NHS 5-Year Forward View – the end of the NHS

There are two documents on this page. The first is a brief account; the second is more detailed. Both are chilling. There’s also a YouTube film of Anna Athow speaking on this.

1. A brief account:

Simon Stevens, chief executive of NHS England, October 2014

Click to access 5yfv-web.pdf

Simon Stevens was recruited from his former post of President of global health at UnitedHealth, one of the biggest US health corporations.

FYFV is written in code, to give the impression that it is in favour of sustaining the NHS according to its founding principles and merely wants to make it more financially sustainable.

Closer scrutiny reveals a five year plan to impose “new care models” (NCMs), inspired by the US health market. These would replace our current GP surgeries, District General Hospitals (DGHs) and tertiary care.

The plan depends on a gigantic shift of clinical services out of DGHs and into large new out-of-hospital providers fashioned after American health maintenance organisations, such as Kaiser Permanente. The remaining hospital care would be divided between dumbed down smaller hospitals and networks of large specialised providers, often using ‘prime contracting.’ The closure of fully backed A&E departments would accelerate.

FYFV alleges that these NCMs, as well as much more ‘self-care’ by patients, would drastically reduce demand for hospital care and ramp up “efficiency”, such that it would be possible to save up to £30bn a year by 2020.

The plan is predicated on an attack on the national terms and conditions of the NHS public sector workforce, the downgrading of its training, and drastic reduction in numbers employed.

The aim is to cut staffing costs by: increased productivity up to 2-3% a year, meaning more patients per nurse; reduced skill-mix; local pay; 24/7 working with unsocial hours paid at reduced rates; staff required to work “across organisational and sector boundaries” (that is to be outsourced), and have “flexibility to deliver new models of care, including the development of transitional roles” (meaning lower-qualified staff taking on doctors’ and nurses’ roles). There would be a huge increase in unpaid labour in the form of volunteers.

This plan is about destroying our NHS services and imposing NCMs, as attractive investments for multinational corporations, which are already circling like vultures to enter the healthcare market opened up by the Health and Social Care 2012. It must be resisted.

Defend our NHS publicly funded, publicly provided.
Defend our NHS structures: our general practice, DGHs, tertiary care, ambulance services etc.
Defend our NHS public sector workforce.
For more information on the abolition of our NHS including what you can do, see:
Keep Our NHS Public: http://www.keepournhspublic.com/index.php
Norfolk Keep Our NHS Public: https://keepournhspublicnorfolk.wordpress.com/
Prof. Allyson Pollock’s NHS Reinstatement Bill: http://www.nhsbill2015.org/
Five-year forward view 2nd ed


2. A more detailed account:

Simon Stevens, chief executive of NHS England, has produced his ‘Five Year Forward View’. Given his track record of championing private health-care, it is no surprise that he envisages the end of public provision:

Comment on the ‘ NHS five year forward view’ Part 1 13.12.14. Anna Athow

The Five Year Forward View produced on 23rd October 2014, is written very persuasively to suggest that by bringing in “ new care models” the NHS can survive despite massive funding shortfalls, to become a “ better NHS “.

It is the first official plan of Simon Stevens the chief executive of NHS England ( NHSE ), the architect of the NHS plan 2000 which introduced the major privatisation reforms to the NHSin England; PFI building programme, the purchaser provider split, payments by results, independent treatment centres and foundation trusts. (1 ) He was recruited from his recent post as director of Global Health for the US health corporation UnitedHealth. (2 ) The ‘ new care models’ are modelled on this insurance based American healthcare.

In fact the five year View outlines a plan to destroy every vestige of the NHS which still survives in England, because the logic of imposing the ‘new care models’ means that the current so-called “ out dated models” must be eliminated.

The View avoids describing the massive crisis enveloping every aspect of the service; A&Es full to bursting, general practice imploding due to a lack of 8000 GPs, bed shortages, mental health services desperately failing patients, ambulance times being breached etc. due to the £20bn QIPP cuts imposed over the last 5 years. The View applauds these £20bn cuts as a wonderful increase in efficiency. ( P 7 ) So, with this whitewash, we are forewarned that this is a dangerously misleading document.

Because of the deceptive way this report is written, the reader may not realise that the aim of the plan is privatisation of the provision of majority of clinical services over the next five years. Nowhere in the View are the words ‘privatisation’, ‘competition’ or ‘market’ mentioned. Code words like ‘ innovation” and “ partnership” and ‘prime contracting’ are used instead.

