Mark Exworthy

Mark Exworthy

Today’s publication of the “5yfv” (5 year forward view) marks a seminal moment for the NHS. Since Simon Stevens’ return to the NHS earlier this year, there has been anticipation as to the new Chief Executive’s intentions. Although he has presented some earlier ideas1,2, the “5yfv” is significant for its content, style and what it does not say.

Stevens has given an insightful diagnosis of the challenges facing the NHS and cogent prescription for his remedy. Whilst this 40 page document offers some tantalising glimpses of what’s possible or even likely, much of the challenge of enacting this strategy will be in the detail of implementation. Such great expectations may yet be dashed locally3. Two key themes are worth mentioning here.

First, the report identifies financial incentives to behavioural change (nudges) as one route to better prevention, but this might yet prove controversial changes. Making such payments whilst also saving £30billion may be hard to justify with other pressing claims. Second, employee well-being is significant but the type and scale of incentives for action from employers is unclear. There is a danger that too much focus is on individual fixes to organisational problems, as demonstrated in Nick Clegg’s speech on public service reform yesterday. Third, the report notes that we have said similar things about prevention in the past. Moreover, the lessons of the Wanless report were not heeded. Can public health deliver the increasingly tough messages on lifestyle choices that the report demands, and will there be sufficient political will to follow through on them?

First, breaking down barriers between different parts of the service is of course laudable but has been an elusive goal in the past. The range of models offered includes much of what is being attempted already, although with an overarching framework. Second, the new Multi-specialty Community Provider harks back to former ways of organising and delivering community health services, albeit with general practice remaining `semi-detached’ from other services. Third, the promise of no more structural re-organisation (especially of commissioning organisations) will give some relief to the service. But will this promise be sustained? The average life expectancy of commissioning organisations since 1991 has been around 2-3 years.

The report presents an enticing blend of vision and implementation. It is a broad strategy with scope for local innovation and experimentation. The report seeks a middle ground between `one size fits all’ and a thousand blooming flowers, but this is intriguing as to its implementation. The recent history of the NHS would suggest that national intervention will follow quickly when the local diverts too far from the national model.

It is also important to note what was not mentioned in the document. Calls earlier this year for charges for GP visits or hotel services in hospitals4 have not materialised. Indeed, Stevens notes the `improvements’ in the NHS despite such charging. We also did not hear the bark of a second dog – the private sector. Rather than being explicitly stated, it was implicit in the text. The “range of contracting and organisational forms” (p.20) that is in place already, signals that the plurality of health and social care organisations will remain or even increase.

To understand better the significance of this document, it is useful to compare “5yfv” with another strategy with which Simon Stevens was closely involved – the NHS Plan (2000). This comparison also shows how the best laid plans might be scuppered by `events.’ The NHS Plan was a strategy for “investment in the NHS with sustained increases in funding.” How things have changed? “5yfv” is a strategy in a time of austerity, and the financial deficit that used to be termed the ”Nicholson challenge” – maybe now the “Stevens shortfall.” Stevens now proposes a 5 year plan whereas the NHS Plan boldly envisaged 10 years! Whereas the NHS Plan heralded (yet further) centralisation, the “5yfv” places much more emphasis on `going with the grain’ of local developments. However, the NHS Plan was arguably the start of greater involvement in the NHS of private and 3rd sector providers. Stevens remains `relaxed’ about the sources of new forms of innovation.

Today’s report is less grandiose than its predecessor. In the era of Blair’s big tent, the NHS Plan had 25 signatories from the `great and good’ in the preface, even ahead of Tony Blair’s foreword. The NHS Plan also had 100 more pages than the 5yfv! With its relative brevity and snappy acronym today’s document feels like a report for the social media age.

The NHS Plan went on to have repercussions across the service which, arguably, are still being felt now. It set in train a series of reforms in Strategic Health Authorities and what became PCTs. Such early-mid 2000s reforms set the context for the Lansley reforms.

“5yfv” offers an enticing glimpse of the NHS in 2019. Stevens’ renowned analytical skills have been brought to bear on a compelling vision of the next 5 years. However, implementation will be tricky in highly constrained financial context. A key determinant will be politicians’ decisions after the next election – whether Stevens will be `allowed’ to implement his strategy or whether (as has happened before) Westminster will re-asset its influence. The public once again feel that the NHS is their biggest concern6. For the NHS, the stakes could not be higher. 

  3. Exworthy, M., Berney, L. and Powell, M. (2002) ``How great expectations in Westminster may be dashed locally’: the local implementation of national policy on health inequalities.’ Policy and Politics, 30, 1, pp.79-96.