Intended for healthcare professionals

Observations The Future of the NHS

The NHS Five Year Forward View: implications for clinicians

BMJ 2014; 349 doi: (Published 31 October 2014) Cite this as: BMJ 2014;349:g6518
  1. Mahiben Maruthappu, senior fellow, Chair and Chief Executive’s Office, NHS England,
  2. Harpreet S Sood, senior fellow, Chair and Chief Executive’s Office, NHS England,
  3. Bruce Keogh, national medical director, NHS England

The Five Year Forward View is a look at what the NHS could achieve, given the range of resources that may be available. It sets out how the health service needs to change, arguing for a more engaged relationship with patients, carers, and citizens to promote wellbeing and prevent ill health. Here, we outline how the Forward View supports clinicians to provide better, higher quality and more integrated care.

New models of care are presented, including multispecialty providers, primary and acute care systems, urgent and emergency care networks, viable smaller hospitals, specialised services, modern maternity services, and enhanced care homes. The commitments to support clinicians are discussed, including specific proposals for primary care, initiatives to improve the health of NHS staff, dealing with gaps in the NHS workforce, and the use of technology and innovation to further enable clinicians.

The Five Year Forward View sets out how England’s health service needs to change. Mahiben Maruthappu, Harpreet S Sood, and Bruce Keogh describe how the report’s proposals support clinicians in providing better, higher quality, and more integrated care

The recently published NHS Five Year Forward View sets out the shared perspective of the NHS’s national leadership bodies about what the NHS could achieve over the next five years given the range of resources that may be available.1

It is important to acknowledge some of the strides the NHS has made over the past 15 years. In 2000, patients were waiting 18 months and sometimes much longer for hospital treatment after referral. Today, most patients start treatment within 18 weeks.1 Over the same period, public satisfaction with the NHS has nearly doubled, cancer survival is at its highest ever, and there are more than 160 000 extra whole time equivalent clinicians.1

However, with the advent of the global financial crisis, growth in funding over the past five years has been heavily constrained. Despite almost £20bn (€25bn; $32bn) of efficiency improvements, services are under pressure, with increasing acceptance that “more of the same” will not be possible.

As clinicians, although we have achieved much, given these conditions, we must now act on the opportunity to change. There is broad consensus on what this change should look like and the type of health services that will be necessary. Historical demarcations need to be dissolved—between health and social care; mental and physical health services; and primary, community, and specialist care. Cross sectoral action to improve the health of our population must be taken. Hospitals need to do less, through fewer unnecessary emergency admissions, and general practice needs less to do, through the avoidance of unnecessary ill health.

New models of care

To achieve change we need new care models: systems that support clinicians in providing a higher quality and more integrated service. For the first time since 1948 the Five Year Forward View proposes a range of new models entailing locally driven change, where local communities, patients, and clinicians play a central role in designing and providing these services. It is clear that there isn’t a silver bullet; precise solutions will vary across the country, but common principles exist. Although flexible, the models of care the Five Year Forward View suggests include:

  • Multispecialty community care providers: These present opportunities for GP practices to shift outpatient consultations and ambulatory care out of hospital settings, with larger group practices employing consultant physicians, geriatricians, paediatricians, and psychiatrists to work alongside community nurses, therapists, pharmacists, social workers, and other staff. These providers could take over the running of local community hospitals, permitting diagnostic services to be expanded.

  • Primary and acute care systems (PACs): These are vertically integrated services combining hospitals and GP surgeries, permitting, in particular, greater investment and expansion of primary care in areas with high health inequalities. Alternatively, in some contexts, primary and acute care systems could take the form of accountable care organisations, such as those adopted in Spain, Singapore, and the United States, where providers take accountability for the whole health needs of a registered list of patients, under a delegated capitated budget.

  • Urgent and emergency care networks: Drawing on the success of major trauma centres, networks of linked hospitals will be formed, ensuring that patients with the most serious needs get to specialist emergency centres. The system, which currently comprises accident and emergency services, urgent care centres, community mental health teams, primary care, ambulance services, and community pharmacies, will be made less complex. Better coordination will help patients to get the right care, at the right time, in the right place.

  • Viable smaller hospitals: NHS England will work with smaller hospitals to examine new models of medical staffing and other ways of achieving sustainable cost structures, building on the earlier work of Monitor and on the Royal College of Physicians’ Future Hospitals initiative. New organisational models for smaller acute hospitals will be introduced, to enable them to gain the benefits of scale without necessarily having to centralise services.

  • Specialised services: Where the relationship between quality and case volume is strong, NHS England will work with local partners to drive consolidation through a programme of three-year rolling reviews. Such services may include specialised surgery and some cancer pathways. NHS England will look at the development of networks of services over a geographical area, integrating different organisations around patients, and using innovations such as prime contracting and delegated capitated budgets.

  • Modern maternity services: The NHS will conduct a review of future models for maternity units, which will make recommendations on how best to sustain and develop maternity units that deliver fewer than 4000 babies a year. Efforts will be made to ensure that tariff based NHS funding supports women’s choices, in addition to making it easier for groups of midwives to set up their own NHS funded midwifery services.

