NHS England’s five year plan

We are grateful for the Editorial by Iaccobuci (BMJ Editorial 30Oct 2014) and the review by Sir Bruce Keogh’s team (Mahiben Maruthappu, Harpreet S Sood, and Bruce Keogh BMJ Observations 31Oct 2014), both of which help to flesh out the sparse bones of The Five Year Forward View. As Neurosurgeons, we do not share the apparent enthusiasm for the 'View’, but recognise that as frontline provider clinicians we must at least take part in the debate, and must seek to alter these policies for the short and long term good of patients.

Both these articles on the ‘View’ imply that in order to effect change ‘someone’ will need to drive its interpretation locally: ‘The plan will hinge on how local areas will interpret it and take it forward’ - Iacobucci . We agree that important elements of our pathways hinge on local processes, but in the last two years we have seen a singular lack of guidance on how to do this. We have lost local perspective and leadership by handing the financial reins to the CCG’s; they are unlikely to welcome the additional burden of commissioning complex Specialised Services. We are uncertain where this leaves patients, doctors and other workers in these services.

For the Specialised Services (10 million patients in their lifetime), the residue of planned commissioning, there is the threat of further dissolution. Obviously we want to contribute to any reorganisation necessary to make these services sustainable and accessible, but ‘Where the relationship between quality and case volume is strong…drive consolidation through a programme of three-year rolling reviews…’ (Keogh) of course means reducing the number of providers. Plans to do this have met with considerable resistance – the consolidation of cardiac Surgery in Newcastle and Leeds being an example – and attempts to justify closures or expansions on the basis of quality of patient outcome have set clinicians against each other. Similarly ‘prime contracting’ and ‘delegated capitated budgets’ ( Keogh) imply restricting the commissioning process to areas where it is perceived that money can be saved, creating a rationing environment where we will compete against each other with quality only as a pretext. The reality will be that Trusts will be pressurised to prune services based on cost, in the knowledge that service development may jeopardise their profits. This will result in worse, not better, access for patients.
The shunting of responsibility for Specialised Commissioning onto the CCG's is a risky and untried approach, especially illogical where local, economically driven commissioning policies will be insensitive to the viability of Trusts. This will almost certainly pitch CCG's against Trusts at a time when we need cooperation to deliver the Primary Care agenda.

80% of NHS funding is spent on Hospitals, so one can see what both Government and NHS England are aiming at. However spending cuts have reduced patient access to both GP’s and Specialists, and Cancer figures are deteriorating. Delays in referral will not be helped by the tokenism of putting Specialists in GP practices without access to Labs and Imaging. Indeed patient flow would work better the other way: patients could have tests done in one visit to the Hospital/ Speciaist, removing the need for complicated and delaying referrals – which really would save money. The massive increase in A&E activity this year reflects the public voting with their feet about the need for reform and about the failure of GPs to deliver the service they feel they need, especially in diagnosis. It is difficult to envisage NHS England recognising and acting on this: perhaps the Primary And Acute Care programme will, as common sense prevails; current and recent NHS policy would however suggest otherwise.

Clinical Leaders need to focus on helping the public understand better when they need our services and how to access them. The lamentable figures for Brain and CNS Tumour diagnosis - >70% are diagnosed from their A&E visit despite numerous visits to Primary Care - indicate that there is a serious problem somewhere, whether it is lack of time to take a proper history, lack of neurology training, or having consultations with multiple GPs. This is compounded by the Postcode lottery of GP access to MRI and CT. This is not the fault of GPs themselves, but of the unreasonable demands placed on them. Though the UK often finds it hard to learn from Europe, models in Germany or France show that more direct access to hospital diagnostic services seems to work - that focusing on streamlining patient access to services might save money in bureaucracy, paperwork and bus-fares, as well as leading to dramatic improvements in outcomes. We must understand deficiencies in access pathways and processes before implementing changes.

The Great British Public is unhappy with the status quo; it is the system that must change and we have to afford it or lose the NHS altogether. Combining Hospital and GP services is already accepted by the public, and such a move can happen organically, with predictable costs and easily measurable benefits. Politicians and NHS England must learn from the White Paper mistakes and not repeat them with yet more wasted effort.

The Health and Social Care Act 2012will continue as Lansleys’s fiasco until the fundamental flaw in separating funding streams for patients between Health and Social care is recognised. This schoolboy error will thwart anyone who wishes to develop community based initiatives - ie the ‘Multispecialty Community Care Providers’ envisaged in the ‘View’.

We do not share the current enthusiasm for The Five Year Forward View as it does not address the issues that will allow rationalisation of services to make them affordable and sustainable. Particularly lacking is a clearly defined administrative structure to oversee and help implement change. Politicians should take the responsibility for rationing healthcare to fit our budget where rationing is admitted and necessary, rather than leaving this to frontline clinicians: like the GPs, we will struggle with the competing roles of advocate and gatekeeper.

Julian Neely wants rationing and charging to save the NHS. Rationing is the word that dare not speak its name, although it is inevitable. But charging is a distractor. Given that a set amount of money is needed for the NHS, then the most efficient way of raising that money is through general taxation. Any other way gives money to insurance companies and affects those who are least well off - not the really poor, who would be exempt, but the almost poor, who would end up being poor because they were ill.

For years, everyone has known that the most important unanswered question is, "What is the NHS for?" Because of politics and media manipulated indignation no answers have emerged.

nevwgoodman@mac.com