Anna: Anna Charles
Dave: Dave Buck
Helen: Helen McKenna
Harry: Harry Evans
Anna: Hello and a very warm welcome to The King’s Fund and to today’s online event where we’re going to be talking about what’s in store for the health and care system over the next year and beyond. We’re going to cover a whole range of issues including looking at what’s on the horizon for integrated care, population health, the future of the workforce and innovations in technology as well as discussing the implications of the new NHS long-term plan. I’m joined for the discussion today by three of my colleagues from The King’s Fund. I’m Anna Charles, I’m a Senior Policy Advisor here at the fund and with me we have Dave Buck, Helen McKenna and Harry Evans. Would you just say a little bit about yourselves?
Dave: Yes, so my name’s David Buck, I lead the fund’s work on public health and health inequalities.
Helen: And I’m Helen McKenna, I’m a Senior Fellow here at the fund and I cover policy and communications spanning the full range.
Harry: I’m Harry Evans, I’m a Researcher here at The King’s Fund and I lead on a lot of our work around digital and technology.
Anna: Great, so this is our first online event of the year but it’s actually, although we’re only three weeks in, has already been a very busy year for health and care policy. So you’ll know probably that we’ve had the publication of the NHS long-term plan, just over two weeks ago now. But that’s actually just the first thing in the pipeline of a whole raft of things we’re expecting this year.
So we’ve been promised a new Green Paper on the future of social care, another one on prevention, a new plan for the workforce and some really important announcements on spending for critical bits of the health and care system. Then on top of all of that, we expect to see local areas working to implement the initiatives announced in the long-term plan. So plenty to think about and plenty to ask our expert panel about this morning during the discussion.
Just before we start that discussion I want to say a few words about how the session will work and how you can join in the discussion. So we’ve got around an hour. I will start off by asking a few questions to Dave, Helen and Harry to set the context and get the discussion started. But we’re going to use most of the time to take questions that you’re sending in. So please do send them in early and send them in frequently.
You should be able to see a box on your screen where you can type in your questions and comments. As you send them through they’ll come up on a screen that I’ve got in front of me here. We’ve got over 2000 people registered for today’s online event from a huge range of backgrounds and different interests, so I expect we’ll get lots of questions, so if you can keep your questions relatively short that will help us get through as many as possible.
You can also join in the discussion on Twitter by using the hashtag #kfonline throughout the event. So I think that’s everything we need to cover. Helen, I wonder if I could come to you first to just set some context for us, because we’re going to spend most of the time this morning looking forward, gazing into our crystal balls, but it would be useful just I think, to look backwards a little bit about where we’re coming from. So from your point of view, from someone who tracks the health and care landscape, what were the key developments we saw last year that have got us to where we are now?
Helen: That’s a really good question Anna. So I think 2018 was a really busy year with lots going on for the NHS and social care. So we had the NHS’s 70th birthday which was a huge celebration, I guess, of just how much the NHS has achieved since it was created in 1948 but also a moment for the system to reflect and I think there were some big questions asked at that point around the sustainability of the system in the future because it had, kind of, reached a little bit of a, I guess, funding crisis in terms of lower funding growth since 2009-2010 and that really starting to have an impact on the service.
So we were seeing and we are continuing to see performance on waiting time standards slip and also deficits in the provider sector and some impact on the quality of care that patients are receiving. So actually there was a big moment for the NHS and the government responded by announcing that they are going to invest more money in the system. So there’s going to be a 3.4 per cent annual average increase over the next five years for the NHS and that is a really important additional amount of funding for the NHS and comes at a really important time. I think we would say that is a good settlement for the NHS but there are issues with the fact that it can’t do everything. It won’t be able to fully transform services as well as improve standards all at the same time with that amount of money. It’s, kind of, below what the long run average is for the NHS but it’s nevertheless a good settlement when you think about what other public services are experiencing.
We also had a new Secretary of State, in Matt Hancock and he’s got a new set of priorities, as you’d imagine with a new Secretary of State, and I think some of those are around digital services and Harry can say a little bit more about that when we come onto it, and also prevention, so there’s that going on.
Then I guess, there was the threat of Brexit and that’s still looming as an issue and also the way that dominated the discussions and has put the NHS under pressure and is also impacting on the workforce in terms of the numbers of people, EU nurses for example leaving the NHS, now being hired in the numbers joining the system, and also more broadly workforce issues, workforce shortages having an impact on services. I think those are the big issues that dominated last year, I’m sure I’ve missed out a few and people will have their own thoughts on what those are but those are just some of the big ones.
Anna: A challenging question to ask you to sum up a year in just a minute, but I thought you did very well. So building on that then, what do you see as the kind of big things on the horizon for this year? What’s the direction of travel? What are the key things you’re looking out for?
Helen: Yes, so I think the direction of travel really builds on what’s come before. So we’ve got the policy platform that was created with the NHS Five Year Forward View that will continue in terms of transforming care, integrating services and so we’ll see sustainability and transformation partnerships and integrated care systems continue to build and hopefully spread across the country. I think there’s that shift from competition to collaboration that has been happening over the last few years, while the NHS is trying to operate within the legislative framework that it currently has that came about through the 2012 Act and the NHS is continuing to try to operate in that framework.
