Comment
Throughout its history, the British National Health Service (NHS) has faced and survived change. It has done well in the past 15 years—public satisfaction has doubled, waiting times have fallen, and health-care associated infections have decreased.1 In recent years, however, conditions in the UK have changed with an ageing population, increased burden of chronic diseases, and rising expectations of patients. No health service in the world has managed 5 years of little or no growth without either increasing funding or cutting staff or services.1 The NHS has been an exception. Moving forward, however, the NHS will require investment, demand for services to be curbed, and a shift in care delivery to maintain and improve the quality of services provided. There is broad consensus that change is needed and what these new models should look like. The NHS Five Year Forward View,1 published on Oct 23, 2014, outlines the ambitions and vision to achieve these necessary changes. The imminent priority is to ensure that the NHS continues to provide high-quality, safe care while setting a path towards sustainability. The NHS has the infrastructure, resources, and capacity to do this. It was recently ranked as the highest performing health system with the second lowest per capita spending in a comparison of 11 industrialised countries’ health-care systems.2 Additionally, the UK has a leading pharmaceutical and biotechnology sector, world-class research centres and universities, and is a global role model in quality improvement. But along the way the NHS needs to evolve. In partnership with health-care colleagues, it is important to capitalise on the opportunities offered by new technologies and treatments and to stimulate the creation of new models of care. One size does not fit all. As highlighted in NHS Five Year Forward View, there is a need to identify health communities with similar demographics and disease burdens and empower them to provide care that is locally driven for local needs. Traditional barriers will need to be removed between health and social care, mental and physical health, and primary, secondary, and community care to ensure care is integrated around the patient. The NHS, for example, needs to provide 7-day services and multispecialty practices where primary care and hospital care teams www.thelancet.com Vol 384 November 1, 2014
work together from the same location to ensure the highest quality care is always available. These new care models will bring flexibility for the workforce and will be more convenient for the patient, while maintaining the principles and values of the NHS. The power of data and technology needs to be harnessed to complement care delivery models. Greater transparency saves lives and improves the safety of health services.3 Giving patients access to their electronic medical records will improve information flow across multiple providers—from primary to secondary to social care—and enhance the coordination and convenience of care, patient experience, and clinical outcomes. In addition, data on the performance of health professionals will be published to help health professionals see how they are doing compared with their peers, and allow patients to make more informed choices. The NHS will become one of the leading places in the world to test innovations. This future role will require staff, technology, and funding to be aligned in a health system, with universal coverage, that serves large, diverse populations. Technology will be used to support an increase in observational studies and to develop quicker, lower cost randomised controlled trials embedded in routine primary and clinical care. The NHS needs to invest more in its workforce and empower citizens, patients, and communities; without their support, these ambitions will be difficult to achieve. The workforce of the NHS accounts for a large proportion of the NHS budget, and is an important driver for change. As outlined in NHS Five Year Forward View, gaps in skills and talent will be addressed and employers will be encouraged to retain and train their existing staff, including supporting clinicians and managers to deliver the care. Patients and citizens will also need to play a greater part in the health system; they can start by taking prevention seriously. The growing burden of preventable diseases associated with unhealthy lifestyles, such as obesity and diabetes, will substantially increase future health-care costs. As a tax-funded NHS, and not a social insurance system, there is the advantage that employers do not pay directly for their employees’ health care. However, employees need
Oli Scarff/Staff
A future vision for the NHS: the case for change
See Editorial page 1549
1551
Comment
to be supported in workplaces to adopt healthier lifestyles; there is merit in employers providing effective workplace health programmes. Local government should also be given enhanced powers to make local democratic decisions on public health policies related to alcohol, junk food, tobacco, and other issues that affect physical and mental health. With this vision, the NHS will remain a universal health-care system providing free care at the point of use. It will require a collective effort by the public, the NHS workforce, and the UK Government to move the NHS forward so that we can create an NHS that is fully fit for the 21st century.
*Harpreet S Sood, Mahiben Maruthappu, Bruce Keogh Chief Executive’s Office (HSS, MM) and Office of National Medical Director (BK), NHS England, London SE1 6LH , UK [email protected] We all contributed to NHS Five Year Forward View. 1
2
3
NHS England, Care Quality Commission, Public Health England, Monitor, NHS Trust Development Authority, Health Education England. NHS five year forward view. London: NHS England, 2014. http://www.england.nhs. uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed Oct 24, 2014). Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall: how the performance of the US health care system compares internationally, 2014 update. New York: The Commonwealth Fund, 2014. National Advisory Group on the Safety of Patients in England. A promise to learn—a commitment to act: improving the safety of patients in England. London: Department of Health, 2013.
