Forwards or Backwards?


The NHS Five Year Forward View– the Stevens Plan – is better than we feared but worse than we hoped for.

Let’s start positive and say that much of the analysis sounds correct and highlighting the huge funding gap is right.  Equally some of the other barriers to change are identified.  Bringing flexibility into structures and stopping top down restructuring is good.  Thinking differently about what to do with GPs is good.  Care closer to home, using smaller hospitals, better use of technology (!!), integrated providers, investing in the workforce, investing in primary and community care is all good stuff.  A stronger role for personal budgets across all of care has advantages (but also serious risks).

Probably nothing there that is new or innovative.

On the big picture this is still an NHS Plan not a plan for a care system. It still perpetuates the NHS as an Empire, remote from other public services and driven by powerful vested interests. On a good day it might agree to a bit of cross service working.   Nothing in the Plan addresses the democratic deficit, nothing addresses the need for co-production with patients and communities as assets.  Nothing gives patients and the public the Voice they deserve.

On the role of local authorities there is not much.  The NHS is not the vehicle for driving reduced inequality or for integration across the rest of public services or for leading on prevention and care education.  That has to be the local authorities – they have the strategic role – they have to be the strategic decision makers and budget poolers.  Care providers work within the strategy and local authorities may delegate planning/commissioning to other public bodies.

Moving to the money there is hopeless optimism.  The “savings” from the next round of the Nicholson Challenge are not credible, it’s not going to happen.  Most savings so far have been through wage restraint and that is not feasible for another 5 years.

Then there is the fact that fixing social care adds to costs and has to be done to prevent additional NHS costs. And the pressure to make more of social care free at the point of need is very strong and has costs.

So not £8bn more like £20bn is needed to fill the gap.

Then structures and the boring stuff.  Local flexibility is good but then you have the post code lottery – how far will that be tolerated?  Who decides what constitutes the NHS locally and what rights do we have?  Do localities that succeed get more funding or less?  Do poorly performing localities get penalised with cuts?  Can they raise their own additional funding, is it that flexible?  Does local flexibility require stronger engagement with local communities, if so how?

Then how do you fund the new structures?  The answer looks like through contracts, competition and payment by volume/results – which does not work!  The Plans architect says all it needs is for the NHS to be better at contracting!

It has to be accepted that for the foreseeable future some provision of care services will be done by private providers – especially in social care.  It may well be true that for some services the private sector may be engaged through contracts.  But that is wholly different from the model assumed in the Plan where we have compulsory competitive tendering and a “level playing field” and every organisation joined to every other through legally binding contracts.  We are into privatisation, EU Procurement and TTIP territory – not a good place to be.

And that is linked to the continuance of a purchaser/provider split and the kind of commissioning we know does not work.  Groups of GPs won’t make it work anymore than PCGs, PCTs, larger PCTs or clustered PCTs.  And assuming providers have to compete for business and so to keep their income does not work either.  Giving local flexibility over the payment rules looks like a potential disaster; we will need multiple failure regimes.

The idea of Multispecialty Community Providers as a business owned by GPs as described is problematic.  It should be a public body. The idea that we can allow groups of GPs in CCGs to commission primary care services is not tenable – their vested interests are far too strong.

So it’s a mess just like the current system but with more money.

Putting more money in but keeping the regulated market will not get support and it won’t work.

What we need is a Plan to move from where we are now to where we would like to be without using market competition as the driving force, without restructuring but with adequate funding; including investment to make changes.    There can be such a Plan although it is far from easy.  But this isn’t it even if some bits are good.