I think in terms of things we’ll be looking out for, obviously there was the long-term plan, don’t forget to mention that one. That came out a couple of weeks ago I think now and that I guess, also sets the direction of travel. There’s a lot in that for the NHS to be thinking about over the next five to ten years, a lot to deliver within that, but then there’s also things that we’ll be expecting to happen over the next year. So we’ll be looking out for a Green Paper on social care, that was meant to come out at the end of last year and so we’re waiting with bated breath for that. There will also be a Green Paper on prevention, we hope. I guess, NHS England and NHS Improvement, those two organisations are continuing to come together both at a national and regional level and then you’ve got the potential, again, impact of Brexit looming, will we or won’t we? And if we do how will we? And then potentially a general election depending on how all of this pans out. So in some ways, yes there’s stuff that we know will happen and then there’s so much that’s unknown.
Anna: So we’re definitely not going to struggle to fill this hour I think is the conclusion that I would take from that. Dave what about for you, what are the things to look out for over the next year, big things on the horizon?
Dave: Well Helen’s already stolen my thunder a little bit. So we had the prevention Green Paper which follows up from the, I think, A Vision for Prevention from Matt Hancock and the Department for Health and Social Care before the long-term plan so we’re eagerly awaiting that. Obviously we’ve also got spending reviews, so it’s interesting that the long-term plan says that actually we’re dependent on what happens to public health funding and social care funding and so we’re waiting for that, around what happens to public health funding from my perspective in particular.
There are also things that are in the pipeline over the last couple of weeks that haven’t really been nailed down, that we hope will be nailed down, and a couple of those include, again on the funding issues, business rate funding for local government, so potentially a very different way of funding local government services, possibly removal of the public health ring fence. The fair funding review which is looking at how local government money is allocated across many, many services, many of which are not health specific but certainly impact on health.
So on that side of the fence there’s a huge amount going on in local government, lots of uncertainty, which is going to be really, really important for people’s health and particularly because the long-term plan is focused more on integration and place-based approaches, it cannot ignore what is going on in the local government side.
Then also there are things going on around the obesity plan, chapter 2 as it was called, strangely called chapter 2. There are lots of consultations that are going through the system, so a lot of that actually introduced consultations, some of them are out now, some of them will continue to come out through next year hopefully.
So we won’t really know where the approach to obesity has got to until those come to a conclusion and then of course, yes Brexit. So whatever happens on that, that’s going to have an impact on people’s health, not just the NHS and I think today if not yesterday, I think Public Health Wales produced a health impact assessment and Brexit and the possible indications on Wales, so it will be worth looking at that for people. Obviously, that is very Welsh-specific in the Welsh context but I’m sure that would be of interest to people interpreting whatever happens with Brexit is going to have some impact. Some positive, potentially, some negative.
Anna: It’s interesting, because I think when we’ve had discussions internally here, there’s obviously been lots of excitement here and elsewhere about the long-term plan but we’ve talked about it as being, sort of, one bit of the jigsaw for health and care and I think you’ve picked up some really key bits there about things we’re still waiting for that impact on people’s health and wellbeing. Harry what about you? Other things that you would add as key things we’re waiting for or looking forward to this year?
Harry: Yes, I mean, I think technology is a good place to start. 2018 was a really big year as Helen’s already alluded to in terms of getting a Secretary of State who’s really behind this, really wants to drive the technology agenda which is brilliant, which is great if you want to see this kind of area flourish, but I think 2019 will be a really important year for making sure that we get that right.
In terms of the long-term plan, I think it really confirms the existing direction of travel for technology, it kind of, codifies some of the things we knew already about digital and what was going to be happening but puts that down on the page, makes an actual commitment for what we can expect. More digital first primary care, more sharing of information and then a lot more on using that data in interesting ways.
So population health management for example and targeting, trying to target some of the people we think are most at risk in the system right now, using the data that we’ve got on them. So, some really interesting things. I think it’s fair to say that technology attracts as much controversy as it does excitement, so we’ll probably see some further controversy which is really great from a juicy wonky point of view but I think certainly it’s an exciting area, there’s some real interest in how we develop artificial intelligence technology, how we get that into practice, how we get people using that, doctors, nurses, actually using those kinds of technologies. So I think there’s a lot going on.
The other thing I just wanted to touch on is what we’ll see actually engaging with patients and the public, and the plan kind of made a bit of lip service to engaging patients and the public but there should be some exciting work that Healthwatch are leading on in terms of getting that into STPs and ICSs which I think is really key. There’ll be a bit of work around this integration index, to try and assess what it is that patients’ experience of integrated care should look like and how do we measure that. But I think it’s fair to say that the plan could have done a lot more and gone a lot further in terms of talking about how we do that public engagement well and especially as integrated care systems, STPs, move into their next phase.
Anna: And that’s interesting, I suppose particularly around the integrated care systems and as they develop across more areas of the country, a lot of what we’ve seen in our work so far is around how much of that happens at a local level and can’t really be mandated from the centre. So I think that point about the importance of public engagement is really important for local areas to bear in mind as they take those plans forward and put the ambitions into practice. Just sticking on your technology point Harry, we’ve had a good question already from James Chapman who’s Managing Director at Safesteps and he points out that there are some targets in the long term plan around trusts being fully digitised by, he’s put 2024 here, do we think that’s going to be extended to other bits of the service? So he’s mentioned community services and social care, particularly citing care homes?