Apparent warm sentiments for the NHS in the ‘Forward’ disarm the reader. This praises the NHS as the “proudest achievement of our modern society” and states admiration for the values of “universal “healthcare” “regardless of ability to pay” P 3). It proclaims “ “ So to sustain a comprehensive high quality NHS, action will be needed on all three fronts – demand efficiency and funding. “ p 5. It says that nothing in its analysis “ suggests that continuing with a comprehensive tax-funded NHS is intrinsically un-doable.” P 5.

These claims are untrue. There is no market based healthcare system in the world that can provide universal, comprehensive healthcare to high standard, free at the point of use.

This pretence at support for the founding principles of the NHS, is completely undermined, once the practical proposals in the View are scrutinised.

The authors are very politically sensitive to the fact that the NHS will be a key issue at the next general election in May 2015. They therefore claim that the View seeks to avoid “ a further national reorganisation”.

But that is precisely what this is; a fast track demolition plan for the NHS as founded. The Telegraph called it a revolution without fanfare ( 3 ). In fact, it is a counterrevolution without fanfare.

The centrepiece of the strategy is to shift hospital care into the ‘community.’ This will be done through moving a lot of current hospital work into new “ out of hospital providers” which will subsume the GP surgeries. There will be a vast increase in ‘care in your own home’, to be largely delivered by carers, relatives and an army of volunteers. The new hospital network will be modelled on foreign private providers. The accessability of competent urgent and emergency care will be drastically reduced, as will specialist hospital care.

Just to underline the importance that the View places on the imposition of ‘the new care models’, it quotes an estimate that their adoption “ could avoid the need for another 17,000 hospital beds – equivalent to opening 34 extra 500-bedded hospitals over the next five years.” P 36. One might be forgiven for de-coding this statement to mean that the ‘new care models’ will enable the closure of another 34 district general hospitals ( DGHs ) in the next five years.

Cash A theme of the report is the demand for billions of extra pounds in funding. They need this money to pay for the ‘double running’, so that the investment to bring in the new care models can be found, at the same time as sufficient funds to keep the current structures hobbling on till they are destroyed.

We are told that if demand for NHS services continues to be fulfilled at current levels, then, by 2010, the NHS will have a shortfall of £30bn. ( P 5& P36)

It says, if only DEMAND is reduced – by suitable prevention measures and the adoption of the ‘new care models’- , and if only staff EFFICIENCY is pushed up to 2- 3% a year with the help of the ‘new care models’, then the NHS could manage with injections of cash, totalling £8bn in the next 5 years. By which time the NHS would be suitably transformed.

Some of this cash, will be derived from selling off NHS land and assets. P 27 Already Chancellor Osborne committed to £2bn of extra funding in April 2015, a quarter of which will contribute to the new out- of- hospital providers.

In plain man’s language, by 2020, the View plans that the reforms to the training and terms and conditions of staff would have been pushed through, and the new ‘care models’ commissioned, so that they could be put out to tender for international health corporations to snap up as “ productive investment” ( p36 ) ( i.e. as yielding a profit AA)

End of current NHS workforce. To this end a “ modern workforce” is to be created through a ‘Shape of Training Review’ for the medical profession and a ‘Shape of Care’ review for the nursing
profession, so that “we can future proof the NHS against the challenges to come.” P 30 “ The risk is” it claims “ that the NHS will lock itself into out dated models of delivery unless we radically alter the way in which we plan and train our workforce.”

The View demands a completely different workforce to “increase productivity and reduce the waste of skills and money”. It wants staff “to work across organisational and sector boundaries.” It wants staff with the “ flexibilities to deliver new models of care, including the development of transitional roles.”. P 30

The View also wants 24/7 working of staff and local pay. P 9& 23

“More generally… NHS employers and staff and their representatives will need to consider how working patterns and pay and terms and conditions can best evolve to fully reward high performance, support job and service redesign..etc” P 31

P 36 describes how these competing ‘ new care models’ will compete to drive up efficiency, with a race to the bottom which they call ‘ “ catch up” ( as less efficient providers matched the performance of the best )’ This is a recipe for reduced skill mix, with various non doctors in ‘ transitional roles” doing doctors work, and carers doing nurses work. It would allow the rapid shifting of staff out of the public sector to private companies with altered terms and conditions. This is an outsourcer’s dream. It is a declaration of war on all NHS national contracts and the NHS unions.

