Editorial Thursday 23 October 2014: A subtle subversion – NHS England’s Five-Year Forward View

‘Where there is no vision, the people perish: but he that keepeth the law, happy is he.’ – Proverbs 29:18

Simon Stevens is a subtle subversive: a highly effective character type. NHS England’s Five-Year Forward View sets out his broad direction of travel. And it sends a neat, subtextual message to political and system leaders, which they may even at some point notice.

An unsubtle subversive such as myself would summarise the FYFV’s message to political and system leaders as taking a copy of the 2012 Act and scrawling a huge cartoon cock and balls all over it.

Put less graphically, the message behind the FYFV is ‘we're going to be doing this. And we’re going to deliberately, blatantly ignore key parts of the 2012 legislation, and you're not going to stop us, because we know that you know that it's already overspent chaos in the NHS, and it’s going to get worse as the money goes ‘ping!’ That OK with you? Splendid'.

It doesn’t engage with the 2012 Act’s legacy of a leaderless system, which has often left NHS providers and indeed commissioners unhelpfully uncertain of who is supposed to be in charge.

It goes beyond simply ignoring the 2012 Act, promising “meaningful local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied”.

The big, vague role for the centre
There is a big, vague role for the centre in the promise-cum-threat that “the national leadership of the NHS will need to act coherently together” on this agenda.

The marriage between this and the promise in the same paragraph to “back diverse solutions and local leadership” will be worth watching, as will the tension between these “diverse solutions” and the offer for local communities to “be supported to choose from amongst a small number of radical new care delivery options”.

You can have any colour, so long as it’s a Multispecialty Community Providers or a Primary & Acute Care System?

The FYFV also offers boldness and radicalism, and is admirably clear-eyed about the scale of the challenges ahead. A "radical upgrade in prevention and public health" has long been a rhetorical mainstay of policy documents.

Progress has been uneven, to put it charitably. We are still on the lowest of the three courses outlined in the Wanless Reports for HM Treasury.

Changing the determinants of ill-health is a heroic endeavour; yet vital if we are to bend the demand curve downwards.

Simon Stevens had wisely been wary of raising expectations of a detailed, NHS Plan-type programme: this is not that. The NHS Plan was, rightly, a creature of its time – one when the NHS faced elective waiting lists measured in years and A&E trolley waits measured in days. The FYFV rightly opens by recognising and celebrating the NHS’s fantastic achievements in many areas.

The challenge of modernising the NHS is existential rather than episodic; a process, not a fashion - and it is clear that modernists’ architectural maxim ‘form ever follows function’ informs the plans for new local care models: Multispecialty Community Providers and Primary & Acute Care Systems.

The FYFV pragmatically recognises that providers will have a critical role in reshaping health systems and economies. The challenges facing the NHS are considerable, and will not be met without a more mature approach to partnership across the sectors and silos.

The question here, and in many areas, is about the ‘how’ of change: the ‘what’ is fairly generally agreed (a move to better-integrated health systems), and the ‘why’ is very simple: quality and finance.

There are of course risks: not least that implementing the new local care models may butt heads with the Monitor/anti-competitive remit from the 2012 Act, and indeed with the Competition and Markets Authority.

Independent sector providers in particular may feel entitled to challenge these via Monitor’s subsumed Co-Operation and Competition Panel remit.

Clearly, work must follow to create clear advice that will allow providers acting in the best interest of patients to avoid the jeopardy of vexatious legal challenges to reforms.

Back to the intermediate future
It’s reassuring to read that “there is also value in a forum where they key NHS oversight bodies can come together regionally and nationally to share intelligence, agree action and monitor overall assurance on quality”.

Perhaps this could be some form of regional authorities of health, overseen by an NHS executive?

Implementation-light
The FYFV is opaque about the operational details of how we will do the twin track of winning hearts and minds to deliver this change, and of the strategic means of making the changes happen.

Some of this is pragmatic acceptance that the management resource available to the NHS (45% of the 2008-9 level) means that this is inevitably going to have a home-made, locally-made flavour. This has the advantage of enabling local ownership and co-production, alongside the inevitable disadvantage of Curate’s Egg Syndrome – the capacity and capability to do this will be good in parts.

To be fair(ish), we must remember that this calls itself a view, rather than a plan. But in the near(ish) future, we’ll need more detail on the how. Implementation is much more than a plausible auto-correct of integration: it’s pretty important.

Oh, and we’ll use IT and encourage diffusion of successful innovations. Which will be nice.

Inflating hopes
The FYFV wasn’t expected to be a financial plea-bargain: Simon is too smart an operator to play the megaphone diplomat. Yet it would have lacked any face validity if it had not mentioned the widely-agreed £30 billion funding gap by the end of this decade.

The FYFV’s taxonomy of analysing this gap is expressed in terms of “demand, efficiency and funding”. It’d be a smart strategy for the FYFV to be annually updated with a progress review in these three equally important domains of reform.

The FYFV's proposed £8 billion of cumulatively increased funding by 2020 (thank you, Twitterers for highlighting our previous lack of clarity about this) would be funded in a tax year by about 2p on the basic rate of income tax. It's not an outlandish sum.

One big omission
There is one major omission in the FYFV: its complete absence of stock photos of manically-grinning NHS patients and staff. This is an unforgivable oversight.