Harry: Yes, that’s a really interesting question. I think the plan is suitably vague around some of those things. I think on the community services side, it’s something that they probably will push for and community services is relatively, I suppose, has been relatively ignored so far in what NHS England have been trying to do when they push forward their digitisation. So I think we’ll probably see a bit more in that space. Whether or not they can become fully digitised by 2024, I don’t know. I would imagine that’s quite a leap to be honest for a lot of those services but there’ll be movement in that area no doubt.
Social care is a much more difficult question. So digitising providers and the incentives that exist in terms of private providers being served by where they’re getting the money from in order to do this, especially if they’re very small providers, it’s really difficult to see how that digitisation is going to take place. I think it’s really important, I think it’s fundamentally important because if we’re talking about integration between social care and the NHS, we need to be talking about sharing information but I think the actual way that that will happen and the mechanism for that, I’m not entirely clear about.
To be honest, I think Matt Hancock as the Secretary of State for Health and Social Care really needs to be thinking about taking his interest in digital into social care and thinking about that because I think there’s a lot of benefits to be got from thinking about digital social care that currently just aren’t being thought about.
Anna: Okay, you’ve laid down the gauntlet to Matt Hancock to digitise social care there Harry. Helen, just picking up on the point around primary and community care particularly, so not just looking at acute services. I think the NHS long-term plan said quite a bit about primary care, community services and this ambition to sort of boost them, is there anything more you can say about what we think that’s going to look like in practice if I’m a District Nurse working in a service or a GP, what changes might I expect to see over the next year or looking forward beyond that?
Helen: Yes, so one of the big things that the plan announces or is pushing, is this whole concept of primary care networks and also it’s also saying that there’s going to be an additional £4.5 billion in the sector which I think is really helpful and very important. So with these primary care networks, they’re kind of a new concept and I think are going to be a good way of kind of bringing general practice to work at scale and bringing in other community services.
But I think one of the big issues or concerns that we have with that is, certainly in terms of succeeding and delivering some of the plans that are set out for this sector, is that there are quite considerable issues with workforce shortages. So in particular, GPs are retiring at a rate that they’re not being replaced and actually this is creating real pressure in the system. So I think in terms of deliverability we have some concerns about whether the plans that have been set out can really be achieved.
Anna: And sticking on the theme of the long-term plan we’re getting quite a few questions in about that specifically. Dave I wonder if this is one for you perhaps? Someone from Kent County Council, Zan Brooker has asked a question about the role of local authorities. So he’s highlighted the things that the long-term plan says around possible changes to public health commissioning and where that happens. He’s also highlighted the references there are in the long-term plan to the expectation that local authorities will engage with integrated care systems to be part of those partnerships locally. What would be your viewpoint on what the long-term plan has said with regards to that and the impact that might have for local authorities across the country?
Dave: That’s two great big questions and Kent’s where I live, so hello Kent. I think it’s fair to say that most people, and I can’t remember exactly where it is, there’s a couple of sentences taking the commissioning question first, a couple of sentences at various points saying … I can’t remember the form of words, so it’s a bit nomic saying that NHS England and the government will consider NHS England taking a stronger role in commissioning certain services, particularly sexual health and some child health services. I think frankly that was, at least from the people I’ve talked to, that was a surprise to lots of people in local government, where did this come from and what does it mean?
I think there’s been lots of speculation about what it might mean but until we actually hear from NHS England or the Department of Health of what they think it means, I think it’s all speculation. So you can interpret that in many ways, but I think what’s been quite unhelpful is that actually that was put in the plan, left there and in a way there’s no clarity about what that actually means and as people will know, since 2013-2014, local government has been commissioning a lot of public health services including those mentioned in the plan.
So on a positive perspective on that, you could say, actually NHS England and the government have recognised that there are some real problems with public health and primarily funding and so the question is, is their view the issue is about who’s going to be commissioning it and that’s a problem? Or is it them coming, perhaps riding to the rescue saying, “Actually we’ll bring some of our resources, some of our knowledge, some of our expertise, some of our people to help you deliver what you have to deliver,” and frankly we don’t know which of those things it is or what blend it is of that.
More generally, I think many people were disappointed about just the sense of not enough language about partnership between the NHS and other sectors across the NHS Plan. Obviously one thing it can’t be criticised for is lack of detail. So there’s lots and lots of detail. In some areas that gets picked up but generally in terms of its overall narrative about partnership, that includes local government and that sense of, the way I interpreted it at least was, we’re rolling out integrated care systems now, they’re the thing to go, of course we need local government there, come and join us. Which is great, but there’s an expectation on local government to come and join the party as opposed to, you know, we have health and wellbeing boards in every part of the country and one of my issues is, how does the future of integrated care systems rolled out relate to what health and wellbeing boards are for and are attempting to do? And the NHS Partners are supposed to be in the health and wellbeing boards. So we’ve got some of the structures in place already, so what is the plan around how these relate to each other? And there was very little or no detail on that.
So whilst it’s welcome that in the plan it says that we want local authorities to take part in integrated care systems, there is something about how does that work locally when you’ve got structures already? Has NHS England really thought about that and thought about how it works through existing structures which have been there for quite a long time and are supposed to bring all those partners together already? So, some open questions, I think it’s fair to say.
