UK King's Fund warns underfunding could impede NHS Five Year Forward View

The King's Fund, a UK health charity and think-tank, has issued a report entitled "Policy Changes to Implement the NHS Five Year Forward View: a Progress Report", marking the two-year stage of the UK government's ambitious Five Year Forward View for reform of the National Health Service (NHS). The report evaluates the initial aims of the project and assesses progress in each area, alongside problems and unforeseen issues. The full report may be accessed here.

The Five Year Forward View (Forward View) was designed in 2014 by the NHS and other government bodies to set out important changes to the NHS to enable it to deal more effectively in future with a growing and ageing population. The recommended mechanisms in the scheme principally involved integrating primary and secondary care and putting greater emphases on disease prevention and patient- and community-centred control of healthcare. Rather than prescribing specific changes, the Forward View outlined care models customisable to the needs of local populations, with some flexibility in application of solutions, leadership, payment structures, and regulatory requirements according to local needs (see United Kingdom: 23 October 2014: NHS England's chiefs reveal plan to help bridge USD48-bil. funding gap anticipated to emerge over next five years).

In the two years since the Forward View was published, new care models have been tested around the United Kingdom at 50 "vanguard sites" and local leaders in 44 areas have been instructed to draw up Sustainability and Transformation Plans (STPs) indicating the roadmap for transformation of services within their local areas, within available funding. NHS England, NHS Improvement, and the Care Quality Commission (CQC) have made regulatory changes to the NHS to support implementation of the project.

However, these initiatives have been rolled out in the face of growing financial pressure in the NHS. The report highlights that, at this stage, most healthcare providers are in deficit, and there is additional pressure from the failure to meet key targets for patient care and significant staff shortages. Importantly, there have also been major cuts to funding for social care and public health, which are critical to the success of a future integrated system. As a result, national and local leaders have been "preoccupied with tackling these pressures", according to the report, alongside the push to transform services outlined in the Forward View.

Specific areas previously highlighted in a 2015 study by the King's Fund are assessed in turn in the report: new models for commissioning and paying for services, NHS regulation, delivery of improvements in healthcare by local leaders, and the contribution of a transformation fund. Overall, the report acknowledges that progress in implementing the suggested policy changes for the Forward View has been mixed, but the greatest progress has been in establishing new care models and STPs, along with devolution of more responsibility to public sector leaders, such as has been implemented in Greater Manchester. In addition, more unified regulations have resulted from improved communications between NHS England and NHS Improvement, setting out a clearer role for the Care Quality Commission (CQC) in performing quality control across organisations and services and identifying innovations in payment systems to support new care models.

The greatest concern voiced in the report is a "lack of funding to support transformation", with almost all the additional funds available to the NHS in 2016–17 having been used to sustain existing services, largely in reducing deficits for NHS acute providers. Sustainability has become a preoccupation with both local and national NHS leaders because of growing pressures on health and social care as a growing and ageing population places "ever greater demands on a system already under huge strain". As a result, "much less of their time has been dedicated to transformation than might have been expected, given the central importance of the Forward View". The report highlights year-on-year increases in accident and emergency department attendances, emergency hospital admissions, high bed occupancy rates, and increasing delays in transfer of care to the public health sector, which is facing its own cutbacks.

In its overall analysis, the report is still generally supportive of the aims of the Five Year Forward View, precisely because integration of care and investment in community-based solutions offer a major part of the solution to future demands of the ageing population, and should not be seen as a barrier. As part of this, a need remains for an increased focus on prevention, early intervention, admission avoidance, and at-home support for independent living. However, it warns that "the challenge is that developing alternatives to care in hospitals and care homes requires investment, which is currently in short supply". It strikes a parallel with the transformation in the 1970s of mental health services, where the major focus was shifted from hospitals towards care in the community, which was largely achieved with "adequate funding" over successive governments and sufficient time allowed for implementation. The authors conclude that "the lessons are clear and need to be acted on with urgency".

Outlook and implications

This urgency in reviewing NHS funding has been echoed today in a published letter to the UK Chancellor, Philip Hammond, from the chair of the government's Health Select Committee, Dr Sarah Wollaston, following an inquiry by her committee into NHS finances. According to Dr Wollaston, quoted in UK general practitioners' journal Pulse Today, a figure of GBP10 billion (USD12 billion) cited by the government as extra NHS investment, is "incorrect" and the Department of Health (DH) budget will only increase by GBP6 billion, since cuts of GBP3.5 billion have been implemented elsewhere in the NHS, including public health grants to local authorities, to be made between 2014 and 2021. Dr Wollaston also warns in her letter that funding the NHS by cutting other healthcare budgets "puts at risk the achievement" of the Forward View and that investments need to be made now to achieve long-term savings. During her committee's inquiry, the CEO of NHS England, Simon Stevens, reported that, despite real-term increases from the spending review, per-capita NHS funding would stall in 2017–18 and decrease in 2018–19. Dr Wollaston therefore requests a review of the NHS funding settlement for these years to ensure the NHS can meet rising demands.

In response, a Treasury source told Pulse Today that the government stands by its GBP10 billion figure in real terms and that local government will have access to up to GBP3.5 billion of new support by 2020.

Dr Wollaston's committee previously voiced criticisms of the government's published healthcare spending figures last July, warning of a "false economy" of cutting back on public health and health education, which was likely to be unsustainable and to create further financial problems for the NHS in future (see United Kingdom: 21 July 2016: UK health committee inquiry calls figures for last NHS spending review "misleading").

With combined pressure from an influential body such as the King's Fund and the chair of its own select committee on health, it may be difficult for Theresa May's government to ignore such explicit warnings. However, it remains to be seen whether the requested additional funds become available and whether they can be directed towards effective healthcare reforms that benefit patient care in the longer term without neglecting the severe current pressures in acute patient care. With three years remaining on the Forward View, it appears evident that if beneficial changes are going to be made from the system, increased allocations of both time and money will be required.