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What no waiting times! NHSE 5 Forward View – Localism, Challenge and Culture Change?

November 18, 2014


I am surprised to be writing this – but the NHS England 5 Year Forward View  is rather hopeful – there is no reference to waiting times in the whole report!


It affirms the resilience of the NHS despite the government’s austerity programmes.

“No health system anywhere in the world in recent times has managed five years of little or no growth without either increasing charges, cutting services or cutting staff. The NHS has been a remarkable exception.”

Its honest about where the NHS needs to improve, in particular the:

  • failure to implement the Wanless ‘fully engaged scenario’ by respective governments and the impact this has had on prevention
  • impact of barriers created by ‘artificial boundaries between hospitals/primary care, health/social care and generalists/ specialists
  • impact of austerity on funding
  • failure to shift funding from hospital to community

“hospital consultants have increased around 3 times faster than GPs and there has only been .6% increase in the number of nurses working in the community over the past 10 years”

It identifies three key gaps:

  • Health and Wellbeing – and the risk that ‘deep’ health inequalities will widen
  • Care and Quality – highlighting some of the particular challenges for a number of groups in particular vulnerable people over the age of 85
  • Funding and Efficiency – the need for ‘reasonable’ funding


It sets out a range of actions – some of them are helpful while others recycle existing NHS cultural approaches.

So we see the usual focus on behaviour change (hard hitting campaigns, labelling, targeted personal support….yawn) but not enough on advocacy, welfare rights and debt advice – even though there are many NHS services that do provide these. For these we need to turn to the recent Kings Fund/Joseph Rowntree report Tackling poverty: Making more of the NHS in England

“England is too diverse for a ‘one size fits all model’

There is a welcome emphasis on localism with a call for more power for local leaders and commitment to support whole system wrap around service models that bring together health care and community. Two models are proposed – one feels more General Practice led (Multi-Speciality Community Providers) and the other more Hospital led (Primary and Acute Care Systems).

What feels particularly hopeful is an assertive shift to break the purchaser provider split:

“It may make sense for local communities to discuss convergence of care models for the future. This will require a new perspective where leaders look beyond their individual organisations interests and towards the future development of whole health care economies and are rewarded for doing so”

Finally, there are some sections on the importance of the voluntary and community sector and communities. There appears to be a growing understanding of the important role that the VCS can play in building relationships with citizens and helping to bring a whole person approach to support through initiatives like social prescribing and volunteering.

This includes recognising that funding regimes must be more accessible to the VCS.

“we will seek to reduce the time and complexity associated with securing local NHS funding by developing a short national alternative to the standard NHS contract where grant funding may be more appropriate than burdensome contracts and by encouraging funders to commit to multiyear funding wherever possible”

Where next?


Lets face it NHSE has inherited a cultural legacy that is too often hierarchical, target led, out of touch with place and used to pleasing government first and communities and citizens second. Thus far its approach to commissioning primary care has felt removed and not sensitive to local need – particularly with regard to disadvantaged communities.

If this documents ambition is to be realised NHSE needs to review its existing structures and the skill sets of its staff. There is talk of an ‘organisational fitness review’ the outcome of this will be crucial to the success of this forward look.


While the front end of the report has solid reference to the impact of inequalities and its causes the actions towards the end of the document are not so crisp. The clearest call seems to be the expectation that hospitals will step in to create community services in disadvantaged areas using the suggested Primary and Acute Care Systems model. If I was in General Practice I would feel uncomfortable about this.

There needs to be an explicit programme of work that focusses on the most disadvantaged communities with a commitment to ensure that additional resources for primary care are fast tracked to these communities.

The voluntary sector

While it is refreshing to see a stronger recognition of the contribution of the VCS and of volunteering there needs to be a major shift in investment and capability. The commitment to simpler procurement, grant aid and longer term funding is welcome. However, there needs to be more substantial and long term investment in:

  • Capturing good practice and improving VCS capability
  • Using portfolio approaches – as pioneered by the BIG lottery and the Health and Social Care Volunteering Fund to drive innovation and capture learning
  • Infrastructure Organisations – both local and regional
  • small grants – targeted at “below the radar” community groups – The Community Development Foundation have produced a good briefing on this recently.

What do you think?

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