On 7 January, the NHS long-term plan (formerly known as the 10-year plan) was published setting out key ambitions for the service over the next 10 years. In this explainer, we set out the main commitments in the plan and provide our view of what they might mean, highlighting the opportunities and challenges for the health and care system as it moves to put the plan into practice.

Introduction

For nearly a decade, the NHS has experienced a significant slowdown in funding growth, while demand for services – and the cost of delivering those services – has grown rapidly. Cuts to public health and social care funding have added further pressure. As a result, NHS performance has declined. Key waiting time targets are being consistently missed and the finances of NHS providers have deteriorated rapidly; in 2017/18, the year-end aggregate provider overspend was £960 million. Workforce shortages are widespread, with more than 100,000 whole-time equivalent staff vacancies in hospitals, including more than 40,000 nurse vacancies. Last year’s winter crisis – the effects of which were still being felt well into the summer – underlined the fragile state of the service.

In June 2018, the Prime Minister announced a new five-year funding settlement for the NHS: a 3.4 per cent average real-terms annual increase in NHS England’s budget between 2019/20 and 2023/24 (a £20.5 billion increase over the period). To unlock this funding, national NHS bodies were asked to develop a long-term plan for the service. The resulting document, the NHS long-term plan, was published on 7 January 2019.

This settlement represents a substantial improvement on the funding growth the NHS has seen since 2009/10, which has averaged approximately 1 per cent a year in real terms. Yet it remains below the average increases of 3.7 per cent a year since the NHS was founded and is less than the 4 per cent annual increases we and others have argued are necessary to meet rising demand and maintain standards of care.

NHS funding 2019/20 to 2023/34
NHS funding 2019/20 to 2023/34

The plan builds on the policy platform laid out in the NHS five year forward view (Forward View) which articulated the need to integrate care to meet the needs of a changing population. This was followed by subsidiary strategies, covering general practice, cancer, mental health and maternity services, while the new models of care outlined in the Forward View have been rolled out through a programme of vanguard sites.

It is important to stress that the funding settlement applies to NHS England’s budget only. This means that some important areas of NHS spending included in the Department of Health and Social Care’s budget – such as capital and education and training – are not covered by it. Local authority public health spending and social care are also excluded. Consequently, it is a plan for the NHS, not the whole health and care system. While it seeks to strengthen the NHS’s contribution in areas such as prevention, population health and health inequalities, the plan is clear that real progress in these areas will also rely on action elsewhere. The Spending Review, which is due to be published later this year and will outline the funding settlement for local government including social care and public health, will therefore have an important impact on whether wider improvements in population health can be delivered, as will the Green Papers on social care and prevention when they are eventually published.

Improving services

Clinical priorities

Perhaps the most striking commitments in the plan relate to a group of clinical priorities, chosen for their impact on the population’s health and where outcomes often lag behind those of other similar advanced health systems. These priorities include cancer, cardiovascular disease, maternity and neonatal health, mental health (see separate section below), stroke, diabetes and respiratory care. There is also a strong focus on children and young people’s health.

Clinical priorities
Cancer, cardiovascular disease, maternity and neonatal health, and mental health, are just some of the clinical priorities outlined in the plan.

In cancer care, the plan aims to boost survival by speeding up diagnosis. It includes a package of measures to extend screening and overhaul diagnostic services with the aim of diagnosing 75 per cent of cancers at stages I or II by 2028. A review of cancer screening programmes and diagnostic capacity will also be undertaken to report back in the summer. In 2020, a new waiting time standard will be introduced requiring that most patients get a clear ‘yes’ or ‘no’ diagnosis for suspected cancer within 28 days of referral by a GP or screening.

The maternity and neonatal section builds on the measures being implemented following the National Maternity Review with the aim of halving still births, maternal mortality, neonatal mortality and serious brain injury in newborn babies by 2025. Among a range of commitments, continuity of care during pregnancy, birth and after birth will be improved, bed capacity in intensive neonatal care will increase in areas where this is currently lacking and mental health services and other support for pregnant women and new mothers will be improved.

The plan sets out a number of actions to improve detection and care for people with cardiovascular disease (CVD) and respiratory disease, prevent diabetes and improve stroke services. The aim is to prevent up to 150,000 cases of heart attack, stroke and dementia over the next 10 years. In addition to the focus on maternity and neonatal services, specific commitments are included to improve outcomes for children with cancer, increase support for children with learning disabilities and autism and improve children and young people’s mental health services (see below). A new children and young people’s transformation programme will oversee the delivery of the commitments relating to children and young people. 

