The Five Year Forward View (FYFV) hardly caused a ripple in the health pond when published last autumn. It was welcomed by most, including all the main political parties as Simon Stevens, its author, encouraged the impression that it is all about keeping the NHS wedded to its founding principles, merely wanting to make it more financially sustainable.
When Andrew Lansley sold us the Health and Social Care Bill by promising to put GPs in charge, many believed the spin.
I worry we are being duped again. As a retired GP of 30 years I know that feeling when a large document lands on the desk. To preserve our sanity it’s unlikely to be read, let alone scrutinized as is really necessary.
The FYFV is cleverly written by management consultants and needs a forensic translation. I fear it is a Trojan horse. My concern is that the new models of care proposed are inspired by the US health market. Remember that Stevens, head of NHS England, previously worked for UnitedHealth, a large US health corporation.
The new models of care will be out-of-hospital providers (like the American Health Maintenance Organisations) which would replace GP surgeries, district general hospital (DGHs), community and ambulance services, maternity and full A&E, which Stevens describes as ‘outdated models of care’.
Its success depends on a gigantic shift of clinical services out of DGHs and into these out of hospital providers. The remaining hospital care will be divided between smaller hospitals and networks of large specialized providers (explaining one reason for ‘reconfiguration’). This allows a further bed reduction of 17,000, the equivalent of 34 DGHs. We already have one of the lowest bed/population ratios in Europe at 2.8/1000. In Germany it is 8.3.
The closure of A&E departments would accelerate in line with the plans of the medical director of NHS England, Sir Bruce Keogh, to reduce the 140 major consultant-led A&E units down to 40-70.
The FYFV also requires the removal of the GP ‘block’ and the reduction of staff costs. A different workforce from that presently used in the public sector is necessary and can only be achieved by ending the national negotiations for wages for NHS staff. If this happens, then number will be drastically reduced.
De-professionalisation will lead further to reduced standards and worse staff ratios but we will have more volunteers from our ‘Big Society’.
Staff will be required to work ‘across organizational and sector boundaries’ (ie outsourced, and transferred to private companies) and have ‘flexibility to deliver new models of care, including the development of transitional roles’ (ie meaning lower qualified staff taking on doctors and nurses roles such as at NHS111). Hence the Shape of Training review for the medical profession and the Shape of Caring review for the nurses.
The introduction of multi-specialty community providers signals the end of the traditional NHS GP as they mutate into HMOs like Kaiser Permanente which commissions and provides care for a registered population. This is why Federating is being encouraged. GPs will be employed.
The second new model of care, the primary and acute care system, will probably be established by the injections of cash and from NHS land transfer to PropCo
All the NCMs are perfectly suited for franchising out to the private sector and to be attractive to multinationals: TTIP (the Transatlantic Trade and Investment Partnership) will make this irreversible.
The test-bed for the NCMs is to be the Greater Manchester (‘Devo-Manc’) proposals: the ‘trailblazer for the objectives set out in the FYFV’ according to NHS England.
Watching political change after change has become part of life for GPs. We are battle-weary and struggle to keep our heads above water with the day-job. But we’ve never experienced anything brings together all the pieces in the marketisation of the NHS, for which competition and the Health and Social Care Act set the agenda.
The working lives of GPs will be very different in a few years’ time.
Dr Paul Hobday is a retired GP from Kent and is standing for the NHA in Maidstone and the Weald.