NHS England chief executive Sir David Nicholson has followed up on his call for a ‘big conversation’ on the future of the NHS by publishing a document that sets out its challenges in an attempt to garner support for change.

The NHS belongs to the people: a call to action’ says the NHS could face a funding gap of £30 billion by 2020-21, as a result of the growing gulf between flat funding and rising demand driven by an ageing population living with a growing burden of chronic disease.

In a statement on the NHS England website, Sir David says this gap “cannot be solved from the public purse” and that the NHS and the public will instead have to accept radical changes, “freeing up NHS services and staff from old style practices and buildings.”

The document argues that mergers and service reconfigurations – moving some specialist services into larger centres, while shifting other services out of hospitals and into the community – will be needed.

However, it has proved hard to gather support for such changes over the past decade. In response, NHS England is planning to hold a series of public meetings to discuss the issues, and to collect responses via the NHS Choices website.

The two strands of feedback will contribute to a new, long term strategy for the NHS that should be in place by early 2014, so it can be reflected in clinical commissioning group plans over the following two years.

“We are facing demands, opportunities and investment unimaginable when the NHS was created in 1948,” Sir David added in his statement.

“New data is available now to highlight where we get it right – and as importantly, where we get it wrong.

"We are setting all this out today – including the funding gap – to encourage the public and doctors and politicians to have an honest and realistic debate about how they want their local NHS to be shaped.

“With the new independence of NHS England and the establishment of GP-led commissioners, we can find local answers to meet these challenges.”

Sir David has been warning about the financial problems facing the NHS for some years.

In 2008, he accepted reports from the King’s Fund and Institute for Fiscal Studies, which warned that a decade of New Labour funding increases were coming to an end, but the NHS had failed to address the productivity and prevention issues that would have put it in a position to cope.

In response, he launched the ‘Nicholson challenge’ for the NHS to find £20 billion of efficiency savings by 2015.

These are supposed to be achieved through quality, innovation, productivity, and prevention initiatives, to prevent the rising waiting lists and deteriorating quality of previous financial contractions.

At the NHS Confederation’s conference last month, Sir David reported that the NHS had managed to meet the first two years of the challenge; but that it had done so mainly by cutting administration and holding down wages.

It has yet to address the innovation and prevention aspects of the QIPP agenda; and today’s move is an attempt to shift it in this direction.

It can also be seen as a move by Sir David, who has announced that he will leave the NHS next year, to secure the basic principles of the NHS, in the face of the ‘Liberating the NHS’ reforms, which could be used to introduce more competition.

The title of today’s document reflects the opening of the NHS Constitution, which Sir David supported, and has had painted on NHS England’s new buildings.