Primary and community services

In line with the Forward View and the General practice forward view, improving care outside hospitals is one of the headline commitments in the plan. Encouragingly, the plan backs this goal with money: by 2023/24, funding for primary and community care will be at least £4.5 billion higher than in 2019/20 – ensuring that their share of NHS spending increases over the period.

The plan confirms that general practices will join together to form primary care networks – groups of neighbouring practices typically covering 30–50,000 people. Practices will enter network contracts, alongside their existing contracts, which will include a single fund through which network resources will flow. Primary care networks will be expected to take a proactive approach to managing population health and from 2020/21, will assess the needs of their local population to identify people who would benefit from targeted, proactive support. To incentivise this, a ‘shared savings’ scheme is proposed, under which networks will benefit financially from reductions in accident and emergency (A&E) attendances and hospital admissions. The existing incentive scheme for GPs – the Quality and Outcomes Framework (QOF) – will also see ‘significant changes’ to encourage more personalised care.

There is also a strong emphasis on developing digital services so that within five years, all patients will have the right to access GP consultations via telephone or online. Primary care networks will also roll out the successful approach pioneered by the enhanced health in care homes vanguards so that by 2023/24, all care homes are supported by teams of health care professionals (including named GPs) to provide care to residents and advice to staff.

Alongside primary care networks, the plan commits to developing ‘fully integrated community-based health care’. This will involve developing multidisciplinary teams, including GPs, pharmacists, district nurses, and allied health professionals working across primary care and hospital sites. Over the next five years, all parts of the country will be required to increase capacity in these teams so that crisis response services can meet response times set out in guidelines by the National Institute for Health and Care Excellence (NICE). Access to social prescribing will be extended, with more than 1,000 trained link workers in place by the end of 2020/21.

Mental health and learning disabilities

Mental health funding

As with primary and community services, national leaders have used the long-term plan to reassert their commitment to improving mental health services, both for adults and for children and young people. This begins with funding: the plan reaffirms that mental health funding – provided through a ring-fenced investment fund – will outstrip total NHS spending growth in each year between 2019/20 and 2023/24 so that by the end of the period, mental health investment will be at least £2.3 billion higher in real terms.

In adult services, the plan signals an extension of commitments in the Five year forward view for mental health beyond 2020/21 to 2023/24. It aims to create a more comprehensive service system – particularly for those seeking help in crisis – with a single point of access for adults and children and 24/7 support with appropriate responses across NHS 111, ambulance and A&E services. It also highlights the need for capital investment, as identified by a recent review of the Mental Health Act, to ensure suitable therapeutic environments for inpatients.

Mental health support teams in schools

Similarly, the plan commits to a significant expansion of services for children and young people in line with the proposals outlined in the Green Paper on young people’s mental health – for example, the creation of ‘mental health support teams’ in schools. To support these changes, the plan mandates that investment in children and young people’s mental health provision will grow faster than the overall NHS budget and total mental health spending.

There are two significant commitments to developing new models of care. The first is to create a comprehensive offer for children and young people, from birth to age 25, with a view to tackling problems with transitions of care. The second is to redesign core community mental health services by 2023/24, reinforcing components such as psychological therapies, physical health care and employment support, as well as introducing personalised care and restoring substance misuse support within NHS mental health services. These commitments will be backed up by new waiting time standards covering emergency mental health services by 2020, children and young people’s mental health services and, over the next decade, adult community mental health treatment.

There is also a strong focus on improving care for people with learning disabilities and autism. Commitments include increasing access to support for children and young people with an autism diagnosis, developing new models of care to provide care closer to home and investing in intensive, crisis and forensic community support. The aim is that, by 2023/24, inpatient provision for people with learning difficulties or autism will have reduced to less than half of the 2015 level.

Acute services

Urgent and emergency care

The plan includes a significant package of measures aimed at reducing pressures on A&E departments. Many of the measures build on previous initiatives, including the introduction of clinical streaming at the front door to A&E and the roll-out of NHS 111 services across the country. 

The plan commits to rolling out urgent treatment centres (UTCs) across the country by 2020 so that urgent care outside hospitals becomes more consistent for patients. UTCs will be GP-led facilities and will include access to some simple diagnostics and offer appointments bookable via NHS 111 for patients who do not need the expertise available at A&E departments. Alongside this, the plan aims to improve the advice available to patients over the phone and extend support for staff in the community by introducing a multidisciplinary clinical assessment service (CAS) as part of the NHS 111 service in 2019/20.

