Last reviewed 18 November 2014
In October 2014, NHS England published a strategy for the next five years, called Five Year Forward View, for the NHS in England. This document, produced as a result of discussions between health and social care organisations, including NHS England, Public Health England (PHE), Care Quality Commission (CQC), NHS Trust Development Authority, Monitor, and Health Education England, identifies the vision for the NHS, describes a range of care models that could deliver better care, targets areas for transformation and gives actions to be taken to achieve this.
Since 2010, it has been recognised that the NHS has had to deliver reductions in expenditure of about £20 billion over five years with probably more thereafter. In addition, there is an acknowledgment that the way the NHS has delivered care in the past will not meet the challenges of an ageing population with an increasing number and complexity of long-term conditions. A different approach to health and social care is therefore required.
Why is change required?
Although the NHS has achieved much over the past 15 years, it is no longer able to keep pace with the increasing needs of an older and sicker population, providing the latest drugs and treatments in the context of cuts in social care funding.
Despite having become £20 billion more efficient, it is apparent that further efficiencies can no longer be sustained through making savings with services as they are currently configured, and there are still unacceptable variations in care, for example between mental health and physical care.
To continue the delivery of services as they are, set against a background of a widening health and well-being gap (resulting in greater health inequalities and huge spending on avoidable treatments); a care and quality gap (leading to a failure in meeting the changing unmet needs of people) and funding and efficiency gap (resulting in an imbalance of system efficiencies and a reduced ability to fund new treatments), would mean large variations in care across the country.
All this implies a need to move away from a system that has not fundamentally changed since the inception of the NHS in 1948, with the artificial divide between primary and secondary care located in outdated buildings, fragmented services across health and social care, little investment in prevention and a large amount of funding for treatment.
The future NHS would be different in that there would be integrated health and social care on a local level together with specialist care being provided in centres.
What is being proposed?
Three key areas for focus have been proposed:
preventive care and public health
allowing people to have greater control of their own care
breaking down the barriers between primary and secondary care, physical and mental health care, and health and social care and other agencies, and engaging communities in the process.
Prevention and public health
The future health of the younger population, NHS sustainability and economic prosperity of the country depend on a radical focus on prevention and public health. A fifth of adults still smoke, a third drink alcohol to excess, a third of men and half of women take no exercise and one in five Year 6 children are classified as obese. This is leading to a huge burden of avoidable illness; for example, nearly three million people have diabetes and seven million are at risk of becoming diabetic. All of these will be needing health and social care in the future.
Local authorities have the statutory responsibility to improve the health of their local populations and already a few have started to implement actions in supporting PHE’s priorities on smoking, alcohol and obesity, for example in limiting junk food outlets near schools and working with the police on action on alcohol.
The NHS itself can play a part in secondary prevention. For example general practice has a key role in delivering pro-active primary care where there is the best use of evidence-based intervention strategies to identify people at risk of certain long-term conditions. There is a proposal to establish a systematic diabetes prevention programme linked to the new Health Check to cover the country over the next five years. Other long-term conditions will follow suit.
In order to keep people at work, NHS England will seek, in the next Parliament, an agreement to a scheme to fast track individuals who are at risk of falling out of employment due to mental health problems in order to save “downstream” costs for sickness and unemployment benefits.
Supporting workers in the NHS needs to be improved with a systematic approach to the health and well-being of staff being implemented. There must be encouragement not only for smoking cessation, but also maintaining a healthy weight, having access to healthy food during their shifts and supporting active travel to work.
Helping people with long-term conditions
Even though people with long-term conditions are heavy users of the NHS most of their time is managed outside of the health service. Empowering these individuals to help them achieve their own life goals is important in making best use of resources. This can be achieved by improving access to information about their condition, good clinical advice and seeing their own patient records. In addition, enabling individuals to make choices about their care through evidence-based education courses will promote better care. These choices can be supported through integrated personal commissioning, a process by which health and social care funding are combined for people with complex conditions. This budget will be managed either by the individuals themselves, or on their behalf by a local authority, a voluntary organisation or the NHS.
Breaking down barriers and engaging communities
Five and a half million people in this country, from the young to older people, are carers. The NHS will be planning ways in which flexible working arrangements can be introduced for employees who have major unpaid carer responsibilities.
In the social care arena there is a proposal from the Local Government Association that volunteers who help provide care for older people should receive a 10% reduction in their council tax bill. Schemes supporting people who volunteer in the NHS are also being considered such as family and carer liaison, education of people with long-term conditions and assisting in vaccination programmes.
