The Five Year Forward View outlined a medium term strategy but concerns over care quality require more immediate solutions, say Nigel Edwards and Richard Taunt

Just over a year ago the Five Year Forward View set out how the NHS must adapt over the remainder of the decade to meet future need. At its heart was a welcome recognition that “business as usual” would, in the long term, not provide patients with the comprehensive and high quality service they expect.

One year on, the NHS is still under intense pressure. Despite pledges of extra money, it is increasingly clear the health service is in financial trouble. Almost four in five trusts ended the first quarter of this financial year in deficit. And despite the important focus on the need to monitor and improve care quality, a recent Care Quality Commission report stated that patient safety remained its biggest concern across all health and care services.

‘There are clear signals that in some areas quality is declining’

The Nuffield Trust and Health Foundation’s joint QualityWatch programme aims to help policymakers and healthcare leaders make sense of quality across health and social care. In our annual statement, we highlight areas of excellent care – from high vaccination and screening rates to reductions in unplanned admissions for children.But there are clear signals that in some areas quality is declining.

The trends we highlighted last year – of deteriorating access to hospital, mental health and social care services – have continued. The NHS has suffered from growing staff disengagement and vacancy rates.

The forward view proposes solutions to many of the challenges facing the NHS – from making clear the need for further funding, to outlining the ways in which services need to adapt. But in most cases they will not address the huge challenges ahead in the immediate future.

Against the odds

chief executive, Nuffield Trust

Nigel Edwards

We are concerned that a number of the conditions for addressing the current financial challenge, maintaining quality and improving services do not appear to be in place. People working in the NHS want to deliver high quality care, but they are increasingly battling against the odds to do so.

First, there needs to be greater realism about the level of quality the NHS can provide with the resources available to it. Currently NHS policy is focusing on additions to what can be offered, for example seven-day working, or NHS England’s cancer treatment strategy. But the NHS is struggling to preserve the quality of some existing services, let alone new ones.

At the same time, there is not yet a convincing plan to achieve the extremely challenging efficiency savings of at least £22bn needed to prevent a £30bn projected funding gap by 2020.

‘NHS policy is focusing on additions to what can be offered but the NHS is struggling to preserve the quality of existing services’

Second, on top of the tight and worsening financial position of the NHS, there will be further financial pressures as social care, staff training, public health and other related non-ringfenced budgets are subjected to cuts.

Third, the overall management of the NHS as a system seems to be in some disarray.

Many within government believe the NHS simply needs to become more efficient to save money but, as staff costs account for the biggest chunk of the NHS budget, this could have worrying and unintended consequences.

Warning lights

Richard Taunt

Richard Taunt

Meanwhile contradictory guidance from regulators on staffing levels and the requirement to balance the books is creating confusion within the NHS. This may be one of the reasons why the health service is losing top leaders – just at the point when their contribution is most vital.

Given these multiple areas of concern, one would expect a stronger sense of urgency from those at the centre. There rapidly needs to be a credible plan to dealing with the service’s plummeting finances, as well as a coherent approach to improving the morale of the workforce.

On top of this, action is needed to equip us with answers to many of the questions most fundamental to understanding the impact of financial austerity on quality.

We do not know how the strict rationing of publicly funded social care is affecting older people’s health and wellbeing. We still know exceptionally little about patient safety in primary care. And we have virtually no data about the quality of services for children and adolescents with mental health problems. These data gaps are concerning – as is the lack of a plan in addressing them.

‘A credible plan is rapidly needed to deal with the service’s plummeting finances and improve the morale of the workforce’

The warning lights on care quality that we highlighted last year now glow even more brightly. So far we have seen a gradual decline in some elements of quality.

But complex systems under high levels of stress can suffer sudden and catastrophic collapse – often without a lot of warning. There have been examples of this in the past – for example at Stafford Hospital. 

It is very difficult to predict whether crises in the quality or availability of services are likely to become more common – even routine – or whether the gradual decline we are tracking through QualityWatch will continue.

One thing is clear: patients cannot expect the speed at which they access care to improve anytime soon.

Nigel Edwards is chief executive of the Nuffield Trust, Richard Taunt is director of policy at the Health Foundation