Five-Year Forward View: Emphasis on primary prevention is vital

NHS England Chief Executive Simon Stevens has set out a new vision for the future of healthcare in England in The Five-Year Forward View, which outlines the way in which NHS services need to change and improve. It represents a collaboration between six leading NHS groups: Monitor, Health Education England, the NHS Trust Development Authority, Public Health England, the Care Quality Commission and NHS England.This is the second in a series of articles asking doctors to give their opinions on the Five-Year Forward View and features the views of Dr Jonathan Pearson-Stuttard.

The latest official statistics – which show that the NHS in England has missed its four-hour A&E waiting time target and that its performance has dropped to its lowest level for a decade – underline the need to focus on primary prevention strategies in order to improve the nation’s health and thereby reduce pressure on NHS services.

I am pleased to see that Simon Stevens’ ‘Five-Year Forward View’ places greater emphasis on the importance of primary prevention policies than previous NHS strategies. Such policies could include reducing sugar, salt and alcohol intake.

These policies remain underused across the UK health service, yet they could contribute substantially to addressing the challenges of an ageing population, with multiple co-morbidities. Furthermore, such policies have a vital role to play in tackling health inequalities – an issue yet to be effectively targeted. The real challenge, however, will be converting such pledges into universal, cost-effective policies.

Tackling large public health issues, such as obesity and high alcohol consumption, requires a coherent strategy across a number of organisations, both on a local and national level. Whilst the transfer of public health services from the NHS to local government in the 2012 Heath and Social Care Act may allow closer working relationships with social services, and many other organisations able to influence health, there are, of course, teething problems. Unlike those who work in the NHS, those who sanction policies seek re-election every five years.

Simon Stevens is in a prime position to lead by example in encouraging a coordinated approach from NHS England, Public Health England and, crucially, the government. While the Five-Year Forward View was generally well received across the political parties, with an election just a few months away, the proposals would carry more weight if there were open commitments and implementation plans from the parties. I’d like to see Simon Stevens alongside Public Health England, lobbying the government for more effective primary policies, such as the introduction of sugar-sweetened beverage taxes, as has been done in the city of Berkeley in the US.

“Adjustment of service provision in key areas, such as A&E, does not require large, top-down changes”


The health service has had a difficult few years in the media during the largest reorganisation in its history, undertaken much against the advice of many clinicians, and unions. Adjustment of service provision in key areas, such as A&E, does not require large, top-down changes. It could be implemented by those directly involved in that area e.g. emergency care staff, GPs and hospital managers.

Bad press and major upheaval mean that morale in the health service is often low and the public often feels disillusioned, forgetting how fortunate we are to have one of the top services in the world, which is, of course, free at the point of access. Unlike the politicians implementing such changes, Simon Stevens brings credibility across the sector. The previous sweeping reforms had a negative effect on clinicians, so re-engaging the heart of the NHS, while holding politicians accountable, will be key to successfully addressing the issues highlighted in his maiden report.

The report calls for a more local-level approach to local problems. This has many merits. Allowing hospital trusts and local councils to tailor services to their local population needs, and to apportion more funds and services to issues specific to each group, should, in theory, enable more optimal and effective patient care. However, this approach also creates several challenges, for which leadership and guidance from central bodies will be crucial. Healthcare planning and policies need short-, medium- and long-term plans, plus continuity of personnel and infrastructure. With local management tenure periods often short, central bodies must provide the stability and support to ensure sustainable goals are achieved across all timeframes.

Adopting a more local approach could also improve clinician engagement in management and leadership and a subsequent trickle-down effect from hospital boards to the shop floor throughout each organisation. This, in turn, could help to maintain a balance between evidence-based guidelines and the innovative thinking within the NHS that has been the backbone of many medical advances. However, this must begin with Simon Stevens leading the way in working with regional leads and clinicians and effectively engaging the public in the successes and real challenges of providing a first-class health service.

“Tailoring policies according to the demands of each hospital trust and local council is commendable”

Simon Stevens’ report has been generally well received, highlighting key issues and general approaches to tackling them. However, with an NHS fresh from the fall-out from the sweeping reforms of 2012, most on the shop floor will be reserving judgement until more implementation specifics are disclosed and words are translated into action. Tailoring policies according to the demands of each hospital trust and local council is commendable. However, to succeed, meticulous, cohesive planning, by local and national teams is needed to create strategies for the immediate, medium and longer term that will far out-last any political term.

Furthermore, continuity will be key both in the strategy itself and the personnel throughout NHS management and service delivery. One thing is clear: there is very little appetite for further sweeping reforms in the NHS. The Five-Year Forward View provides reason for cautious optimism, especially in terms of its emphasis on public health and primary prevention. The real challenge now begins for Simon Stevens in implementing his strategy with cross-party political commitment.

About the author:

Dr Jonathan Pearson-Stuttard is an Academic Foundation Year 2 doctor at Oxford University Hospitals NHS Trust. He is currently researching the effectiveness, both health and economic, of population level health policies, and works in acute medicine and elderly care. He is a member of

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