The Five Year Forward View is no longer fit for purpose

There will be more money for health and care services. Discussion in Cabinet appears to have moved on from the merits of more funding to when and how additional funding should be delivered.

The mantra from Number 10 and 11 that the NHS had received for the funding it had asked for has been replaced by a series of incremental funding concessions – an additional £350m in the Budget to ease deficits, a small (and unpublicised) top up in the Spring Estimates, a slug of cash to ensure some real terms growth in spending for the remaining years of the FYFV period and now more money to fund the Agenda for Change pay deal.

Yet these additional resources – welcome and necessary as they are – do not amount to an investment. Instead they are political hazard money, designed to keep the financial wolves from the door of hospitals and an angry electorate from the door of Downing Street.

They also make it difficult for the NHS to plan, let alone transform. So we are stuck in a cycle of crisis and bailout, something which is not very good for the politics of health, the morale of the workforce or indeed the health of the nation.

This challenge has not been lost on the Department of Health and Social Care. Senior officials are musing about how health and care services can be made “an investable proposition” in the eyes of the Treasury. Readers might not like the language, but these officials have an important point.

FYFV: a lost cause

The FYFV was once this proposition. It gave a reason to invest, but both sides will argue that the investment was made on a false prospectus. The NHS points to the absence of funding for public health, social care, training or staff pay rises to back up the totemic £8bn.

The Treasury, for its part, will argue that transformation has stalled and that the NHS has failed to live within the means it envisaged for itself.

Complicated plans to promote integration, healthy living and new care models remain important, but alone they do not provide a reason to believe that the NHS is an investable proposition

Whatever the merits of these arguments (and I suspect I can predict where most readers’ sympathies will lie) and indeed whatever the strength of the ideas set out in the FYFV, the point is that it no longer provides common ground.

Complicated plans to promote integration, healthy living and new care models remain important, but alone they do not provide a reason to believe that the NHS is an investable proposition.

It is time to move on.

NHS is an unattractive investment

In the absence of a unifying optimistic vision (and remember that when the FYFV was published, it was both unifying and optimistic), the nature of the debate on health and care funding has made the NHS less – and not more – appealing as an investment.

The Treasury is also likely to hold funding back for as long as possible for fear that it might be wasted

Arguments such as “the NHS needs £X00m to avert crisis” (insert figure depending on where we are in the year) or “social care faces funding black hole” might be correct, but they do little to inspire confidence, instead making health and care services look like the public service equivalent of ToysRUs.

The Treasury might (finally) accept that it has little option but to provide funding, but it is hardly likely to do so with any enthusiasm. It is also likely to hold funding back for as long as possible for fear that it might be wasted. And so the cycle continues.

Wanted: a new vision

Health and care services need a new vision which can excite politicians and reassure the Treasury. This has to be about more than simply averting a short term crisis. If we are to achieve a longer term funding settlement, what will it buy?

How will services look different and what will this mean for patients, staff and the public? This has to be about more than just transactional changes, technocratic tweaks or inventing another acronym.

Of course this vision needs to be grounded in reality, and it needs to be honest that funding pressures will continue to grow in the NHS, as they will in every health system. However, it must also create some excitement about how things can be better.

Such a vison should include a retail offer to the public (more digital delivery of primary care?), as well as concerted action to free up NHS staff to use their skills to the full (greater responsibility for the non-medical workforce?).

This vision needs to be honest that funding pressures will continue to grow in the NHS, as they will in every health system and create excitement about how things can be better

It also needs to set out a compelling vision for how health outcomes can be improved (how about extending action to encourage earlier diagnosis of cancer into a concerted attack on late diagnosis of all conditions, including mental ill-health?).

There is little evidence that this vision will come from the government or the Opposition. The creation of NHS England may have removed (some) of the day-to-day politics from the NHS, but it has also reduced the incentive to create a new political vision for what health and care services should deliver.

Nor, however, can it just come from Simon Stevens, the man the NHS has relied on so often in the last few years to pull a rabbit out of a hat. The FYFV was his plan, as government ministers were so keen to point out. Instead, others will have to step forward.

Clinicians who talk about leadership will need to show it. Patients who want their voices to be heard will need to speak up with new ideas. Suppliers who aspire to be partners will have to step up. Yes, even commentators will have to do more than opine on other people’s ideas. If we want a good longer term funding settlement, then we all need to give the Treasury a reason to invest.