  • Enhanced health in care homes: In partnership with local authority social services departments, and using the opportunity created by the establishment of the Better Care Fund, NHS England will work with local NHS organisations and the care home sector to develop new shared models of in-reach support, including medical and medication reviews.

These are some of the care models that will be promoted in England across the next five years, jointly with local communities and leaders, to provide a system that supports clinicians and delivers better care.

Supporting clinicians

The NHS could better enable and support clinicians. The Five Year Forward View commits to developing a system that works for clinicians, not simply in delivering care but also in maintaining their own health.

New deal for primary care

General practice is one of the great strengths of the NHS but is under severe strain. The number of people choosing to become a GP is not keeping pace with the growth in funded training posts, in part because primary care services have been under-resourced in comparison with hospitals. The Five Year Forward View makes a commitment to invest more in primary care, stabilising core funding. It suggests several steps, including provision of new funding through schemes such as the Challenge Fund to support new ways of working. There will be investment in new roles and in returner and retention schemes. NHS England will also work with clinical commissioning groups and others to design new incentives to encourage new GPs and practices to provide care in under-doctored areas. Efforts will be made to improve the public’s understanding of how pharmacies and online resources can help them deal with minor ailments without the need for a GP appointment, to control demand.

The NHS as a healthier workplace

It has been estimated that the NHS could reduce its overall sickness rate by a third, the equivalent of adding almost 15 000 staff and 33 million working days, at a cost saving of £550m.1 Only a third of NHS trusts offer support to staff in keeping to a healthy weight, and three quarters of hospitals do not offer healthy food to staff working late night shifts. This needs to change. The NHS will therefore see the introduction of work based health schemes; “active travel” schemes for staff and visitors; and a review, conducted jointly with the Royal College of Occupational Health, of the support provided in the workplace. Efforts will also be made to tackle obesity among NHS staff, by cutting access to unhealthy products on NHS premises, implementing food standards, and providing healthy options for night staff.

Tackling immediate gaps in key areas

In the past year alone the number of staff at foundation trusts has increased by 24 000, a 4% rise.1 However, this change has not fully reflected changing patterns of demand. Numbers of hospital consultants have risen over three times faster than GP numbers, reflecting a trend towards a more specialised workforce. To reduce gaps in key areas Health Education England will take action, putting in place new measures to encourage employers to retain and develop their existing staff, increasing productivity, while reducing the waste of skills and money. The NHS will consider the most appropriate employment arrangements to enable current staff to work across organisational and sector boundaries. Health Education England will work with employers, employees, and commissioners to identify the education and training needs of our current workforce, equipping them with skills and flexibilities to deliver new models of care. There will be greater investment in continuing professional development. NHS employers and staff will also be encouraged to consider how working patterns, pay, and terms and conditions can best evolve to fully reward high performance, support job and service redesign, and encourage recruitment and retention in parts of the country with high numbers of vacancies.

Technology and innovation

Technology will be used to better enable clinicians in delivering integrated care. The National Information Board, which brings together organisations from across the NHS, public health, clinical science, social care, local government, and public representatives, will publish a set of “road maps” later this financial year to lay out how this will be achieved. Key elements include:

  • More comprehensive transparency in performance data—such as the results of treatment and what patients and carers say—to enable health professionals to see how they are performing, in addition to helping patients make more informed choices

  • There will be an expanded set of NHS accredited health apps to aid patients in organising and managing their own healthcare.

  • Electronic health records will be fully interoperable so that patients’ records are largely paperless; patients will have access to these records and will be able to write into them.

  • The NHS patient number will, for safety and efficiency reasons, be used in all settings, including social care.

  • Family doctor appointments, and electronic and repeat prescribing will also be routinely available online everywhere.

To better empower clinicians in improving practice, innovation in the NHS will be accelerated. In particular, the NHS will continue to support the work of the National Institute for Health Research and the existing network of specialist clinical research facilities. NHS England will also develop the active collection and use of health outcome data, offering patients the chance to participate in research, and will work with partners to ensure the use of NHS clinical assets to support research in medicine. The costs of randomised controlled trials will be reduced, not only by streamlining approval processes but also by harnessing clinical technology. The rollout of the Clinical Practice Research Datalink will be supported, and efforts will be made to enable its use in observational studies.

Clear ambitions

Our nation’s commitment to universal healthcare is clear. However, while our values haven’t changed, the world has. We are now faced with an opportunity, collaboratively and collectively, to realise change, using our experience to adapt and improve the NHS. The Five Year Forward View sets out what this change may look like and how it can be achieved. It presents ambitions for supporting staff, including new care models that enable clinicians to better serve their patients. Amid one of the most difficult times the NHS has faced, we do have reason for optimism; and although challenges lie ahead, we can indeed achieve a world leading service fit for the future.


Cite this as: BMJ 2014;349:g6518


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; externally peer reviewed.


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