The RCP’s five-point plan for the next UK Government See Editorial page 1549
In September, 2014, the Royal College of Physicians (RCP) launched its five-point plan for the next UK Government (panel).1 With the 2015 UK general election approaching, the RCP’s plan calls on government and politicians to stop reorganising the National Health Service (NHS) from the top down, to increase NHS funding to avoid a crisis in care, and to commit to an NHS free at the point of delivery. If the NHS were a patient, we would be failing to treat it holistically—primary, secondary, and community care are separately commissioned and administered, as are medical education, public health, and medical research. Like many of our patients, the NHS is hampered by the disconnect between these crucial components of good health. Financial and organisational barriers to cooperation need to be removed to integrate all of these elements to provide better care. The next UK Government should commit to a long-term vision that gives patients joined-up care. Specifically, it should be easier for hospitals, general practitioners, and social care teams to work together, Panel: RCP’s five-point action plan 1 Remove the financial and structural barriers to joined-up care for patients 2 Invest now to deliver good care in the future 3 Prioritise what works in the NHS and improve what doesn’t 4 Promote public health through evidence-based legislation 5 Adopt the Future Hospital model as a template for service redesign
1552
and there should be a review of the barriers that prevent integrated care, including the role of largescale tendering of health services in England. In future, financial incentives must help, not hinder, patient care. Fines that target one part of the health system, such as penalties when patients are readmitted to hospital, should be removed, and the commissioning focus should value quality above all other commissioning imperatives. The RCP’s Future Hospital Programme,2 which takes forward the work of the Future Hospital Commission,3 provides an excellent model for hospital service redesign. The Future Hospital Programme has now begun its operational phase with development site partners in NHS Trusts in England and Wales. Our partners’ projects, which include projects on integrated care for frail older patients and on standardised pathways and streamlined care to achieve safe, efficient clinical management for all patients, embody the Future Hospital principles that seek to remove barriers to accessing the early expert care that improves patient outcomes and enables specialist medical care to reach from wards into the community.4 The next UK Government might want to stamp its own identity on prospective changes in the NHS, but we would caution that such an approach could be counterproductive. In 2013, the independent Future Hospital Commission’s report5 was published and accepted by key medical organisations, patient bodies and representatives, regulatory bodies, and health www.thelancet.com Vol 384 November 1, 2014
Throughout its history, the British National Health Service (NHS) has faced and survived change. It has done well in the past 15 years—public satisfaction has doubled, waiting times have fallen, and health-care associated infections have decreased.1 In recent years, however, conditions in the UK have changed with an ageing population, increased burden of chronic diseases, and rising expectations of patients. No health service in the world has managed 5 years of little or no growth without either increasing funding or cutting staff or services.1 The NHS has been an exception. Moving forward, however, the NHS will require investment, demand for services to be curbed, and a shift in care delivery to maintain and improve the quality of services provided. There is broad consensus that change is needed and what these new models should look like. The NHS Five Year Forward View,1 published on Oct 23, 2014, outlines the ambitions and vision to achieve these necessary changes. The imminent priority is to ensure that the NHS continues to provide high-quality, safe care while setting a path towards sustainability. The NHS has the infrastructure, resources, and capacity to do this. It was recently ranked as the highest performing health system with the second lowest per capita spending in a comparison of 11 industrialised countries’ health-care systems.2 Additionally, the UK has a leading pharmaceutical and biotechnology sector, world-class research centres and universities, and is a global role model in quality improvement. But along the way the NHS needs to evolve. In partnership with health-care colleagues, it is important to capitalise on the opportunities offered by new technologies and treatments and to stimulate the creation of new models of care. One size does not fit all. As highlighted in NHS Five Year Forward View, there is a need to identify health communities with similar demographics and disease burdens and empower them to provide care that is locally driven for local needs. Traditional barriers will need to be removed between health and social care, mental and physical health, and primary, secondary, and community care to ensure care is integrated around the patient. The NHS, for example, needs to provide 7-day services and multispecialty practices where primary care and hospital care teams www.thelancet.com Vol 384 November 1, 2014