Clinical assessment service

Over the same timeframe, all major A&E departments will introduce same day emergency care (also known as ambulatory emergency care). This will see some patients admitted from A&E undergo diagnosis and treatment in quick succession so that they can be discharged on the same day, rather than staying in hospital overnight. The plan estimates that up to one-third of all people admitted to hospital in an emergency could be discharged on the same day by rolling out this model. Despite ongoing concerns about operational performance in emergency care, the plan does not make any commitment on the four-hour A&E target, postponing any decision to restore performance standards until the Clinical Review of Standards reports in the spring.

Same day emergency care

Ambulance services are tasked with implementing the recommendations of a recent review of operational performance led by Lord Carter and will be subject to a new commissioning framework.

Wider acute services

Unlike some previous NHS strategies, the long-term plan does not assume that moves to strengthen primary and community care will reduce demand for inpatient hospital care. Instead, its plans for hospital bed numbers and staffing assume that acute care will grow broadly in line with the past three years (although the plan does not specify what figure it is using for this).

The plan includes an ambitious pledge to use technology to fundamentally redesign outpatient services over five years. The aim is to avert up to a third of face-to-face consultations in order to provide a more convenient service for patients, free up staff time and save £1.1 billion a year if appointments were to continue growing at the current rate. It is not yet clear what this redesign will involve.

Although the plan notes that these changes will have implications for how waiting times performance is calculated, there is no commitment to meet the 92 per cent target for 18-week waits. Instead, over five years, the volume of planned activity will increase year-on-year to reduce long waits and cut the number of people on the waiting list (currently more than 4 million). The commitment to reduce long waits is given teeth by the reintroduction of fines for providers and commissioners where patients wait 12 months or more.

Reducing delayed discharges from hospital remains a priority. The plan aims to cut the average number of daily delayed transfers of care (DTOC beds) to around 4,000 and maintain that level over the next two years before reducing it further (DTOC beds averaged 4,580 in November 2018). Changes to primary and community care may help here, although investment in social care will also be crucial.

The plan signals changes to the configuration of hospital services. NHS Improvement will back hospitals that want to split their services into ‘hot’ and ‘cold’ sites (for emergency and planned work respectively). Trusts will be supported to collaborate to improve services (for example, through provider groups) and, where appropriate, formal mergers will be green-lighted. Further consolidation of specialist stroke services is also signalled and there is a commitment to a standard delivery model for smaller acute hospitals serving rural populations.

Resources

Finance and productivity

Although on current forecasts the NHS as a whole is expected to be in balance in 2018/19, many individual providers and commissioners are struggling to eliminate deficits. When the Prime Minister announced the new funding settlement, she was clear that, over time, all NHS organisations should get back into balance. The penultimate chapter of the plan sets out how this will be achieved.

There are commitments to return the provider sector to balance by 2020/21 and for all NHS organisations (commissioners and providers) to balance by 2023/24. To achieve this, NHS Improvement will deploy an accelerated turnaround process in the 30 worst financially performing trusts and a new financial recovery fund, initially £1.05 billion, will also be created for trusts in deficit who sign up to their control totals. Much of the detail relating to these initiatives is left to the recently published Planning Guidance.

The problems currently being experienced by providers partly reflect flaws in an NHS financial regime that is in desperate need of reform. The measures in the plan – which follow on from changes to the system of central financial support already announced by national NHS bodies – are an effort to address this. They include changes to the payment system to support a shift away from activity-based payments to population-based payments, although this will need to fit with ‘ring-fenced’ funding set aside for primary and community care and mental health services. The plan also proposes changes to the ‘market forces factor’ (an adjustment made to the tariff to reflect the costs of delivering services in different areas), to be phased in over the next five years.

There are a number of measures aimed at supporting delivery of integrated care and incentivising system-based working to improve population health. In 2019/20, as part of the process of moving towards system control totals, sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) will be given more flexibility to agree financially neutral changes to control totals for individual organisations within their systems. From 2019/20 onwards, further reforms will give ICSs greater control over their resources will be introduced, through a process of ‘earned financial autonomy’, to be assessed on the basis of their financial and operational performance. Changes to the commissioning allocations for Clinical Commissioning Groups (CCGs) will support the plan’s focus on tackling health inequalities and better reflect need for mental health and community services.

There is also a focus on ‘getting the most out of taxpayers’ investment’ in the NHS – to be delivered in part through productivity growth of at least 1.1 per cent a year for the next five years. To achieve this, the plan sets out 10 priority areas which largely expand on existing schemes such as erostering, centralised procurement, e-prescribing, stopping low-value treatments, and improving access to information, with the plan suggesting that uptake of these will be on a ‘comply or explain’ basis at board level. The plan also requires the NHS to deliver savings from administrative costs of more than £700 million by 2023/24, with commissioners expected to deliver £290 million and providers £400 million.

