Implementing the NHS five year forward view: let’s not forget engaging patients and communities

My colleagues Chris Ham and Richard Murray have today published a clear and important report setting out the main policy priorities needed to implement the NHS five year forward view. It focuses on areas where a fundamental redesign of policy is required – from commissioning and payment systems to regulation and leadership and improvement support.

In many recent conversations with other researchers and with leaders in the system, I’ve been struck by how often ‘implementing the Forward View’ is essentially synonymous with ‘establishing multispecialty community providers and primary and acute care systems’, with the occasional mention of some of the other care models listed in chapter three. It’s entirely understandable. Organisations define how services are funded, organised and delivered. And for many of us, organisations define what we do if not who we feel we are. When faced with the immense challenge of refocusing the mammoth NHS into a service fit for our needs in the 21st century, the neat leap to a suite of structural solutions and priorities is too tempting to ignore.

But I’m worried that this risks leaving behind what, for me, is the more radical and more fundamental chapter of the Forward View – chapter two, on engaging patients and communities.

This chapter eloquently makes the case for the importance of radical change to the relationship the NHS has with the patients and communities it serves, and points to some important national initiatives in support of this, such as NHS Citizen and integrated personal commissioning. But it doesn’t offer the same jump to an appealingly neat set of answers.

You could argue this is a good and sensible decision. But to me it misses an opportunity to make the case to local leaders that there is no shortage of interventions and approaches to choose from.

Indeed, in a competition for the best acronyms, a differently written chapter two could have easily given chapter three’s multispecialty community providers (MCPs) and primary and acute care systems (PACs) a run for their money. To name but a handful, it could have recommended a focus on:

Looking at individual engagement, at the end of last year we published a report in association with National Voices that set out the eight key ways in which the health and care system needs to be working to give individuals greater control of their own health and care. And looking at community engagement, just recently this excellent summary from Jane South and colleagues of community-centred interventions to improve health and wellbeing has been published.

I’d be the first to say that putting people and communities genuinely in control of their health and care requires fundamental cultural changes and a shift in power that goes much deeper than a set of models or interventions.

But as local areas make their choices between multispecialty community providers, primary and acute care systems and variants thereof, we must make sure that we are also embedding and extending evidence-based approaches to individual and community engagement into these new models of care.

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#542897 Stephen Kearney
Action to Regenerate Community Trust

Strategic and potential transformational engagement in communities is rarely successful because there is no methodology that first builds trust, respect and relationships with people.
If you are interested in a method that works please take a look at and
In partnership with Brighton University we can move mountains with the resource.
The question is: are the agencies ready to engage so that power can intelligently shift to make the NHS a people's organisation again. And what if marketisation and the impact of the economies of scale on local people that want to help run services?

#542898 Stephen Kearney

Sorry. Eyesight failing. Should read
Intelligently shift power and of not if.

#542900 Mark Duman
Patient Information Forum (PiF)

Thanks for flying the flag!
In an supposed outcomes based system we still seem fixated by form not function. Patients want quality care that's less fragmented and don't care for more acronyms nor the health and social care divide. Only yesterday did I note that the NHS England Innovator programme consists of mainly senior docs. That's great but where are other health & social care workers and or course users. The talk has never been louder, the walk is sadly a limp at best. Here's to The King's Fund setting an example as we did there in the late '90s by ensuring every event and publication they issue can boast the 'Patients Included' logo. Yours tiredly, MD

#542901 Hilda Yarker
Head of Patients & Information

It is interesting to me that Catherine felt the need to write the article above, when one would believe that empowering patients and engaging communities seems so intrinsic to the 5YFV that it is almost a given this change is already happening across communities and the commissioning landscape. The reality is so far from the truth, old practices are so embedded and ingrained within NHS culture that it is going to take far more than the 5YFV and the voice of a growing number of advocates to bring about the changes needed. I suggest that there are at least areas of investment needed to effect change, the first is a focus on leadership (I know I am not the first and only person to recognise this, so I take no credit for regurgitating the opinion of many). The second for me is a different and growing conversation with patients and communities, the NHS has created a dependent culture (I'm sure with the best of intent), the vast majority of patients and carers I engage with would admit that they are passive recipients of health and social care. Many have articulated to me that they would not know where to start in beginning a conversation with their clinician, never mind being confident enough to engage in the creation of care plans or personal health budgets, or shared decision making.

This isn't just investment in monetary terms, this is an investment of time and energy with support needed from many partners including the third sector and housing federations, both of whom play a vital role.