work together from the same location to ensure the highest quality care is always available. These new care models will bring flexibility for the workforce and will be more convenient for the patient, while maintaining the principles and values of the NHS. The power of data and technology needs to be harnessed to complement care delivery models. Greater transparency saves lives and improves the safety of health services.3 Giving patients access to their electronic medical records will improve information flow across multiple providers—from primary to secondary to social care—and enhance the coordination and convenience of care, patient experience, and clinical outcomes. In addition, data on the performance of health professionals will be published to help health professionals see how they are doing compared with their peers, and allow patients to make more informed choices. The NHS will become one of the leading places in the world to test innovations. This future role will require staff, technology, and funding to be aligned in a health system, with universal coverage, that serves large, diverse populations. Technology will be used to support an increase in observational studies and to develop quicker, lower cost randomised controlled trials embedded in routine primary and clinical care. The NHS needs to invest more in its workforce and empower citizens, patients, and communities; without their support, these ambitions will be difficult to achieve. The workforce of the NHS accounts for a large proportion of the NHS budget, and is an important driver for change. As outlined in NHS Five Year Forward View, gaps in skills and talent will be addressed and employers will be encouraged to retain and train their existing staff, including supporting clinicians and managers to deliver the care. Patients and citizens will also need to play a greater part in the health system; they can start by taking prevention seriously. The growing burden of preventable diseases associated with unhealthy lifestyles, such as obesity and diabetes, will substantially increase future health-care costs. As a tax-funded NHS, and not a social insurance system, there is the advantage that employers do not pay directly for their employees’ health care. However, employees need
Oli Scarff/Staff
A future vision for the NHS: the case for change
See Editorial page 1549
1551
Comment
to be supported in workplaces to adopt healthier lifestyles; there is merit in employers providing effective workplace health programmes. Local government should also be given enhanced powers to make local democratic decisions on public health policies related to alcohol, junk food, tobacco, and other issues that affect physical and mental health. With this vision, the NHS will remain a universal health-care system providing free care at the point of use. It will require a collective effort by the public, the NHS workforce, and the UK Government to move the NHS forward so that we can create an NHS that is fully fit for the 21st century.
*Harpreet S Sood, Mahiben Maruthappu, Bruce Keogh Chief Executive’s Office (HSS, MM) and Office of National Medical Director (BK), NHS England, London SE1 6LH , UK [email protected] We all contributed to NHS Five Year Forward View. 1
2
3
NHS England, Care Quality Commission, Public Health England, Monitor, NHS Trust Development Authority, Health Education England. NHS five year forward view. London: NHS England, 2014. http://www.england.nhs. uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed Oct 24, 2014). Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall: how the performance of the US health care system compares internationally, 2014 update. New York: The Commonwealth Fund, 2014. National Advisory Group on the Safety of Patients in England. A promise to learn—a commitment to act: improving the safety of patients in England. London: Department of Health, 2013.
The RCP’s five-point plan for the next UK Government See Editorial page 1549
In September, 2014, the Royal College of Physicians (RCP) launched its five-point plan for the next UK Government (panel).1 With the 2015 UK general election approaching, the RCP’s plan calls on government and politicians to stop reorganising the National Health Service (NHS) from the top down, to increase NHS funding to avoid a crisis in care, and to commit to an NHS free at the point of delivery. If the NHS were a patient, we would be failing to treat it holistically—primary, secondary, and community care are separately commissioned and administered, as are medical education, public health, and medical research. Like many of our patients, the NHS is hampered by the disconnect between these crucial components of good health. Financial and organisational barriers to cooperation need to be removed to integrate all of these elements to provide better care. The next UK Government should commit to a long-term vision that gives patients joined-up care. Specifically, it should be easier for hospitals, general practitioners, and social care teams to work together, Panel: RCP’s five-point action plan 1 Remove the financial and structural barriers to joined-up care for patients 2 Invest now to deliver good care in the future 3 Prioritise what works in the NHS and improve what doesn’t 4 Promote public health through evidence-based legislation 5 Adopt the Future Hospital model as a template for service redesign
1552
and there should be a review of the barriers that prevent integrated care, including the role of largescale tendering of health services in England. In future, financial incentives must help, not hinder, patient care. Fines that target one part of the health system, such as penalties when patients are readmitted to hospital, should be removed, and the commissioning focus should value quality above all other commissioning imperatives. The RCP’s Future Hospital Programme,2 which takes forward the work of the Future Hospital Commission,3 provides an excellent model for hospital service redesign. The Future Hospital Programme has now begun its operational phase with development site partners in NHS Trusts in England and Wales. Our partners’ projects, which include projects on integrated care for frail older patients and on standardised pathways and streamlined care to achieve safe, efficient clinical management for all patients, embody the Future Hospital principles that seek to remove barriers to accessing the early expert care that improves patient outcomes and enables specialist medical care to reach from wards into the community.4 The next UK Government might want to stamp its own identity on prospective changes in the NHS, but we would caution that such an approach could be counterproductive. In 2013, the independent Future Hospital Commission’s report5 was published and accepted by key medical organisations, patient bodies and representatives, regulatory bodies, and health www.thelancet.com Vol 384 November 1, 2014
