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.
In addition to the Workforce that is required to deliver the long term plan, the other significant challenge is the expectation that Integrated Care System will act as vehicle to deliver this plan. Currently there are no signs of this in wider health economy and it is imperative that centrally driven drivers to breakdown the fragmented system be in place with a strong leadership to help make this work.
I agree with Clare that the process of cervical screening of women is inappropriate and traumatising to many women. It would save the NHS time and money to send women a self-test kit if they request one, and not to endlessly harass women who do not want to undergo the test. I also don't think the risks and reliability of the test are clearly communicated to patients. Campaigns to increase uptake of the test are patronising and dismissive of women's feelings; they are likely to further discourage women from attending. A test of this sort is not merely 'unappealing', it is deeply traumatising... Many women are able to endure it only because they have been socialised to dismiss their own feelings and prioritise others.
Thank you for contacting us. I'm sorry to hear about your poor experience of care, particularly with regard to accessing cervical screening.
Unfortunately we're not best placed to advise on your situation but there are a number of organisations that might be able to offer advice, information and support.
The Survivors Trust has a free and confidential helpline. You can find more information on their website: http://thesurvivorstrust.org/
With regards to accessing health services there are a number of organisations that can offer information and advice:
Patients Association: https://www.patients-association.org.uk/ and Healthwatch: http://www.healthwatch.co.uk/
I'm sorry that we're not able to help directly but I hope those bits of information are useful to you.
Dear Cally Palmer.
Will the NHS Long Term plan include the commitment to provide what is currently absent throughout the whole of the NHS, i) appropriate provision of cervical screening for the at least 1 in 5 women who have experienced rape & sexual violence ii) such that they can go for screening *without* needless reactivation of rape trauma by NHS clinicians who seem to have a range of very curious & often inappropriate reaction to hearing the four-letter "R" word.
This daughter of a GP who was the answerphone for her single mother GP, while she physically drove to patients houses to see them in the night, is just wondering because I am 8 years adrift of cervical screening because an utterly lovely nurse, compassionate and experienced in every way decided airily to tell me that the single incident of rape rendered me at greater risk of cervical cancer. Probably top of the list of "things not to say" to a Rape Survivor at a cervical screening appointment. (I was the 1st 7yo ever to be able to spell "myocardial infarction" Can I have a Parliamentary NHS prize for that?)
This daughter of a GP & grand-daughter of a doctor not decorated for evacuating casualties from the beaches at Dunkirk but with 2nd highest military decoration for running a hospital for a week under appalling bombardment, with a citation signed by one BL Montgomery has offered her skills as a teacher and a Rape Survivor to the local Medical School, who acknowledged I was right in every aspect including that there is no preparation of Medical students for the health care implications of Rape and sexual violence/abuse nor even the basic demographic facts that at least 1 in 5 women have experienced sexual violence and probably dont need rape trauma reactivating needlessly by the extraordinary things that leak out of people's mouths when they hear the four letter "R" word from a patient disclosing medical information necessary for treatment.
However both the female anaesthetist and female surgeon appreciated the extensive lesson I gave them in real consent and what that might mean to a Rape Survivor. Curiously in a GMC "Consent" survey, there were 6 pages of demographic groups but not the single most one implied by the term "Consent" for whom consent particular in relation to physical touch, particularly by biological natal males, night have particular connotations.
Happily for me, after many many needless re-traumatisations by medical practitioner including highly educated consultants, I have developed a special script for introducing myself as a Rape SURVIVOR no that is not spelled "v-i-c-t-i-m".
Survivors (many do DIE in sexual homicide) of rape and sexual violence/abuse do not have the benefit of the "lightening doesn't strike in the same place" magic potion and if we also have no access to cervical screening then campaigns "wagging rather paternalistic fingers for failing to show up are in fact rather CRUEL because we WANT the screening, we certainly do NOT want unnecessary cancer particularly in the nether regions in which ANY medical intervention has additional implications and contra-indications which to date nobody seems to be preparing very very well-intentioned nurses and doctors for. It is also unkind to these practitioners who I with my background KNOW want to "do no harm" but often DO because they simply have not been sensitised and are simply not communicating to Survivors(victims) of rape and sexual violence/abuse in ways that the majority will feel confident in disclosing HIGHLY relevant medical information which will necessarily PREVENT needless harm to future health including mental health. Jo's Trust once again ran their smear campaign, I figured the 'smear' problem years ago.
DO the at least 1 in 5 women who have experienced rape and sexual violence actually appear in the 10 year plan at all? They do not feature AT ALL in PHE's press release of this week March 2019. Happily, I have alternate brain configuration HIGH Functioning Aspergers, extremeley high attachment to logic and maths which means that I am capable of recognising that 1in4 "no-shows" is astonishingly CLOSE to 1 in 5 women who have been subjected to sexual violence (including me).
Alternate brain configuration scarily HIGH Functioning Aspergers (Autism) means I am a rape survivor who is proud of the most heroic act of my life and I am even a #MeToo veteran from 1998, 19 years too early! ity also means I have advanced education in Engineering processes and associated IT systems including queuing theory with tricks for 'disappearing' waiting lists and succeeding in MATHEMATICAL tasks like halving no-shows in a single calendar year. These are all skills that seem curiously lacking in NHS systems I encounter that dont even seem to record "consent" properly or in any way that is meaningful for any patient let alone a rape survivor.
Being autistic I really struggle with these well-intentioned campaigns that simply CANNOT work because they are simply NOT applyin g themselves to KNOWN KNOWNS. Rape Survivors EXIST - Get over it! WHY are you telling us to go and get screening that you are (unwittingly) making it impossible for us to ACCESS. Why would you waste money like that. Oh and why have you introduced touchscreens with seemingly ZERO consideration of the infection implications of TOUCH. I mentioned it to my GP (retd) Mum and she said "Blimey, you're right, they a re going in everywhere." So, isnt that going to be an IDEAL vehicle for turning a localised flu-bug into a nationwide emergency and WHY dont you put adverts on public transport on the very surfaces everybody is touching & why dont you teach men basic toilet hygiene that all the research agrees they dont have before forcing women to have to dehydrate when they have visits to hospitals. Oh dear I sound like one of those 2 year olds but actually WHY?
PS: I am 8 years adrift of my cervical screening so I am wondering if I need to wait another 10 years to get into the NEXT NHS 10 Year Plan, never mind actually have provision made for such a thing. You can start to feel that the NHS & PHE actually think it is desirable for rape survivors to die prematurely. Of course rape and sexual violence hardly leaves the news headlines but it is as though people in the NHS imagine that these events are not happening to actual women (1 in 5 women and 1 in 200 men but men is included in women so don't worry I *wasn't excluding anyone).
PPS: I am a lesbian (of the British Blinking Empire for human rights I dont seem to have as a Rape Survivor not even the right to life) so reasonably familiar with the relevant biological architecture... and I noticed that in Germany they simply send you a kit at home and you can do it yourself. I bet some enterprising dykes might even hold cervical screening parties except most of us arent like gay men at all but partners could do this for each other.
PPS: why wouldnt a sexual health "expert" understand that a patient coming for a MH appt wrt Rape probably doesnt need to see a gyny chair in all its re-traumatising glory?
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.
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.