Helen: Yes, but can I just ask because I guess, does that all need to be detailed in a plan or where you have a proactive health and wellbeing board, why can they not just join the party?
Dave: That’s alright, although you could argue, why doesn’t the ICS join the health and wellbeing board party? So you’re right ,we can’t define that, but there’s no narrative around that, there’s no sense of that, because it’s a very good question. Why doesn’t the NHS plan say that? It doesn’t, so there’s still that sense of, we are sorting ourselves out, oh we need you, come and join us. As opposed to a more open place based, in my view, approach. I think it’s great that ICSs do want more local government contribution, I’m not questioning that but there is something about the context and the language in which it’s phrased.
Anna: I think it speaks to this tension for, well any plan like this, of walking that tightrope between setting the right direction, setting out what the priorities are, but not being overly prescriptive as well. So would we want a more detailed road map for how local authorities become engaged in ICSs or do we just want more signalling or the importance of their role? Because I guess a lot of how this works in terms of how they’ll be a core part of ICSs, if they can be a core part of ICSs, will ultimately come down to local arrangements, local relationships, but would we want to see more emphasis on the key role of that in the plan rather than a sort of prescriptive outlining?
Dave: This goes back to the work on the vision for population health before Christmas. You said it absolutely right, locally, it’s what works for you locally that counts and the leaders for this may be an integrated care system in some places, it may be a local authority in others. It may be the elected mayor, there are lots of different vehicles for this. I guess, I’m just worried and it could be an over worry about the NHS saying, “We’ve got the answer, here’s the answer it’s ICS, come and join in and that’s the way it’s going to happen everywhere.” And I think what we find locally is that actually you’re quite right there is a lot of local variation.
In some places the ICS is going to be a partner but it may not be the dominant form, particularly for population health. In other places it may be, so I guess it’s just that sense of humility on behalf of everybody, in the NHS and its partners, about the right form for the right place.
Helen: Just to add there, because I think, let’s not forget that the NHS plan is a plan for the NHS and it is inherently therefore, limited in terms of what it can tell local authorities to do and they have their own statutory responsibilities and the NHS does not manage local authorities. So I think there are actually genuine limits to what the NHS can do in terms of instructing how local authorities come together with them and in some ways it has to be the NHS’s plan, including for integrated care systems.
Dave: I guess I would argue that it would have helped to have a stronger sense of partnership and reflecting existing systems and organisations that already exist. So there is a mention of health and wellbeing boards but think it’s only once in the whole plan, 136 pages, where it says ICSs and health and wellbeing boards will work together. So what does that mean?
So I just think there’s a history of previously and this is one of the issues around STPs wasn’t it? We’ve talked about it, we’ve got the answer, so I fully accept that the NHS England can’t and shouldn’t tell other local partners what to do but there is a sort of and maybe I’m overinterpreting it but there is a sense of, “We’ve got the answer, you just have to come along and join us.”
Helen: And at risk of prolonging this conversation a little bit too long, I just have one question for Dave on this, which was just around health and wellbeing boards, were only mentioned once in the plan. I don’t know because I’m not involved heavily in this area but how effective have health and wellbeing boards been?
Dave: That’s a very good question. Like many other things, I think some of them have been very effective, some have not been effective. You’re quite right, there’s not a giant piece of work, LGA colleagues may be tearing their hair out at this listening to me, but there have been various review of health and wellbeing boards, some academic reviews and some sort of more practice reviews and like all NHS institutions, like STPs and existing ICSs, there’s great practice in some places and not so great and not so effective in others. So there’s nothing new about that and I’m not saying that health and wellbeing boards should be the prime driver, I’m just saying, let’s not try and squeeze everything into the ICSs, the organisations, in order to answer all of the questions we’ve got because there may be other organisations locally that they can work with as opposed to who’s the prime.
Anna: So, moving on slightly, but still sticking with the theme of STPs and ICSs, which is capturing the interest of the panel but also I can see through the questions of our audience. Helen we’ve had a question from Gerald Heddle who is a Lay Member in West Kent CCG, so more questions from Kent around the future of commissioning and how that relates to the developments we’re seeing around STPS and ICSs, do we know where we’re heading with the yet?
Helen: Really good question and I suspect by the way just before I begin, that Dave has obviously put a big shout out to the whole of Kent and invited them to join the webinar. So hello Kent again, I think yes so the future of commissioning, where is it headed?
Well obviously we’re seeing clinical commissioning groups coming together increasingly and starting to operate on a much bigger footprint, we’re seeing that as part of STPs and ICSs as well. I think there are some big challenges ahead in terms of how we define what goes where in terms of what commissioners will be doing at a local level what happens, what continues to happen at a national level in terms of specialised services and at what footprint people do those things. And whether commission in future becomes much more of a kind of defining outcomes and taking and outcomes-based focus and less on the kind of nitty gritty detail.
Anna: And to flag as well to Gerald and others that we also think it’s a really interesting question and we’re actually kicking off some work here at the fund looking at exactly that question and exactly as Helen was saying around what are the functions that currently sit in commissioning and where do they sit in a changing system if you like? So more to come on that hopefully over the next year or so.
