Future plans for the NHS
The Lancet
The principal challenge for high-income countries that have achieved universal health coverage is sustainability. To address the health needs of growing and ageing populations with multiple comorbidities is increasingly expensive. For instance, if funding for the UK's National Health Service (NHS), the world's largest single provider of health care, remains tied to economic growth over the next 5 years, there will likely be a £30 billion deficit by 2020. Given this stark reality, NHS England published its Five Year Forward View on Oct 23. The report considers how the NHS can continue to be a world leader within the available budget by exploring the extent to which decreased demand and increased efficiency could reduce the shortfall. Three broad approaches are proposed: better integration of care with local restructuring, radical strengthening of public health, and a new deal for general practitioners (GPs). Many would argue that these changes are overdue.
Foremost is the need to dismantle tribal boundaries between different sections of health and social care for a more integrated service in the wider community, a view supported by The Royal College of Physicians in a Comment by Jane Dacre in this issue. New, decentralised, multispecialty community providers will be encouraged to develop patterns of care appropriate to local circumstances. Second, public health needs to be strengthened: tobacco, alcohol, and obesity impose major burdens on NHS resources that must be reduced. In doing so, the government should recognise that health outcomes also have social determinants that require cross-sectoral solutions, legislation, and funding. Social inequalities alone are estimated to cost the NHS more than £5 billion per year. Third, GPs have extensive experience of local needs, interdisciplinary practice, the interface between primary and secondary care, and budget-holding. However, too often in many clinical commissioning groups, GPs are proving to be obstacles to innovation, preferring instead to defend their own interests, rather than those of the public. A new vision for primary care is called for.
New patterns of care will be stimulated by many factors, and greater use of information technology will be essential. Therefore, the commitment in the Five Year Forward View to improved digital technology is welcome, since NHS computing resources have lagged behind contemporary standards, both in availability and functionality. The upcoming Dalton Review will consider alternative forms for organising health care. Some ideas, proposed by the King's Fund, range from buddying hospitals to hospital franchises. Recognised factors to enhance the success of new organisations are teamwork, sharing best practice, patient focus, and local culture.
Understanding cultures in the NHS, patient populations, and local communities is indispensable to develop trust and achieve better outcomes. In this issue, David Napier and colleagues argue in the UCL-Lancet Commission on Culture and health that neglect of culture is the single biggest barrier to achieving the highest health outcomes. The Commission warns that focusing on what cannot be achieved because of cost is an obstacle to imagining what might be achieved through innovation. Cultural competence also needs to guide approaches to patients with unhealthy lifestyles, to avoid blaming those who are already disadvantaged.
The NHS enters this reorganisation from a position of strength. In June, 2014, The Commonwealth Fund rated health-care systems from Australia, New Zealand, and nine countries in Europe and North America on 80 performance indicators. The UK was rated top overall for 2011, and first for access, quality of care, coordination of care, safety, efficiency, and patient-centredness; all accomplished at the second lowest cost of US$3405 per person. The principal factor for the effectiveness of the NHS is her staff. Their creativity and professionalism must be respected and allowed to flourish in new models of care. In this respect, the intention to make the NHS a better employer and to improve education, development, and training is fundamental. Another positive influence is the integration of research findings to inform care, which will be especially important for evaluating innovations.
Unlike previous reorganisations of the NHS, the Five Year Forward View is proactive and offers an opportunity to build on existing excellence with clinical leadership. It should stimulate debate on the future of the NHS in preparation for the May, 2015, general election. Principled pragmatism to find innovative solutions that respect the philosophy of the NHS ought to be encouraged, provided that it is accompanied by transparent and independent accountability.
See also
The Lancet, Volume 384, Issue 9954, Pages 1551 - 1552, 1 November 2014
A future vision for the NHS: the case for change
Harpreet S Sood a, Mahiben Maruthappu a, Bruce Keogh b
