The headlines are all about the money. The NHS England boss Simon Stevens’ progress report, published on Friday at roughly the halfway point of his strategy document, the Five Year Forward View, consists of 75 pages studded with cuts in a bid to show that his organisation is not the basket case that the prime minister, Theresa May, is said to believe it is.
Hospitals throughout England are to be asked to free up 2,000 to 3,000 beds to improve the flow of patients needing urgent or emergency care. It will be done by abandoning waiting time targets for the kind of procedures, like new hips and knees, that fill the elective surgery lists. The clinical evidence in favour of some surgical interventions is to be carefully re-examined: that may mean not offering some operations at all. GPs are being asked to stop prescribing common medication that can be bought over the counter. Here is the evidence that the NHS, in an era of unprecedented financial pressure, is trying to manage on a budget that, although it has been broadly protected so far, is in fact unsustainable. Two-thirds of NHS trusts and foundation trusts were in deficit last year; by the end of this parliament, spending as a share of GDP – at 8.5%, already below the average of the 15 richest countries in Europe – is expected to fall further behind.
But after an unedifying exchange at the start of this year between Mr Stevens and Mrs May about the increase in NHS spending over at parliament (she said £10bn, he said £8bn – he is right), the NHS England boss wants to send a quite different message to government. The “Next Steps” document acknowledges the financial pressures, but describes a system in transformation that is broadly succeeding in delivering more for less in every priority area from cancer to mental health. It highlights progress towards restructuring health provision by area, integrating health and social care, and tackling bottlenecks in hospital discharges through bottom-up, locally led coordination in so-called sustainability and transformation plans (STPs). Making this work, so that demand for costly hospital care is reduced, was central to the original vision of the forward view.
Since this is the NHS, reform is never easy. Supporters of change, like NHS workers in Dorset, say their incentive is better patient care. Critics say it’s just about saving money. The recent budget included £325m to help the first nine STPs get off the ground and the autumn budget is expected to bring more of the same; not enough to stop the closure of much-loved, politically sensitive maternity units and cottage hospitals. The process of change is already slow and tentative. Protest slows it further, and reduces popular support for it. And, as the Nuffield health thinktank argues, the recruitment crisis for both GPs and district nurses is adding to the difficulties of keeping vulnerable people out of hospital.
The second challenge is a huge own goal made by the Conservatives: the Lansley reforms brought in by the 2012 Health and Social Care Act, which imposed mandatory open competition for all new contracts for services. Mr Stevens sees the sustainability and transformation plans as a way of getting round the fragmented and often failing structures that are now obstacles in the path of joining up different services. But there’s talk of legal challenge from private sector providers, such as VirginCare. The logical course of action is to repeal the act. Mrs May, as a new prime minister, could get away with it. If the STPs deliver the improvements that their advocates believe they will, then a new parliament could declare the act – and many of the reforms of the past 30 years, stretching back to Ken Clarke’s introduction of the internal market – a blind alley. Meanwhile, Mr Stevens can only hope he has persuaded Mrs May and Mr Hammond that NHS England is not a bottomless pit for precious taxpayers’ money, but a flexible, efficient organisation that is worth the big cash injection it desperately needs.