Harry we’ve had a question around workforce from someone called Filippo Polara from the Nursing and Midwifery Council, and I think really a key issue and one that we’ve highlighted in our response to the long-term plan around the sort of central issue of having the right workforce in place to deliver it. Filippo specifically wants to know whether we think that the plan has kind of the right ideas in it, in terms of solutions around recruitment and retention for the workforce?
Harry: So, I mean, I think the first thing to bear in mind is that the plan’s section on workforce is a kind of a skeleton, meant to provoke the discussion that will happen in the workforce implementation plan that’s being worked up over the next few months. So it is just a starting point, and I welcome Helen’s views on this.
I would actually say that I was relatively pleasantly surprised about what was in the workforce chapter in the sense that it was more than just a tokenistic, “We will do some more strategy stuff.” There was more detail than that but not enough detail, we could do with more detail but there was at least some detail in that.
I would say the other thing that I was surprised at was that there were some genuinely new ideas in there which I thought was really good and actually when I compare it to the digital chapter or some of the other chapters that I read in detail, there were probably more new ideas in the workforce chapter than there were in anything else which was hugely surprising but great, fantastic.
So I’d say that, what I would say though, and I think this is really worth hammering home is that some of these solutions are going to be shorter term solutions, if they are going to be shorter term solutions they need to get started on them now not at the end of the year, so it felt like a bit of a missed opportunity to say, “Okay we’re going to leave some of the longer term fixes for the workforce implementation plan but actually right now, we need to do something on international recruitment, we need to do a lot on retention and why can’t we get that kicked off in January not in May or August or whenever the workforce implementation plan gets finished?” I think that was a bit of a missed opportunity there.
Anna: And Helen I know you’ve done a lot of our work with Harry as well, on workforce, can you say a little bit about where are we now in terms of workforce? I guess, what’s the problem we’re trying to fix?
Helen: Yes, so the problem is considerable Anna. So, there are, I think, right now, over 100,000 vacancies across NHS Hospital Trusts and community services and we have done some work, we’re working with The Health Foundation and the Nuffield Trust on this actually and just to plug we have a report coming out later in February, next month, where we will be setting out what we think of the kind of, high level solutions to some of the problems that the workforce is currently facing, but yes, so right now, over 100,000 vacancies.
We’re looking at, if current trends continue that could be as bad as 250,000 by 2030 and if action isn’t taken now in terms of doing the things that Harry says around international recruitment, more of that in the short term and also increasing the number of people in training for the long term then it could be as bad as 350,000 vacancies by 2030 and when you put that into context, right now there are 1.2 million people working in the NHS. That is a huge number of vacancies and would impact quite seriously on the quality of care that patients receive.
We’ve already seen, in fact, the CQC, the Care Quality Commission in their last state of care report that came out last year, they said that in some cases, those shortages in the workforce are already having an impact on the quality of care that patients receive and they will inevitably be impacting on waiting times, on the fact that people can’t access services or it’s taking a long time for them to access services. And there are particular shortages in specific areas, in specific professions.
So nursing, massive issue there, I think around 36,000 vacancies which is again, really quite significant. There are also specific types of doctors where there are shortages and problems in general practice too, so really, really big issue and I think we’d say that is now the biggest issue that the NHS is currently facing in terms of something it really needs to get on top of.
Anna: And specifically picking up on that in relation to the ambitions of the long-term plan, some of those big shortages in GPs, district nurses, they’re a threat to the ambitions of the plan to boost primary and community services. It’s not just about the money.
Helen: Yes, absolutely Anna you’re spot on there. It’s about deliverability, because some of this stuff won’t be able to happen unless the NHS can really tackle the shortages that are going on and coming up and as Harry says, we would have liked to have seen a little bit more on some of those urgent actions being taken rather than in some cases being deferred until later, so there’s this national workforce steering group that’s been set up and they’ll come up with a workforce implementation plan, I think in a few months, and that’s fast but actually there are some things that could happen now. And then also the NHS is limited by the fact, in some areas in terms of what action it can take.
So it’s quite right to be waiting for the spending review in terms of trying to increase the number of training places because the money for that, they won’t have until that is determined in the spending review. But some action does need to be taken right now.
Anna: And actually, we’ve had a question on that from Zoe Price who is a Project Manager at the Getting It Right First Time Programme. She says, “What are the quick wins in regards to workforce?” Very briefly could you just outline what some of those immediate actions that we might want to see, would be?
Helen: Well I think on international recruitment and Harry might want to say a little bit more about this, but certainly, international recruitment is one area where we think they should be going further and faster and that could do with a little bit more central support, I think we’d say and potentially funding support when trusts are doing it locally it can be quite burdensome for them. Some of them are very good at it, some of them find it difficult to attract staff, so that’s one particular issue. I don’t know if you want to say more on that Harry?
Harry: No, I think that sums it up. I think we’ve got to be realistic in part and I think the long term plan was realistic about the fact that in the short term if you’re looking at filling the massive vacancies that Helen was talking about, international recruitment really is the only viable solution to some of those really short term fixes and I think we need to acknowledge that whilst also accepting that after that we need to think really about how we make the domestic workforce sustainable in the long term.