1. “ Stevens captures the zeitgeist with his forward view” 28.10.2014 HSJ http://www.hsj.co.uk/comment/leader/stevens-captures-the-zeitgeist-with-his- forward-view/5076241.article#.VI1iSyhAsrU

2. “ Simon Stevens swith to NHS ‘is like Arsenal signing Mesut Ozil’ http://www.theguardian.com/society/2013/oct/25/simon-stevens-nhs-chief- executive

3. “The health revolution is under way- but no fanfare, please” Telegraph 24.10.14. http://www.telegraph.co.uk/health/nhs/11182590/The-health-revolution-is-under-way-but- no-fanfare-please.html


Comment on ‘NHS five year forward View’ part 2
13.12.14. Anna Athow

The ‘new care models’ being pushed by the five year forward view of Simon Stevens are;
1. ‘Multispecialty Community Providers’ ( MCPs ) ( see below )

2. ‘Primary and Acute Care Systems’ ( PACs ) These combine general practice and hospital services similar to “ Accountable Care Organisations” found in the US.

3. ‘Urgent and emergency care networks’, which would include A&E, 24/7 GP
out -of -hours services, urgent care centres, 111 call centres and ambulance services.

4. “ viable smaller hospitals’
– becoming part of a hospital chain
– turning into a hospital as described in the Royal College of Physicians ( RCP ) ‘Future Hospital Commission’.
– being a vehicle of franchised care such as eye care or cancer care, by “ partnering with a specialised hospital”.
– being taken over by a MCP
– forming part of an accountable care organisation

5. Specialist care
Large centres are to concentrate cancer surgery and orthopaedic operations. The View favours networks of these services, using “ innovations such as prime contracting and/or delegated capitated budgets.”
An example of the former is the planned contracting out of the whole of Staffordshire’s cancer and end of life care for £1.2bn over 10 years. ( 1.2.)

6. Modern maternity services.
The View calls for “groups of midwives to set up their own NHS – funded midwifery services” and for more deliveries to take place at home.

7. enhanced care in care homes

And New Town “ “ green field’ sites as “ new test bed sites for world wide innovators”.

All of these ‘ new care models ‘ are designed for franchising out to the private sector, the greenfield site,s for foreign multinationals.

The MCP is an “enhanced primary care provider” ,“ integrating” primary care, with much hospital care – such as outpatient clinics, and diagnostics etc- with input from hospital consultants, social work, physiotherapy, podiatry and psychiatry.
The federation and networking of GP surgeries would lead to MCP formation, with GPs largely salaried and on a ‘new deal’. GPs may not lead these bodies and would work alongside nurses, social workers, therapists and others in “ transitional roles”.
We are told that “ care would be provided in fundamentally different ways” with fuller use of digital technologies and volunteers.
The ‘ mature’ MCP could eventually take over the running of its DGH.! The latter would not be staffed as DGHs are now, but by resident ‘ hospitalists”, who would supervise the care of patients out- of –hours.
Clearly, this acute hospital would no longer be a proper DGH with consultants in charge of in -patient care and juniors on- call supervised by them.

MCPs would in time be given “ delegated responsibility for managing the health services budget for registered patients. Where funding is pooled with local authorities, a combined health and social care budget could be delegated to MCPs” P 21

PACS vertically integrate hospital and primary care, by, for example a hospital opening GP surgeries with registered lists and providing social care and mental health care as well. These could have a ‘delegated capitated budget’ for the registered list of patients, as in accountable care organisations in the US, or Spain or Singapore. Their organisational forms could include “lead/ prime providers, or joint ventures.”
These forms involve the use of private companies.

Comment AA
What these two models mean is the end of the traditional independent contractor model of NHS GP surgeries, with GPs taking long term personal responsibility for their patients.
The View does not explain that these new bodies are modelled on Kaiser Permanente, an insurance based US Health Maintenance Organisation, ( HMO ), which commissions and provides primary and secondary care for a registered population of patients. The MCPs and PACs would be “ accountable care organisations” ( i.e. Health Management Units see ref 3. ) funded by the state initially. These would have “ delegated capitated budgets” for a population of GP registered patients. These accountable care organisations would be a transition to an insurance based HMO in the course of time.
(descriptions are given of these US accountable care organisations in refs 4&5. The View gives no references.AA )
The drive of all privately run ACOs and HMOs is cost containment and making a profit for the latter. This is done by minimising hospital referrals.
The View calls for Clinical Commissioning Groups ( CCGs ) in the future, not only to commission hospital care, but also to commission GP care and public health care. This would facilitate the fusion of CCGs with MCPs on the road to becoming HMOs.

One of the ‘viable smaller hospitals’ favoured by the View, is that described by the RCP’s Future Hospital Commission. ( 6 )
But the View does not tell you that this RCP described hospital is quite different from the DGH. Staff and services would be truncated. It would mainly deal with medical patients, not surgical patients and would only have a minor A&E. Patients with serious emergency conditions would have to be transported to a hospital with a major A&E.

