There is much to welcome in the reboot of the Five Year Forward View, launched today. National Voices’ previous advice has been: this is a good if imperfect plan, stick with it. That is what the new document confirms. It charts progress, and sets out next steps for cancer, mental health, primary care development, new models of care, innovation, patient safety and more besides. It is a serious declaration of intent to stay the course in sustaining and reforming the NHS to make it more preventative, joined up, high quality and fit for the 21st century.
But something is missing. The 2014 Five Year Forward View devoted a whole chapter to the “new relationship with patients and communities”, recognising that the range of approaches to working in partnership with people were not just a “nice to have” but “precisely the sort of slow burn, high impact actions that are now essential”.
Less than the sum of its parts
On a close read, you can find evidence of these high impact actions scattered through the new text. There are commitments to supported self-management, social prescribing, patient activation, and personal health budgets for people with long term conditions and disabilities. There are pledges to avoid hospitalising people with learning disabilities, to support people with mental illness back into work, and to identify and support carers. Sustainability and Transformation Plans (STPs) will have to step up their game in how they engage with their communities.
Much of this is very sketchy, though the commitment to work with voluntary sector partners nationally and locally provides (we hope) the hook for fleshing out these commitments in partnership.
Nevertheless, the whole feels less than the sum of the parts. It’s great to see a few highly esteemed charities name-checked. But overall there is virtually nothing about the role of the voluntary and community sector, volunteering and social action. There is one reference to the Social Value Act, buried in a footnote! Indeed, the document fails to do justice to all the work that is going on in this space, ignoring for example the wider community contributions to primary care, new care models and work to reduce delayed transfers of care.
So where have the people and communities gone? It seems we have been nudged aside by the needs of a rebooted Forward View for tough, austere, Brexit times. This is the NHS leadership hunkering down on delivery against agreed priorities within their silos. A plan for the re-working of services (A&E, primary care, new models); a plan for performance: (access to GPs, waiting times etc); a plan for the most politically salient conditions (cancer, mental illness). A plan that reasserts the importance of financial “grip”. This is in many ways great, but it starts with the system, not the person or the community.
Filtered through the lens of operational delivery, the original “Chapter 2” vision struggles to get purchase. People powered approaches to health and wellbeing are not just a set of activities, they represent different ways of thinking and behaving, and a wider culture change. They are about “letting go” as much as about “grip”. But the Next steps on the NHS Five Year Forward View’ document is about keeping the show on the road for the next two years. Even the new models of care have been boiled down in this to new models for reducing emergency admissions and reducing bed days.
The argument for person and community centred approaches
But something else is going on. There is a growing body of evidence and practice demonstrating the impact of person and community centred approaches to health and care on quality, outcomes, health behaviours and resource use. NHS England itself commissioned some of this work through the Realising the Value programme. There is also the VCSE Review, the Richmond Group’s Untapped Potential and the People and Communities Board’s high impact actions report.
‘Next steps for the NHS Five Year Forward View’ suggests that the argument for person and community centred approaches is not yet won. It seems that when push comes to shove, “Chapter 2” approaches are prone to be put back in the “nice to have” box.
There are lessons for our sector in how we make the case; and questions about why it does not enjoy stronger internal support within the national leadership of the NHS.
“What’s the matter with you?”
So, this is a welcome re-launch of the Five Year Forward View. It reaffirms a national commitment to a free at the point of use, universal, high quality health and care service. It commits to developing a 21st century service, but was created in a very 20th century style, a Whitehall style: largely behind closed doors and with very little in the way of co-production. It hints at a more collaborative mode of working but its prevailing mindset toward patients and citizens remains more “what’s the matter with you?” than “what matters to you?”
We shouldn’t obsess about the plan. It is only a document and one written largely for political purposes. It probably undersells the degree of culture change bubbling up across the country. And it provides new opportunities for National Voices and friends to help nudge policy and practice in more person-centred directions. Which is what we will continue to do.