But no I do definitely think that there are probably some actions that can be taking in terms of bolstering the role of Nursing Associates for example, Physician Associates as well and the regulators, the NMC in fact are already doing work to recognise those professions as a profession which has a real role in the NHS if treated in the right way. So I think you could probably do some of those things quickly but a lot of these fixes are long term fixes and to be honest, a lot of this is because we haven’t taken that long term approach to workforce in the past and that’s really where the challenge has been and I think we can safely say it’s been systematic failure of national bodies to take this area seriously.
Anna: And supporting the workforce we’ve got as well, it’s not all about new people coming in, but supporting people that are working in the system now. Dave I think you wanted to come in on that?
Dave: Yes, I guess one thing that’s interesting to me about the whole workforce debate, is about to what extent are we looking beyond the existing NHS type trained workforce and I’m not pretending that you can substitute a doctor for a fireman or anything like that but none the less, it was interesting I was at a conference yesterday about housing and health and one of the questions from the audience was, “We’re housing professionals, so we now hear that the NHS hasn’t got enough money, I know that’s a questionable statement but there are 250,000 housing professionals in this country who, particularly in relation to community services are often have great knowledge, about social housing in particular or local government housing, have great knowledge about individuals and residents and the health and wellbeing of those people and in some areas are working really closely and strongly already with NHS commissioners and NHS providers.”
It’s about actually, we’ve got other workforces here and other examples are obviously fire and rescue services really looking at their role. A piece of work that’s coming out soon, and many people have heard this, about the Wigan experience about actually using council staff to check in on and have a greater role in sort of particularly supporting people in the community. So not saying that - actually they can’t fill GP vacancies - but I just wonder whether the whole debate about the NHS and in particular workforce and I know social care workforce too which we haven’t really touched on, is just to say is it actually broad enough? There are all these other people who may be able to help and in some places are. Is that part of the conversation and part of the strategy particularly in the short term but also longer term if we were going to move towards a more population health focus sort of system overall.
Anna: It’s interesting, we’ve had a few comments to similar effect and questions. It sounds like we have an audience member who might have been at the same conference as you yesterday, Tim Rice from Worcestershire County Council.
Dave: That rings a bell.
Anna: So, he was making the same sort of comment about the plan being a bit silent on the role of housing and opportunities for enhancing that. We’ve also had some other questions around looking beyond, I guess, the boundaries of the NHS. One from Ian Silver who’s Chief Executive of Self Management UK and he asks about the role of the voluntary sector in the 10-year plan and what the opportunities might be there?
Dave: Yes, again a great question. As ever I think it’s there in various bits. I think it’s there probably around helping the NHS around delayed discharge, getting people in and out of the NHS system, in relation to personalisation but I think generally I think many people thought It was a bit of a disappointment compared to the five-year forward plan and these two things are very different beasts.
As we know, the NHS five-year forward plan, first of all had multiple authors on it, it just wasn’t the NHS’s plan, so taking Helen’s point from previously, absolutely right it’s the NHS plan, so there’s a limit to what we can expect. None the less, there was quite a visionary strong statement about the role of the voluntary and community sector and the role of communities too, so not just charities and organisations but actually the role of communities as assets for their own health and I think that’s largely missing in this current plan, so that’s a bit of a disappointment.
I think it could be argued that you could start to see those threads within it, you could stitch together that yourself but it’s not there as a core narrative, so that is a challenge and something that personally I found a little surprising and a little disappointing. But the other thing to say about this pan is that it is only a single document at the moment and such as we said about workforce and other things, there’s lots of stuff happening over the next three to six months, so hopefully some of that detail and lots of consultation and working with partners, hopefully some of that will come out in that process that NHS England is leading.
Anna: We have had one question related to that from someone called Mark Hawkins who did say that there is discussion in the long-term plan about people’s role in keeping themselves well and healthy, sort of ownership of their own health and wellbeing and whether there are any big innovations that you’re aware of that could really help people to do that?
Dave: I think there is potential here around digital, for sure and there is something in the long-term plan both about population health management but also about monitoring and all those sorts of things which could help some people. I think we welcome the fact that the term “shared responsibility for health” is there, not just personal responsibility because we all know, all the evidence says that whilst some people can self-manage very well, many people can’t, they need support and help to do so and it’s not just the individual’s responsibility although it is partly the individual’s responsibility, so we welcome that but fleshing that out more. There are some really welcome things in there particularly around smoking cessation support in NHS hospitals and alcohol support also rolling out of diabetes self-management programme more broadly and lots of other things, there’s a lot of detail as I say.
One of the issues for me, there’s always an issue, so it’s always half full, so apologies but one of the issues again is, how that relates to particularly local government’s role, who have responsibility for many of those things already, so again, how does what’s announced in the plan relate to the existing system and how can we avoid that leading to fragmentation and duplication when it’s being introduced?
So there’s some real questions about that, I think particularly from the local government side around diabetes prevention for instance and the plans to roll that stuff out. So it is there. What would be really great, obviously we mentioned looking forward to the prevention Green Papers, we hope to see gain a much more detail about the specifics and how are they going to address some of these inevitable implementation challenges hopefully through the Green Paper and then that will be supported by that spending review bid which hopefully will be successful. So there’s lots of way points along the way before we really see what the full picture is.
Anna: And Harry, just building on what Dave said there, mentioning technology as one of the potential ways of supporting people to manage their own health and wellbeing. I know you keep a close watch on new innovations and technology and educate everyone else at the King’s Fund about it, anything that you’ve come across that you see as a big opportunity or a big change that we’re likely to see?
