Primary and community services get a major boost as part of a drive towards integrated care and population health
The plan confirms a £4.5 billion uplift to primary medical and community health services, trying to make good on the oft-repeated objective to improve out-of-hospital care (but this time without booking any over optimistic efficiency savings). In addition, all of England will be covered by integrated care systems (ICSs) by April 2021 and key responsibilities placed on primary care networks (PCNs) (these are formed of GP practices typically covering 30-50,000 patients, signing an additional contract as an extension to their current contracts). Funding flows and performance frameworks will be reformed to support both ICSs and PCNs.
While this does not add up to greater local freedoms, at least initially, as ICSs will work on an earned autonomy basis and, for example, their contribution to critical national programmes will be on a 'comply or explain' basis, NHS leaders have avoided the temptation to be overly prescriptive about the size and structure of ICSs. Taken together, this all reinforces the strategic direction toward place-based population health.
Detailed proposals on a set of clinical priorities
There is a major push on a range of clinical priorities. These priority areas include children and young people (itself made up of five further sub-areas), cancer, cardiovascular disease, stroke, diabetes, respiratory disease and mental health. In most cases the commitments are sufficiently plentiful to warrant their own individual summaries of milestones for delivery.
The commitments themselves are a mix of high-level indicators, eg, by 2028, the NHS will diagnose 75 per cent of cancers at stage 1 or 2, with the very detailed, eg, in 2019 the NHS will roll out the Saving Babies’ Lives Care Bundle to every maternity unit. Judged on their merits, each of these commitments looks worthy. Taken together, they are a daunting delivery challenge.
Workforce is the key risk
Like many others, we have been deeply concerned about the state of the NHS workforce and its ability to deliver existing commitments, let alone any new ones. We came together with the Health Foundation and Nuffield Trust to set out five tests for the long-term plan on workforce. The plan does not so much fail these tests, as decide not to take the exam just yet. This is partly (but not solely) because the workforce training and continuing professional development budget (CPD) will only be settled in the 2019 Spending Review.
The real meat on staffing will now come in a new Workforce Implementation Plan, supported by a new national workforce group drawing the various stakeholders together (including The King’s Fund). So while the critical importance of the workforce is recognised, the jury is out on whether we can find a way out of the current crisis.
Digital in the spotlight
Most eye catching are commitments on primary care and outpatients. On the former, over the next five years every patient will get the right to telephone or online consultations, usually with their own practice, with the emphasis on digital access. For outpatients, technology will be used to redesign services to avoid up to a third of outpatient visits – that’s 30 million visits a year.
With many other commitments, digital also gets its own set of milestones up to 2024. This is an ambitious agenda in an area where the NHS has struggled before.
And there’s still a lot more to come
As they were tasked, NHS leaders have written an NHS plan within the boundaries of their budgets and responsibilities. Hence the plan commits the NHS to a greater focus on prevention and on health inequalities but quite rightly recognises that even at its best, the NHS is only part of the answer to better, fairer health. As the plan says, we cannot 'treat our way out of health inequalities' – national and local government and other partners are fundamental to making broader progress.
To understand the wider direction of health and care we’ll need to wait for the much-delayed Green Paper on Social Care and the promised Green Paper on Prevention. The Spending Review this year will also set out the answer on NHS capital funding, the training and CPD budget, social care and public health funding.
But the plan also notes a long list of other reviews either underway or to be soon. I’ve already mentioned the Workforce Implementation Plan. We also have reviews on waiting times targets (as part of the Clinical Review of Standards), the Better Care Fund, the commissioning of sexual health services, health visitors and school nurses (currently with local authorities) and a review of the capital funding regime and many more. From the imminent 2019/20 planning guidance and National Implementation Framework we’ll also get more detail on how the NHS is to transition through this year, financial architecture and possibly on how the centre means to assure itself of delivery across all these commitments.
There is a clear thread leading from the NHS five year forward view toward more integrated, place-based care; a recognition of the challenges facing the NHS workforce and a plan for a plan to alleviate them; and often great detail on what will happen next in specific areas that underlines deep engagement with the experts. It’s ambitious but also often reveals a clear pragmatism. Even so this will still require considerable leadership capabilities and capacity to deliver. While many of the remaining uncertainties (the Spending Review, Brexit, social care) are beyond the remit of NHS leaders, it is perhaps the sheer length and detail of this plan that may prove a hostage to fortune in the coming months and years.
Thank you King's Fund as always. Fantastic work and insights.
Workforce is the main issue. Without them who is going to see & care for the patients?
Forget the fancy IT - that's a pipe dream.
The NHS must value and retain its staff as a priority.
In GP specifically, the partnership model is collapsing in many areas as GPs retire early, emigrate for better working conditions, or resign as Partners (due to excessive workload) - and then contract themselves back as locums or salaried GPs for a better work life balance. Who is going to run the Practices safely and effectively once the Partnership model dies?
In hospital there are increasing numbers of 'bank' staff selling their services at hugely inflated rates - often via locum agencies who take a cut - all paid for from NHS funds. It's a false economy.
Junior doctors are not taking up trading posts which are left unfilled leaving unsafe staffing levels and even more pressure on those left behind.
We should train, cherish and reward NHS staff.
Living in one of the least populated parts of England and over 60 miles from our acute hospitals, I welcome the possibility of more investment in digital technology. Already our local Community Hospital has a fracture clinic in Skype contact with an orthopaedic Consultant in Ashington, saving the patient a 150 mile round trip. Similar consultations could be carried out locally, as could pre-op assessments before surgery elsewhere. As NHS England has said, specific examples of existing good practice (e.g. Telehealth as offered by Airedale General Hospital) could and should be copied throughout the country with the potential for huge savings in operating costs.