The Forward View for the NHS

Peter Bird
Peter Bird | 21 February 2017

Planning ahead – The Future Viewed Today

Healthcare and social services are increasingly pressed to do more with less. Mainly with less money; which translates into a reduction in number of hospital beds, reconfiguration of hospitals and multiple efficiency savings. In hospital terms it means smaller, more cost effective ‘estates’. Writing not only as author but also as a patient, smaller estates, fewer beds in hospitals and fewer doctors to staff them, may not be entirely good news; the subject for a future post perhaps? In the meantime, better stay healthy. So, in future patient-customer terms it means realising an expectation that a public educated to be healthier and able to benefit from ‘walk-in healthcare services’, delivered locally within communities, will put lower demands on hospitals.

Demand on hospitals is an issue. Over the last 15 years hospital admissions have increased by 50%. In the same period bed numbers have actually been going down and are down at this time by something like 25% with media reporting news that 15 thousand beds have gone in the last 6 years, as well as reductions in the number of days patients spend in hospital. The pressures on hospitals and specialist social care are real.

So healthcare is aware of the need to reduce demand and items in the news often promote the impact of better health on hospital admissions as a collateral benefit, if not the intended benefit. One recent item, for example, covered research which has established that adding vitamin D supplements to food could reduce healthcare demands on the NHS by reducing cases of bad colds and the flu among the public. Reported as good news of course, clutching at straws possibly, but, in any case, not in itself enough.

To close gaps, and achieve the savings that are necessary overall, health and social care will have to rely on better health within the population and changes in the way that services are provided to make them more efficient and cost effective. There is going to be movement of service delivery away from hospitals, that is decided, and the objective is to move healthcare into communities with an overall reduction in costs. Government is still being asked to back NHS plans with more support financially, at least in the short term, and councils are planning increases in local taxes. There are new items in the news, to this effect, daily.

Sustainability and Transformation Plans

Sustainability and Transformation Plans (STPs) are the formula that government hopes will deliver the longer and broader term objectives. Promoting transformation as the solution they originate as an idea contained in the NHS forward planning guidance for 2020 to 2021 (also known as the Five Year Forward View). Note this guidance, and the STPs, only apply in England.

Created largely by Clinical Care Groups (CCGs), led by clinicians and endorsed by their CCG CEOs, the STPs have the merit that they are sponsored locally and have the collaboration of local medical, clinical, and social care services, in fact care in the community of all kinds. Many of these plans now exist and they are available to review on CCG websites.

If effective they will transform healthcare and enable more locally delivered health and social care to meet the differing, specific needs of patients in their distinct, different communities. Each community defined as a ‘footprint’.

Footprints range from 300 thousand to 2.8 million in population and collectively they span 44 different geographic and social-demographic regions in England, covering 269 local areas. Key to their success: they must be resourced to meet patient needs and take demand away from hospitals. They must also make clear how local councils and social care authorities are going fill gaps in their budgets.

So, assuming the finances work out, STPs are intended to reduce costs in the NHS, though perhaps not overall costs to the local authority tax payer, by an amount that needs to be in the region of £22bn per year. Add to this an increase in funding of £8bn, promised by Government, and the total increase to the NHS will £30Bn per year.

It is not a key point in this post (another post may be?) but the fund for this is the STF (Sustainability and Transformation Fund).

The British Medical Association (BMA) say plans rely on ‘unknown efficiencies’; they may mean ‘uncertain efficiencies’. The CCGs in their STPs should identify the efficiencies, to answer the questions raised by the BMA, and on behalf of the public, patients, healthcare and social care professionals they are particularly attempting to do this in a clear and easily understandable way. Something we have learned from and will endeavour emulate.

For example, they make much use of numerical data, colour and diagrams like this waterfall chart, derived loosely from one of the STPs:

Waterfall Chart

Will STPs Deliver?

Are STPs credible? Having seen some of the STPs they do seem to be credible, but don’t take your CCG’s word for the sanctity of its plans, or plans for the footprint that covers you. There is uncertainty. The BMA remains sceptical, questioning the figures and the size of the gap in capital funding needs that the STF is, in part, required to cover. The STPs contain assumptions and may lack tested historical precedent or diligent sensitivity checks. The Royal College of Physicians (RCP) has also aired this concern and is encouraging healthcare professionals and the public to scrutinise the plans. The advice: find your local CCG website, download its STP and take a look.


While healthcare professional bodies don’t agree across the board, or at best share some reservations, the overarching STP strategy appears to be rational and cohesive. It has an agile, ‘tailored to deliver at the patients’ point of need’, feel about it; and it is always good to see the word ‘agile’ being used, in almost any context.

The new plans set out how local councils, the NHS and community partners, will provide services to support peoples’ physical and mental wellbeing needs, closer to home and in a straightforward and accessible way. Above all they are backed by clinicians and similar professionals and they make categorical commitments, hopefully.

But whether the results of implementing the STPs will turn out ‘agile’, and deliver all the intended benefits, will not be known for a while. In the meantime, that England is too big for a ‘one size fits all plan’ is accepted, and looking at the forward view today, the picture is one of a future when there will be stronger local health and social care services and more doors to open for access to them. But, just in case, let’s hope Government will do more than simply keep the lights on in a few of the very good hospitals that there are across the country.

For more information about STPs and particularly about terminology and abbreviations used in the NHS take a look at websites such as the NHS Website and the RCP Website.

The NHS advice: Stay Well This Winter.


Talk about topical. This relatively optimistic article may be overtaken by contrasting, much more troubled, reports in BBC News today; but at least the King’s fund shares some optimism. In an interview and blog post, Chris Ham, Chief Executive of The King’s Fund, appeared positively hopeful that better use of General Practitioners (GPs), District Nurses and other services would meet health and social care needs.