Harry: Yes, so there’s a lot out there on self-management of long-term conditions, great technology for patients with COPD and helping them manage their condition and people who are very engaged with their own health care often helping them. Internationally I think they might be a bit better at this, but on tackling risk factors, so there’s some interesting technology being developed in Israel, there’s some interesting technology coming out of the US. Some of it wearable and that sort of funky stuff but a lot of it is just apps that help people keep a track of their healthcare.
So there’s some really exciting stuff going on, I think but one of the things that we will always challenge on and certainly is very challenged in England is getting the evidence behind these things. So I think there an emerging evidence base to suggest that certainly some of those management of conditions apps there’s some good evidence building up behind some of those now. I think in terms of the impact of wearables on keeping people healthy, I think the evidence there is probably a bit more mixed but is getting better.
I think the evidence is starting to give us an idea of where these interventions might be useful and show a more nuanced picture around that. So I think it is happening. I think it’s slow and I think we do need to get better at evaluating these things and being a bit more agile about how we do evaluate these technologies but I do think there’s some interesting stuff coming out, not just in England but also around the world.
Dave: Can I just ask Harry about anything around the evidence about who they work for? Because one of the possible issues is self-selection, which is not a bad thing in and of itself, if somebody self-selects and is quite healthy and wants to use one of these things, and that keeps them healthy that’s great, but a sense of, do we know enough at the moment about which population groups benefit and whether the people that need most the benefit are likely to benefit from these approaches?
Harry: To be honest, that is an excellent question and a huge challenge for both the NHS and wider local authorities but also industry and innovators to actually say, “Okay we’ve got these technologies, some of them seem to be working for people who maybe we feel don’t necessarily need the help the most, so for instance patients who are more activated, who are more engaged in their own healthcare. What about the people that - we really need to be hitting the people at the other end of the engagement spectrum? Often they’re in more deprived communities, maybe they have the technology but they don’t have the capacity to really engage with the technology in a way that would help them support their own health. So what do we do about those people?”
Because I’m not seeing a huge amount out there right now which is saying, “Okay digital is going to revolutionise stuff, so let’s take it to the people who need it most first and tackle some of those really difficult problems around health inequalities, around how we address population health.” But the kind of, the people at the really raw end of some of those inequalities, we’re not really doing that at the moment and I think that’s a real mistake and I hope that’s something that we’ll see being addressed in the next year but I mean, innovators haven’t yet gone in that space, I think there might be a few reasons why they haven’t gone in that space.
Anna: We’ve had a good question actually from Geoff Walker, who asks specifically around digital technology and how it could be harnessed to offer improvements and insights into mental health issues? So we know mental health is a big priority in the long-term plan, some really welcome commitments there, it’s been a priority for the Prime Minister and a lot of emphasis there. In terms of technology specifically, anything you’re seeing there or any potential you can really see to make improvements?
Harry: Yes, so a lot of it at the moment is around access to therapies and I think they are really interesting and exciting but I think that’s really an area where it may work for some groups really well, to Dave’s point, does it work for all groups? And if you adopt it at scale, are you going to end up actually harming some of the groups for whom digital access to therapies is not the way to go?
So I think it’s a really good example of where we should be looking at stratifying the population by their digital capabilities and their ability to use digital technologies and then saying, “Okay so we can offer this solution for this group of people, but maybe for this group of people, the still need some of that face to face, they still need a lot more of that.” I think at the moment there’s potential there but we haven’t really seen the evidence to back it up and I’d like to see a lot more on that.
Dave: I think there are some really great potential and Harry and I are involved a little bit with our colleague Matt Honeyman with Demos, with Jamie Bartlet and Joss Smith there, the paper’s our website and on their website, last year or the year before, I can’t remember now, actually exploring insight from people’s interactions through technology and what that might tell us about their mental health. So rather than that access to services, that insight and knowledge and the way that people use, particularly chat rooms etc, is a really rich store of information, lots of ethical issues about scraping that data by the way, but none the less, a third research space in a way, it’s not a survey, it’s not a one to one communication with a health professional, it’s actually how people are exploring and sharing their own stories and whether we can use that information to actually, A, understand how people respond or react to sevices and, B, more importantly how they work with each other in communities for mental health. So I think there’s massive potential in there and there’s a very early paper looking at some of that stuff which was led by Demos colleagues in the centre for the analysis of social media. So I was like, wow the potential here. None the less it’s very early days and there are massive ethical questions, we did get ethical clearance by the way, ethical questions to be answered about the use of that data, but massive potential, particularly around mental health in my view.
Harry: I think if we’re thinking about themes for 2019, it’s not an area that we’ve done much work on but I’m pretty sure that mental health and social media use will continue to be a theme as we’ve seen it become in 2018 and I think the key message there is the nuance in that argument is really important so while some evidence is showing that mental health could be impacted by use of social media, especially in some teenage girls, I think we’ve really got to look at the nuance in the evidence there because it’s not that clear that there is that strong a link between social media use and mental health and if we’re not clear on that and we end up designing interventions that target the wrong thing, or we get social media companies to take the wrong action then that will just be a waste and we will have missed an opportunity to maybe really hit the groups that we need to with those kinds of interventions.
