The National Voices coalition of charities is urging the prime minister to salvage the Five Year Forward View with some whole-system planning, as Don Redding explains
If there is a crisis in health and care, it is not just a matter of winter pressures. It is not just a short term problem. It is a long term – and long foreseen – structural crisis. It is the result of having the wrong care models for 21st century needs.
This was the message from 71 leaders of charities and professional groups that are members of the National Voices coalition, in our letter to the prime minister of 14 February.
The letter was born of significant frustration: first, that despite perpetual efforts to reform, health and care has persistently failed to offer a new deal to the people who are its majority users; and second, that so many of the calls for more funding from stakeholders across the system are unconsciously underpinned by producer, not consumer interests.
More than 70 per cent of the NHS budget is consumed by the one quarter of the population, who have long term conditions, and particularly by those with several conditions who, for example, account for a third of GP consultations
A revised settlement for health and care will need to meet some of the short term needs – especially in refloating social care – but must not be a matter of shoring up the status quo. It must look to the long term and a comprehensive approach to funding and staffing community level care and support.
More than 70 per cent of the NHS budget is consumed by the one quarter of the population, who have long term conditions, and particularly by those with several conditions who, for example, account for a third of GP consultations.
This is a severe challenge to a system providing episodic, reactive care for spells of “illness”. As we told the Commons health select committee’s inquiry into primary care last year: “The core customer has changed, but the model has not.”
It was already clear two decades ago that the rising incidence of chronic conditions would necessitate a transformation to “a system that is proactive and focused on keeping a person as healthy as possible”, as Ed Wagner and colleagues advocated in 1998, creating their “chronic care model”.
The wrong debate
That model was widely exported and discussed, and in 2003 the NHS even published its own version, tailored for the English context. By 2007-08, after several years of rapidly rising NHS budgets, senior officials promoting the world class commissioning competencies were busy warning all and sundry that demand was still rising and could not be tackled simply through “more doctors and more kit”.
The challenge issued by David Nicholson in 2009 is remembered for its focus on making £20bn a year “efficiencies”. Less often recalled is that these were supposed to enable a different approach to long term conditions and end of life care, pursued through the quality, innovation, productivity and prevention (QIPP) programme, with the aim that the NHS would disinvest in hospital care and move much more care closer to home by… 2015.
In 2017 we are not much closer to the transformation goal and, worryingly, the immediate outcomes of austerity have been to ration precisely those resources that people managing long term conditions need most: support for prevention, time with GPs, social care support to stay independent and socially connected, home care, qualified community nursing, and access to non-statutory community based support for health and wellbeing.
Meanwhile, physicians want more physicians, GP leaders call for more GPs, emergency doctors want more emergency doctors, acute providers want protection from reform, and the NHS debate in politics and the media remains fixated on hospitals.
We may sympathise with many of these calls, as staff in all areas find themselves under increasing pressure; and no doubt many service users would like better access to some of these key staff and resources. But provider interests – “more people and more kit” – are no more of a guide now than in 2007.
NHS England needs to step back a little, re-engage its key stakeholders, and generate a renewed “whole system” ownership of planning for the next three years
So what are we advocating? National Voices helped create the Five Year Forward View, and it remains the best plan available for creating a modern, more sustainable health and care service. Moreover, as we reminded the prime minister, it is also the government’s plan: the Department of Health’s Shared Delivery Plan is fully aligned to it.
Some of its implementation has gone askew, however. The support and buy-in of local government, adult social care and public health has waned, particularly with many sustainability and transformation plans seen as “NHS plans”.
NHS England needs to step back a little, re-engage its key stakeholders, and generate a renewed “whole system” ownership of planning for the next three years.
Radically changed models
This would be a more secure basis to ask for what National Voices suggested to the PM: a renewed commitment from government to support the transformation agenda.
This in turn should mean a budget settlement that replaces, over time, the lost funding on four fronts: adult social care, where around 1.5 million people have unmet needs; NHS transformation, where funds were sucked up by hospital deficits; prevention via public health; and voluntary and community sector support for health and wellbeing, which has been hammered by council cuts.
But as should be clear, this is not about funding alone, it is about radically changed care models using the principles first outlined in chapter two of the Forward View – engaging people and communities in primary and secondary prevention, the pursuit of wellbeing, and the skills and confidence to manage their own health and support others to do so.
The Realising the Value programme; the Six Principles for engaging people and communities developed with vanguards by the People and Communities Board; and the latter’s recent report to Simon Stevens on ‘high impact actions’ for Chapter Two have all pointed the way.
The Nuffield Trust’s recent ‘Shifting the Balance of Care’ report is also cautiously positive about interventions like supported self care, community based end of life care, social prescribing, shared decision making and various approaches to better long term condition management.
The integration pioneers and the vanguards, plus some of the progressive GP federations and local areas developing community ‘wellness’ programmes, have begun pointing the way towards more personalised, coordinated and community-engaged services.
Before they are forgotten in the chase for the next ‘big thing’ we need a concerted, high powered, whole system drive, with new money, to take these transformative approaches to a bigger scale and greater depth.
Don Redding is director of policy at National Voices, the coalition of health and care charities