The combination of this dumbed down type of hospital replacing the DGH, and the centralisation of elective cancer and orthopaedic work in large centres, would destroy the current emergency surgical cover currently provided by the DGH consultants for acute emergency admissions.

Urgent and Emergency care
The View’s innocuous sounding title of “ urgent and emergency care networks.” hides the fact that the View plans the running down of scores of A&E departments into minor units. At present 140 non specialist hospital trusts and teaching hospitals have type 1 A&E departments.

The View says there are “185 emergency departments in England and that more use should be made of the 379 urgent care centres, pharmacies and “ ambulance services should be empowered to make more decisions, treating patients and making referrals in a more flexible way.”

But the real intention of NHSE, is to proceed with Sir Bruce Keoghs 2013 plan for only 40 to 70 A&E departments to be major Type 1 departments with back up from the appropriate 7 specialist services ( acute medicine, imaging, intensive care/anaesthesia, laboratory services, paediatrics, orthopaedics and general surgery ) ( 7, 8, 9 ).

Thus the new care model for emergency and acute care relies on a jumble of urgent care centres, pharmacies etc, and a vastly reduced number of major A&E departments. So seriously ill patients would have to be transported from one hospital to another looking for a hospital with a major A&E. This is a recipe for deaths in transit as the ‘golden hour’ is exceeded.

The View is therefore centred on a trashing the real existing accessible and high standard emergency care arrangements, which the DGHs currently provide, in order to carve the latter up and throw the profitable elective bits to the private sector.

‘Co-design and Implementation of these new care models’ P 26
Despite the impression that the change process will be local and bottom- up, the plans for the new care models are to be ruthlessly imposed by the central commissioners, NHSE and its local area teams, using the draconian new powers granted them by the Health and Social Care Act 2012. Pages 26 to 30 are devoted to these coercive measures which are to implement “care model change rapidly and at scale”. The View says that the central commissioners will “ support” the CCGs to redesign services, using financial incentives and penalties and regulation such as ‘ special measures”, to ensure these changes happen.

The significance of this report
This report is absolutely the result of the passage of the H&SCAct in March 2012.
It is the reason why the Act was passed. It gives the new commissioners; the NHS national leadership, erstwhile NHS Commissioning Board ) , the new Monitor, the CQC, and the Trust Development Authority, the powers and the mandate to bring in the market and force through the “ reconfiguration “ of healthcare.

Few have such an accomplished track record of privatising the NHS as Simon Stevens in his role as Tony Blair’s health advisor and architect of the NHS plan 2000, and now he has 9 years experience in the American way.

The five year forward view consists of 39 pages of highly sophisticated propaganda, to sell to the public the notion that the NHS must be transformed into ‘new care models’ based on the American healthcare system.

This article has only touched on some points in the View, but if the reader understands that our DGHs and specialist services and our GP surgeries are being eliminated in order to open the way for private health corporations to run American model HMOs and hospital chains and prime providers, based on a massive denial of hospital care for patients, at the expense of staff, they will have got the gist of this Five Year Forward View.
The deceptive language shows how frightened the establishment is, to tell the public the truth about what they are doing. The health unions should be opposing every aspect of it with all their strength, assisted by the entire trade union movement.
1. “ Richard Branson bids NHS privatization deal worth £1.2bn” D Mail 6.11.14.
2. NHS cancer care could switch to private contracts in £700m plans” Guardian 2.7.14.

3 Adam Smith Institute The health of Nations 1988
Chapter 6 pages 29 – 35. “ Restructuring the NHS itself”

Click to access The%20Health%20Of%20Nations.pdf

Description of accountable care organisations and prime contracting are given in the following two documents.
4. Addicott R, Ham C 920140 “ Commissioning and funding general practice: making the case for family care networks. London: the Kings Fund. March 2014 Chapter four
5. Sir John Oldham, Chairman, Independent Commission on Whole Person Care Pages 24 – 28
“ One Person One Team One System” February 2014
6. “ Future hospital: Care for medical patients” a report from the Future Hospital Commission to the Royal College of Physicians September 2013.

7. “ Keogh reveals the plan to re designate emergency services” Guardian 13.11.14

8. “ A&E overhaul shelved after warning over political backlash” 30.11.14. Guardian
see last section- Prof Willetts confirmation that the run down to only 40 -70 major A&Es is the plan

9. “ The drive for quality. How to achieve safe, sustainable care in our Emergency Departments”? System benchmarks and recommendations. The College of Emergency Medicine. Full report May 2013