In its role as an employer, the NHS will be working to break down the stigma and discrimination that is sometimes associated with mental health and to provide workplace opportunities for people with learning disabilities.
New and different models of care
The traditional model of care of general practice, hospital care, mental health and social care being provided in separate ways is no longer appropriate in the twenty-first century as people are increasingly requiring input from all of these services to provide all-round care. These institutional barriers need to come down as the NHS refocuses on providing care for people with long-term conditions. Patients should be looked after through “episodes of care” which cover their health, social care and mental health, and the NHS needs to manage “networks of care”.
A key change is the move to providing more services out of hospital with health and social care working together to provide integrated care. Although a “one model fits all” approach is not applicable to all of the NHS, there are characteristic features that will facilitate the development of care in the community setting.
NHS England will be investing more in primary care services supporting this change including:
reviewing how funding for primary care can be made fairer across different communities
allowing Clinical Commissioning Groups to commission primary care services that a shift occurs from secondary to community settings
using schemes such as the Challenge Fund to improve access to primary care
training more GPs and community nurses and promoting retention of primary care staff
upgrading the primary care infrastructure and range of services
designing new incentives to tackle “underdoctored” areas
promoting the use of pharmacies as an alternative for the public to go to if they have minor illnesses rather than going to the GP or A&E.
Multi-specialty community providers (MCPs)
General Practice is evolving and primary care in the future will look different, with GPs proactively managing patients with complex and continuing needs, and many other professionals such as nurses and therapists involved utilising digital technologies as well as developing new skills. This may involve a number of practices joining together into federations, networks or single entities as multi-specialty community providers (MCPs).
It is envisaged that some MCPs will be employing specialist consultants in psychiatry, paediatrics and care of older people, and senior nurses to work alongside community health professionals. By working together MCPs will have the capacity to provide outpatient services, ambulatory care, run community hospitals, expand their diagnostic services and provide dialysis and chemotherapy care.
Doctors within MCPs will have the right to admit patients directly to hospital. MCPs may also have a delegated healthcare budget for their registered patients, which could include the funding for social care.
A new integrated care model — primary and acute care systems (PACS)
A new model of integrated care is being proposed whereby many organisations, including general practice, hospital, mental health and community services, can come together to provide care for their populations. For example, in areas where the recruitment of GPs is challenging, hospitals will be allowed to open GP surgeries for registered patients. In this way, Foundation Trusts will be able to use their surpluses to develop these services, and mechanisms will be in place to prevent the traditional model of primary care becoming a feeder service to secondary care.
Other possible examples include a mature MCP running a local district general hospital and a primary and acute care system (PACS) taking responsibility for the health needs of their local registered patients using a delegated capitated budget as an “Accountable Care Organisation”.
Urgent and emergency care networks and specialised care
Urgent care services will need to include the care outside of hospital. This means that patients need to be able to access this care in the community through pharmacies, better access to GP services in the evenings and weekends, and better use of ambulance, mental health teams and urgent care centres in making decisions, treating patients and making more appropriate referrals.
There will be better direction of patients to specialist services, eg stroke or major trauma centres, seven-day services in hospitals and improved mental health crisis services.
Small, viable hospitals and modern maternity services
There will still be a need for localised hospital services providing non-specialist care for their communities. In order to make these institutions viable, they would need to share back-office functions or management with others, be host to specialised services of another hospital, eg ophthalmology, or be part of PACS.
Models of future maternity services will be reviewed to determine how best to sustain maternity care, including NHS-funded midwifery services.
Better care home services
Models of in-reach support, provided jointly by the NHS and care home sector, such as medical and medication reviews and better rehabilitation, will be developed to reduce the need for hospital admissions.
How will this be implemented?
The intention of NHS England is to permit local organisations to develop the models of care that best suit their populations, and this may mean trying out many of the models described in parallel. Some of the changes can be implemented locally, while others, eg local configurations or public health measures, will require the support of the Government.
There is no indication of structural change within the NHS, as there is little appetite for this. Supporting local action will be an alignment of the work of national bodies such as NHS England, Monitor, CQC, PHE, National Trust Development Authority and NICE.
There will be an acceleration of useful health innovations through, for example, fast tracking devices and equipment and better mechanisms for reducing the time between discovery and clinical practice.
Future funding of the NHS
The document states that the vision that is described for the NHS does require investment to set up and embed the new models of care, which can then deliver continued efficiencies to enable the £30 billion funding gap to be closed by 2020/21.
The decision over NHS funding will, however, be determined by how the UK economy is performing overall by the next Parliament.
Five Year Forward View, NHS England, October 2014