Anna: It’s understanding what the issue really is. Now we’ve had a question from Peter Hudson who has asked us to think about the elephant in the room, I wonder if any of you can guess what the elephant in the room might be? Brexit. So Peter wanted to know, he says it’s a difficult question to answer but what’s our view on the implications of various Brexit scenarios or what might be in store and what implication would that have for the health and care system, Helen I think this might be one for you?
Helen: Yes, so really good question. It is the elephant in the room because it’s very hard to actually know what the implications are going to be at this stage because we don’t know how we’re going to leave and whether we’re going to leave and in what exact form we’re going to leave. But what we do know is that if we crash out for example, there will be huge implications for the NHS and we’re already talking about access to medicines and other supplies that patients need, particularly with long term conditions and ensuring that continued access is going to be a really high priority.
Obviously there’s also the impact on the workforce, we’re already seeing over the past year, we saw Brexit exacerbating shortages that already exist. So as I said earlier, the number of nurses leaving the NHS who come from the EU, now last year exceeded the number who came from the EU to join the NHS and depending on how we leave and our future immigration policy that could make things worse for the workforce at a time when we really, really don’t need that and particularly the social care workforce, where there’s this White Paper on immigration, our future immigration policy, I think it’s for consultation, but a £30,000 threshold for people coming in, which they need to meet in terms of earnings and that is for most social care staff, not a goer. So in terms of people continuing to come from the EU to work here and take up social care jobs that would have a huge impact.
There are also other themes of course, other issues that we need to be thinking about in the run up to Brexit. So the impact on research, universities accessing researches, the research field is hugely collaborative with universities across the EU and academics that come here from other EU countries so that could have an impact too and also the impact on public health. So lots of our regulations on public health have come from EU standards and depending on how we leave and the deal that we do, will potentially impact on things like how we deal with air pollution in future, that was a big issue and continues to be a big issue in this country. So yes, there’s so many issues there with Brexit and I guess, the questioner is right, it’s the elephant in the room and it’s quite a scary elephant because we really don’t know what’s going to happen.
Anna: We know don’t we that at the national level the preparations have really ramped up. We’ve seen reports the last few weeks about the focus that’s now being placed on preparing for those different scenarios and what they might look like, so definitely a big one for the forthcoming year. I’d add my own elephant in the room, is around what about social care? So we’ve had this long term funding settlement for the NHS, we’ve had this plan for the NHS, any of you can feel free to come in on this one, what about social care?
Dave: I agree, but back to the other elephant, I think Helen answered that beautifully well, it’s the wider economic implications on health that we just don’t understand and I haven’t looked at it yet but I will look at the public health Wales impact assessment on this, the research collaborations. But on the possibly positive side too, the UK currently is way above virtually all the minimum public health standards, I‘m not saying air pollution perhaps, but in terms of the cross government agreements, across European agreements.
Some people have argued that it might make it easier if there is the political will, which is the critical thing in this country, for instance, to go further and faster on things like food labelling etc. because we’re not so hamstrung by having to be on agreement with all the European regulation.
So in some areas there are potential to go further faster but that depends on political will here in a way. You’re quite right about social care, it’s a shame Simon isn’t with us, our social care lead but I completely accept both the sense that the Green Paper is being delayed, delayed and delayed, and also that correlation with, unless something changes around what we’re expecting from Brexit around workforce and social care.
Harry: And the Green Paper doesn’t deal with the funding which I think is crucial that that’s been ruled out, so not only has it been delayed, delayed, delayed but we’re looking at possibly just more sticking plasters year after year in the budget for social care which is not going to do it, it can’t, it’s creaking at the seams.
Anna: Yes, Helen any additional thoughts from you on the question of social care, what would we want to see happening in terms of the discussion on social care to take that forward?
Helen: We’d like to see a Green Paper, that would be a really good first step and then as Harry says, we need funding reform. That’s a massive issue for social care and it also impacts on the NHS. All this stuff that’s set out in the long-term plan in some ways is predicated on social care being sustainable and on social care doing its bit and right now, the local government budgets its ability to deliver on social care is really compromised.
And so if social care continues to be the weak part of the system, then it really does have an impact on the whole rest of the system and obviously also on the people who receive those services and that’s a huge ethical question for the country in terms of what are we doing on that? I would just like to add one other point before we end, which is, that we’ve been talking a lot about the long-term plan and I need to plug the long-term plan explainer that we’ve literally in the past 30 minutes published online. So for all your long-term plan needs, please visit the website, www.kingsfund.org.uk, to see what the King’s Fund thinks about the long-term plan and also it just explains all the different elements and set is out in what we hope is comprehensible language.
Anna: So you have beautifully brought us to the end of our discussion because we are out of time, it did fly by and we didn’t struggle to fill the time and we probably could fill another hour or more. Maybe we will after the cameras have turned off. So, thanks all it was a really interesting discussion and thank you everyone for sending in your questions. We did have a lot and so I apologise that we haven’t been able to ask them all.
As Helen says, if you do want to know more about what we think or the various issues we’ve discussed today, do take a look at our website, not only for the new long-term plan explainer but also for the other resources that are available there and some of them will be listed on your screen. If you also want to know even more, another option might be to sign up for one of our very popular health and care explained events which we’re holding this year in London and also in Leeds, so you can join us there too. So thanks again and do join us again for the next online event.