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Forging ahead

Futurist research suggests various scenarios of what lies in store for the NHS

An optical illusion of a man ascending some stairs in a room of multiple staircases at different anglesAccording to our recent research of over 100 senior clinical and non-clinical NHS staff, the UK's 'free at the point of delivery' health service could, by 2020, face a fight for what little life it has left. The findings suggest that the NHS — as it struggles to cope with an ageing population, a leaking of talent and the growth of a remodelled private healthcare sector —will not fully recover from austerity cuts that must be made in the years ahead.

The research, conducted in April of this year, intertwined the strategically oriented world of foresight and futures planning (which we might abbreviate to 'Futurism') with the more traditional, tactically focused, world of quantitative market research. Why? Because bold, thought-provoking visions of the future make for great keynote speeches and provide platforms for insightful and enjoyable planning meetings, but how often are their contentions backed up by hard evidence? How often are they actually validated or refined by those who are the real life actors in the scenarios? Hardly ever, we suspected. 

Based on our research findings, Talwar constructed two alternative scenarios to describe how the NHS might look in 2020. Scenarios are a tool to help us explore how the key forces shaping the future may play out by providing stories depicting how they could develop and interact with each other. They are not meant to be predictions or forecasts: however, by exploring alternative — and often quite specific — visions of the future, we can rehearse for a range of possible situations.

Collapse and rehab
The first scenario, entitled 'Collapse and Rehab' begins with a bleakly painted background of public finance deficits and stark warnings about the rising healthcare costs associated with an ageing population. 

In this environment, healthcare professionals are protected, although salaries are frozen and significant cuts are made in areas that the Government considers to be 'non-core'. NICE approvals decline, and over the next 10 years many existing treatments are taken off formulary for cost reasons. 

Doctors and nurses work ever longer hours in response to public calls for more 'face time' and the DH and NHS are locked in funding battles at the same time as conducting perpetual internal reorganisations as they struggle to find the right model for public health care management and delivery. Private sector interest in the provision of UK public health services declines rapidly, and while a need for radical thinking and innovation becomes clearer over time, the fear of getting it wrong coupled with outdated bureaucracy and decision-making approaches make it difficult to drive through serious change. 

By 2015 large numbers of staff have either left the sector or gone in search of new opportunities in the rapidly expanding emerging economies. At the same time, public satisfaction with the service has reached an all-time low and record numbers are now turning to private healthcare.

The 'rehab' phase, post-2015, is driven by a change in government and a radical rethink of public healthcare. A three year transition model is agreed: the goal of the model is to deliver a new structure combining a clear focus on wellness and prevention with an emphasis on community based services, encouragement of locally driven innovation and a major trimming of the DH and NHS structures. 

A 'wellness' drive includes a legally binding requirement for all employers to pay for compulsory genetic profiling for all their staff, in addition to a government commitment to fund the profiling of all UK citizens by 2020. The data emerging from such a large-scale initiative starts to provide a real sense of the health of the nation and the likely costs of treatment versus prevention. Tough legislation leads to a ban on the advertising of any food and drink products considered to contain unhealthy ingredients, with alcohol, confectionary and soft drinks among the earliest targets. 

While internal conflict, confusion and the pains of restructuring still linger, morale in the service has improved; innovation and new thinking is beginning to have a real impact and the outline of a new public health service begins to emerge.

Science leads the way
Meanwhile, in the second scenario, 'Science leads the way', the future healthcare system would be driven by a programme of science- and innovation-based reform, characterised by private sector solutions sharing the wealth with the NHS, radical 'open' innovation encouraged by public ideas, and greater demands on the pharmaceutical industry to prove cost-benefit for new medicines. 

Under a major new initiative, if the private sector creates solutions for the health service using government funding, the service receives up to 50 per cent of all profits resulting from the selling-on of solutions elsewhere. From 2014 onwards, the government embraces the concept of open innovation — encouraging the public to submit improvement ideas that could then be applied across the service or in specific segments of it. 