My experience of working across the north of England as a lead for the wider personalisation agenda and Improved patient experience has taught me that national policy and rehetoric has a long journey yet to travel in activating local commissioners to make radical and difficult decisions in turning the tide. I read a quite recently and apologise in advance for not remembering the author, but I quote 'professionals need to get down from their pedestals and patients need to get up from their needs'. I acknowledge that this does not apply to all as there are some fantastic examples of change emerging, we just need to harness and spread these examples and keep the conversation going ... LOUD & CLEAR.

#542906 Lucia Dedear
Former Carer ( unpaid)

Catherine I am disappointed that you have not mentioned the NHS Five Year Forward Review does NOT have a separate chapter about how unpaid Carers will be identified and supported. Yet, in the review some lip-service is paid to Carers and there is mention of how Carers are valued and important....but their is no outline of how Carers will be identified and supported by NHS starting with Primary Care...GPs. What will The King's Fund do about this ommission considering the current 6.5 million Carers in the UK are saving the public £119bn?

#542907 Terry
Member of the public

After years and years of talks, meetings, conferences and the like producing endless often duplicated recommendations, the Agencies must be very happy that they have been able to get away with these delaying tactics for so long without real action. Perhaps the reality is that they are not capable of ensuring a seamless transaction or ensuring any form of noticeable and progressive change.
What a very sad reflection all this has on our leaders and senior managers. When will someone have what it takes to grab the problem by the scruff of the neck and do the job they are paid to do for us and do it well?
If our 'system' is the envy of the world, God help the others, albeit there are some pockets of great expertise and dedication.
Gone should be the days of group hugs and persuasion, lets really give the public what is required, what we pay them to do and indeed to show that they really do care.

#542908 Ailsa Bosworth
National Rheumatoid Arthritis Society

I totally agree with Hilda Yarker's comments. There has got to be a major shift in the way in which HCPs engage with patients and vice versa. The amount of wheel reinventing going on out there on care plans for example is astonishing and yet it is not a care plan per se that most patients want it is the process of care planning to happen which involves a different kind of conversation with your health professional which takes more time, but enables patients to make genuinely 'shared decisions'. Just giving someone a piece of paper with Care Plan written on the top, does not tick the box. In changing hearts and minds of HCPs (and commissioners) to engage with patients differently and the hearts and minds of patients to work to understand their health problems better and take greater responsibility for their own health, we have a very long way to go.

#542932 Esmat BHIMANI

To Hilda Yarker,
You could not be more spot on. I fully agree that NHS has created a dependency in the public. I can write a book on it from my day to day hands on experience with patients. Something as simple as, when seeing any medical case in grey area, when and if I ask the patient what " would you like" from options x, y, z? The reply I get is" you are the doctor"

In all the reformations, the most important and fundamental step of self responsibility, self care and patient engagement is missing. Our patients do not even know their medications, I am talking of the simplest ones. When I ask, " so what did the specialist tell you"? The reply I get is,"oh, I do not know"?

#542933 Terry
Member of the public

An answer to Mr Esmat Bhimani (above) may well be that very often patients are frightened, anxious and worried because they are or may be ill and under time constraints.
I am not surprised that young and old alike forget what has been said to them and their medications forgotten for this very good reason. Some specialists/doctors tell them little - they are often found head in a computer screen writing up notes rather than communicating.
There will always be the exceptions of course.
When the roles are reversed and the doctor becomes the patient there is often a little more understanding.

#542934 Pearl Baker
Independnet Mental Health Advocate and Advisor

Words fail me, what is the problem! there is no co-ordination, or understanding regarding what 'integration actually means. I am currently advocating for a very elderly lady, my request for a 'Safeguarding' Assessment was completely ignored, until I wrote to the Head of Legal I wonder why!

'duty of care legal definition of duty of care'
a requirement that a person act toward others and the public with watchfulness, attention, caution and prudence that a reasonable person in the circumstances would if a person's actions do not meet this standard of care then the acts are considered negligent and any damages resulting may be claimed in a lawsuit for negligence'.

The Guardian article of the 18th February 2015 should be read, and then understand why the paragraph above was included in my response.

#542937 Janette Edwards
Associate director
XEED north west

So true that patients need to be at the core of their experiences in the nhs. Self management and empowerment is the way forward .HCPs need to listen to what individuals need not presume

#542939 Kathy
Patient with LTC
Member of public

I agree fully with Ailsa Bosworth but a care plan might be a start point from the present nothing. However as one member of a family recently diagnosed with a hereditary condition I am aware how variable treatment and the provision of information is within the NHS. Patients/Carers/Families need information and time to understand it before they can become involved in their own treatment decisions.



You have highlighted a very important issue. The system was too focussed on buildings for a long time. We are, it seems, getting better by focussing on 'structures' rather than buidlings now. I do hope we make the leap to 'person centred care' and 'health' rather than treatment soon.

The least used resources in healthcare are:
The person or should I say the 'patient' (as we like to call him/her)


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