Half a decade is simply not long enough to implement the ambitious new models of care set out in the NHS Five Year Forward View

For the most part, the NHS Five Year Forward View is not a very good five year plan. It is, in truth, a much better 10 year plan.

For all of the ambitious talk of delivering new models of care inside five years, the work to put them into effect is now crashing into the biting reality that a half decade is simply not a long enough period of time to effect change at this scale.

‘In truth, the forward view is a much better 10 year plan’

Devo Manc’s progress in developing its own proposals has been so lethargic that the Treasury last week imposed upon them a deadline of the spending review to actually put some ideas on paper. It is surely now fanciful that £6bn of public money will be handed over to a structure in April 2016 when - in July this year - we have no idea what it will look like.

And, although I am not close to the work of the vanguard sites, I do claim some knowledge of the laws which will govern them. It seems to me that there is still a tendency to plan to merge organisations and to think about the benefits to patients later.

That path will lead nowhere.

The notion that mergers can take place without evidence that they will help is surely, now, consigned to history - but building that evidence base will take time.

Carter won’t make a dent

There is, however, another part of the forward view - the bit about the money - that is proving itself yet again to be a very good five year plan.

The chancellor reiterated last week that, at a time of immense financial pressure, £8bn extra a year would be found by the end of the Parliament for the NHS.

‘I imagine that a small part of Simon Stevens is kicking himself that he didn’t ask for more’

I imagine that a small part of Simon Stevens is kicking himself that he didn’t ask for more, because he probably would have got it - and he will know better than anyone that the science behind the £22bn of “achievable” efficiency savings is largely fictitious.

The need to achieve savings of that quantum is, of course, anything but fictitious, but I am still worried that the government has not steeled itself to the task it faces.

The Carter review’s scandalous examples of waste make good copy, but it is surely self-evident that in trying to reach for those savings - with constrained capacity - managers will have to let go of the areas of expenditure they are gripping at the moment. As new savings are realised, offsetting waste will emerge. The Carter review is not going to make a dent.

Out of reach

More worrying is the decision to instruct the Care Quality Commission to look at efficiency, in addition to safety.

These functions are obviously in conflict: I am aware of no other sector where anyone has sought to combine them in a single regulator, as those who may remember the Department of Health’s 2006 review of regulation will know. But I fear that policy might now actually be being made on the basis that “the path to lower costs is the same as the path to safer care”. I am sorry to point this out, but it really isn’t.

£22bn of efficiency savings, safe care, high levels of access - at best, over the next five years, only two of these can be maintained.

With the Treasury not allowing it be the first, and all of us hoping that it is not the second, it has to be access standards which are sacrificed.

I detect in the abandonment of two of the three 18 week targets that somewhere in the statutory machinery this is recognised, and someone is trying to do something about it.

‘If the NHS is to deliver safe care as the money runs out, they need to get a move on’

But if the NHS is to deliver safe care as the money runs out, they need to get a move on.

We may need to accept that the maintenance of the remaining 18 week target is actually out of reach.

Surely, the four hour accident and emergency target has to be abandoned in some way soon too - it is sucking pressure into hospitals which they are increasingly unable to bear. In this context, the most ambitious plans for seven day GP access are a pipe dream.

Abandoning these access commitments is not going to be easy politically, but then dealing with the £22bn was never going to be.

The NHS’s access standards are totemic.

Indeed, some are written into the NHS constitution and require legislation to change. So somewhere there needs to be a plan:

  • a plan to ensure doctors and other healthcare professionals take the lead in decisions on access targets;
  • a plan to ensure that, if targets are going to be loosened, they are tightened up for at least those who are most in need; and
  • a plan to ratchet the targets back up when the money taps are turned back on.

That plan is the five year plan which needs to exist somewhere, if the vision in the forward view is to be delivered.

Bill Morgan is a founding partner of Incisive Health and a former special adviser to Andrew Lansley

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