A renewed sense of public ownership and engagement leads to a number of new and high impact ideas coming through within two years of launch. The Foundation Trust model has evolved, which has an emphasis on existing facilities becoming centres for radical innovation, with core income generated from licensing out, or selling on, know-how and inventions. 

Fundamentally, there has been a major rethink on the introduction of new treatments, with the onus now on pharmaceutical companies to provide an underwritten business case for any new treatment, in which they now have to demonstrate both clinical efficacy and cost savings compared to current treatments. If the savings do not materialise over an agreed time period, the suppliers make up the shortfall — funded through a compulsory insurance scheme. 

Today's perspective
Such speculative analysis can cause planning meetings between pharmaceutical marketers to over-run drastically but, looking beyond business parks to hospitals, surgeries and clinics, what do doctors, nurses, pharmacists, payers and other NHS influencers think of all this? How much of this do they recognise, and how closely aligned are these competing scenarios with their own interpretation? Most importantly, how would they adapt these scenarios to bring them closer to their own vision of the future? 

We offered over 100 senior NHS staff an opportunity to address these points.

In an online survey we first asked which scenario they felt was the more plausible, a question on which opinion was almost equally divided. Perhaps this is not altogether unexpected; we imagine that most respondents would find certain elements of both scenarios to be credible. When asked about which scenario best reflected their own view of how the health service might look in 2020, the aggregated response leant towards 'Collapse and Rehab', although this was hardly decisive. 

In truth this didn't move us forward: we needed some thoughtful and constructive feedback, and were very pleasantly surprised to find that the scenarios seemed to provide just the right kind of mental spur to free opinion. 

We ended up with a large number of short essays. Using traditional market research categorisation techniques, we sifted and analysed, picking out the major themes and interpreting the different messages so that we could construct a third future scenario. This revision, we contend, should represent the more authentic vision of the health service in 2020 based as it is on the reactions, validations and refinements to our original scenarios as expressed by those who will actually be doing the work.

A third road
You may now want to check that you are seated. 

In this third scenario, the NHS never fully recovers from drastic cuts made between 2010 and 2013 and with economic recovery much slower than expected there is no new public money to rebuild. The private sector continues to shy away, citing lack of growth prospects and an uncertain political backdrop. By 2020 an ageing population has almost drained the reserves and polls show that a majority of NHS staff feel pushed too far and leave in ever greater numbers, bringing staffing to levels that are a critical threat to viability. 

How did we reach this point? Entrepreneurial science and technology policies and patient-driven innovation never fully materialised, with supporters blaming lack of political will, and the government claiming that the private profit model was impossible to sell to the public. Pharma companies successfully pushed back on plans to force them to prove detailed cost-benefit by effectively threatening to take their business elsewhere. Consequently, the relationship with government remained uneasy throughout, and was characterised by regular and intense skirmishes with NICE. 

Since 2015, money has been increasingly attracted to the expanding private healthcare business, which appears to have adapted well to the new environment, changing its models of access and payment to maximise custom, and buying up and renovating old DH real estate. Compulsory genetic profiling has been in abeyance following robust ethical and cost-efficacy opposition from the medical profession and a media and public backlash (despite which, companies in this area continue to enjoy sustained share price growth, so there is a possibility that some still see a future in it). 

In 2016 a taxation scheme on unhealthy products proved a massive vote loser with the public and big business, and was quickly abandoned, with the Government saying that individuals must be allowed to take responsibility for their own health. 

In 2020 a 'pay as you go' trial for NHS services is underway in several English regions, as Parliament continues with a series of high profile debates on whether a national health service can remain free at the point of delivery. And with impassioned contributions on every side, the debate looks set to run and run...

The Authors
John Aitchison is managing director of First Line Research
Rohit Talwar is a global futurist, founder of Fast Future Research and author of Designing Your Future.

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16th August 2010


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