Next steps on the NHS five year forward viewBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1678 (Published 04 April 2017) Cite this as: BMJ 2017;357:j1678
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The NHS Five Year Forward View (1) when published in 2014 had a major flaw, and this has yet to be noted in Ham`s Editorial as he looks at the next steps in 2017 (2).
A plan - for this is what was presented in 2014 - has, of necessity, to recognise current and near-future constraints, by making guesses about political sentiment, economic capability and sustainability. But setting off on a journey without having a pretty clear idea of the destination, a strategic view, is foolhardy. Once identified, a strategy can be folded back to the present.
The major flaw currently is the failure to identify the dominant independent variable that has - and will continue to have - the greatest impact on the efficient delivery of healthcare. This is `technological innovation`. The history of the NHS is littered with examples where the service has had to do catch-up with technology - reconfiguring its workforce, changing the way care is delivered, and redeploying capital budgets to new locations or for the development of new facilities - often years behind the curve.
Some examples include:
• A failure to anticipate the potential impact of the arrival of phenothiazines in the 1950s on the ability to discharge patients from psychiatric hospitals; and the appalling lack of community mental health services necessary to provide support for vulnerable ex-patients.
• Being unprepared to take advantage of powerful combinational developments in fibre optics and endoscopy, digital imaging and new anaesthetics that reduced nausea, resulting in delays in implementing minimal access and day case surgery.
• Failing to develop the use of telecare, and maximising the shift of available technologies to the home for those who might benefit directly by not being admitted to hospital, or allowing earlier discharge; and developing an adequate district nurse workforce to provide support.
`Substitution research` is a dynamic approach which can be used to challenge current conventional planning methods, which tend to start with a careful analysis of the existing position and so risk limiting the freedom to think creatively. This is evident in `Next steps` It is also very useful when used strategically. `Substitution` is defined as the continual regrouping of resources across and within care settings, to exploit the best and least costly solutions in the face of changing needs and demands (3). Of course this has been happening already, albeit without the title, but reactively for the most part.
One useful typology differentiates three kinds of substitution: the introduction of new technologies; moving the location at which care is given; and changing the mix of staff and skill requirements (4). It is the first of these, as the most frequent long-term independent variable, that requires constant scanning outside of the NHS itself. But with identification of technology innovations goes the consequent need to look at the implications for care location, and workforce training and planning. This is a foresight exercise of the greatest importance, and was identified as such by Sir Michael Peckham, Director of R&D for NHS England in 2000 (5) following the publication of Project SHIFT (6).
Perhaps we might start now with a recent headline in the Times: Sound-wave blood test gives results in minutes (7). It is a few years away, no doubt, but needs to be built into strategic thinking now.
Ham states that Simon Stevens, author of the Forward View and chief executive of NHS England, has `focused minds by emphasising the inevitably of hard choices in healthcare` . But this has always been the case, and has served as the bedrock of a muddling through approach. The public and demoralised healthcare professionals now urgently to be shown some light at the end of what has been a very long tunnel. This could be achieved if a systematic approach to substitution was to be employed, with future technologies given the lead role. A horizon-scanning version of NICE perhaps? Whatever, the NHS needs an evidence based Strategic Direction to give a sense of hope.
1. Five year Forward View. NHS England, Oct 2014.
2. Ham C. Next steps on the NHS Five Year Forward View. Editorial, BMJ 8 April 2017.
3. The expression was first applied to healthcare in the Dekker Report, Changing health care in the Netherlands. The Hague, Ministry of Welfare, Health and Cultural Affairs, 1988.
4. A model of the typology and a more detailed discussion of `substitution` is Warner, MM. Contribution to Saltman RB and Figueras J. European Health Care Reform: Analysis of Current Strategies. WHO Regional Office for Europe 1997, 214-217.
5. Foresight Healthcare Panel, Healthcare 2020 - Making the future Work for You. London: the Department of Trade and Industry 2000. Available at http://www.foresight.gov.uk
6. Warner MM. et al, Can Home be Possible for the Frail Elderly? Substitution of Hospital and other Institutional-focused Technologies (Project SHIFT). Welsh Institute for Health and Social Care, January 2003.
7. The Sunday Times 09 April 2017.
Competing interests: No competing interests