. (More information about the Alzira model, can be found on our page on ACOs.)
Initially the FYFV has received a largely uncritical response. For example, the Labour Party’s initial response was supportive, highlighting that the word ‘competition’ did not appear once in the report, although it felt that FYFV left some important questions unanswered. 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 concern that these could not be achieved without more NHS funding and improved pay for the nursing workforce.
And at first sight, the FYFV might come across as 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 (although as time goes on, this aim seems to have faded). It also appears at first sight 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, originating from 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: the FYFV allows some of its final steps.
See also our page on Transformation and STPs.