Over the last five years the Healthcare system has suffered from a significant slowdown in funding growth against a surge in demand on providers; the number of emergency admissions rose by 6.7% in 2018, waiting lists have risen by 46% since 2014 and urgent Cancer referrals have doubled since 2011. Add to this, cuts to public health and social care, a rise in chronic illnesses, an ageing population and a shrinking substantive workforce and it becomes clear that change was required.
A 5-year funding settlement was offered to the NHS, translating to a 3.4% real-term annual increase between 2019/20 and 2023/24 if they were able to articulate a programme of change. Enter the Long-Term Plan. Weighing in at 120 pages, it is certainly long, but does address the issues which have crippled the service. We have explored the top four themes of the plan below.
1. Focus on Population Health
The plan builds on the vision of the Five Year Forward view and confirms a shift towards place-based systems and care, through the introduction of Integrated Care Systems (ICSs). The plan does not define these but states that they will ‘typically involve’ a single CCG and will involve collaboration across the system to improve the health of the populations which they serve.
This will be achieved through the introduction of population health management tools, enabling easy identification of groups at risk, health inequalities and adverse health outcomes to allow ICSs to prioritis and plan services. These will be teamed with an accountability and performance framework and integration index to ensure effective engagement across the ICS.
At the centre of these will be Primary Care Networks (PCNs), formed of GP services, local authorities and social care. They will have a single fund to manage population health and provide targeted support for individuals. Their collaboration will be incentivised by a shared saving scheme, and these networks will financially benefit from reductions in A&E attendances.
ICSs provides a genuine opportunity to address population health and strike a good balance between centrally governed and local systems through clearly articulated expectations and a ‘comply or explain’ model applied to local systems. PCNs will be the key to ICSs’ success. Unfortunately, these will be heavily dependent on effective partnerships with Local Authorities and Social Care, areas equally challenged by the recruitment and retention of a substantive workforce. Whilst the Long-Term Plan targets the NHS component, plans for social care won’t be addressed until later this year.
The plan acknowledges the widespread workforce crisis in the NHS and sets out ambitious plans across all staffing groups. It aims to drop the nursing vacancy rate from 11.6% to 5% by 2028 and increase nurse undergraduate placements by 25%. Similarly, it vows to increase places to read medicine by 1,500 places annually. It also proposes a leadership code and a professional registration scheme for leaders.
A Workforce Implementation Plan will follow the 2019 Spending Review and until this point, these targets do not form anything more than a wish list. Even if these are complementary to the plan, such initiatives could take years to deliver an impact on the workforce of the NHS.
What the plan fails to do is examine the reasons behind the staffing crisis and the frequent tales of bullying and harassment. Without exploring this, there is a risk of addressing a symptom of the disease, as opposed to the root cause, i.e. culture. The failure to tackle this could counter any efforts to increase staffing numbers.
A new market for wellness has emerged, with wearable technology, finger-prick blood tests and the ability to track everything from steps taken to calories eaten. This has magnified the importance of preventing ill health but also presented a widening health gap between health-conscious patients who can afford private interventions and those who cannot. The Long -Term Plan’s focus on this is therefore welcome.
The plan sets out funding for evidence-based prevention programmes to tackle some of the key causes of ill health in the UK; all patients who are admitted to hospital and identify as a smoker will be offered support to quit and funding for the National Diabetes Prevention Programme will be doubled over the next five years, with a digital option being introduced to increase access.
The plan envisages a shared responsibility for care between patients and healthcare professionals, a change which will allow patients to actively play a part within a supportive structure. Shared responsibility could also be accompanied by other initiatives to help patients make healthier choices such as taxes and regulation.
If these elements of the plan are successfully brought to life, there is a potential to improve care and alleviate pressure on the system. However, the focus on prevention means that the plan says disappointingly little about those suffering from multiple-morbidities, especially the elderly. This feels like a missed opportunity to address what would arguably be top-of-the-list of concerns for most Chief Operating Officers.
NHS organisations often find themselves under criticism for failing to adopt technology at the pace of other industries. Indeed, NHS employees are a unique cohort of society who are able to identify fax machines and pagers. The plan’s focus on digital therefore makes for a very welcome, albeit ambitious, read.
It is envisaged that by 2024 there will be local health and care records, which could allow an A&E nurse to access the GP records of a chronically ill patient who has presented during a flare-up. There is also a focus on patients having increased access through the NHS app where patients will be able to access their care plan and correspondence from healthcare professionals. Towards the end of the 10-year period, the vision is for people to be increasingly supported by wearable devices from the comfort of their own home.
These read as bold targets for an organisation which has pushed back the goal of being paperless to 2024. With added challenges of multiple IT systems and poor data achieving these targets do appear to be a tall order.