Workforce

Workforce shortages are currently the biggest challenge facing the health service. The plan explicitly recognises the scale of this challenge and sets out a number of specific measures to address it. However, many wider changes will not be finalised until after the 2019 Spending Review, when the budget for training, education and continuing professional development (CPD) is set. To inform these reforms, NHS Improvement, Health Education England and NHS England will establish a cross-sector national workforce group and publish a workforce implementation plan later in 2019.

For nursing, the aim is to reduce the vacancy rate from 11.6 per cent to 5 per cent by 2028. To achieve this, as well as the previously announced 25 per cent increase in nurse undergraduate placements, the plan commits to funding a 25 per cent increase in clinical nursing placements from 2019/20 and an increase of up to 50 per cent from 2020/21. More accessible routes into nursing will also be introduced, including a new online nursing degree linked to guaranteed clinical placements and continued investment to support an expansion of apprenticeships, with new nursing associates starting in 2019.

The plan reiterates the Department of Health and Social Care’s commitment to increase medical school places from 6,000 to 7,500 per year and suggests that this figure could increase if further funding is provided in the Spending Review. There is also an ambition to shift the balance from specialised to generalist roles in line with the needs of patients with multiple long-term conditions. To support general practice, the intention is to continue to increase the number of other members of the primary care team, such as clinical pharmacists and physiotherapists, although much of the detail on this is again left to the forthcoming workforce implementation plan.

Workforce shortages
The plan outlines steps to address workforce shortages in the health service.

The plan sets a long-term ambition to train more staff domestically. In the meantime, it emphasises the need for a continued inflow of international recruits. The forthcoming workforce implementation plan will outline new national arrangements to support NHS organisations with overseas recruitment and explore the potential to expand the Medical Training Initiative. The ambition is to deliver a step change in the recruitment of international nurses, increasing the number recruited by ‘several thousand’ each year over the next five years.

The plan recognises the important role that volunteers play in the NHS, committing £2.3 million to Helpforce, which has been charged with scaling capacity for volunteering in the NHS.

Digital

Digital technology underpins some of the plan’s most ambitious patient-facing targets. The NHS app will act as a gateway for people to access services and information; by 2020/21, people will be able to use it to access their care plan and communications from health professionals. From 2024, patients will have a new ‘right’ to access digital primary care services (eg, online consultations), either via their existing practice or one of the emerging digital-first providers. By the end of the 10-year period covered by the plan, the vision is for people to be increasingly cared for and supported at home using remote monitoring (via wearable devices) and digital tools. Digital technology will also facilitate service transformation, including the redesign of outpatient services and reorganisations of pathology and diagnostic imaging services.

To deliver ‘digitally enabled care’ as envisaged, the plan reiterates the previously stated ambition that all secondary care providers become ‘fully digitised’ by 2024 (a deadline that has slipped from the original target to be ‘paperless’ by 2020). This will involve NHS organisations putting in place electronic records and a range of other digital capabilities. The Global Digital Exemplars programme will admit new organisations and create models for technology adoption and a shared record through Local Health and Care Record Exemplars.

Digital technology
Digital technology underpins some of the plan's most ambitious patient-facing targets.

To facilitate these changes, a number of policies previously announced by the Secretary of State have now become firm commitments. For example, NHS organisations will be required to have a chief clinical information officer or chief information officer at board level by 2021/22. Similarly, to promote interoperability, there is now a commitment to introduce controls during 2019 to ensure that technology suppliers to the NHS comply with agreed standards.  

Leadership and support for staff

The plan acknowledges that the ability of the NHS to deliver high-quality care and meet the complex challenges it faces will depend on ‘great leadership’ at all levels of the health and care system. While the vision is for leadership that is both compassionate and diverse, its current assessment is that, while this is present in some parts of the NHS, it is ‘not yet commonplace’. 

To build these capabilities, national NHS bodies commit to a range of actions to better support leaders, including doing more themselves to model the style of leadership they wish to see elsewhere in the system, and developing a new ‘NHS leadership code’ that will enshrine expected cultural values and behaviours. Once established, the national workforce group will also consider a range of options to improve the NHS leadership pipeline, including expanding the NHS graduate management training scheme and the potential for a professional registration scheme for senior NHS leaders. All of these actions will build on existing recommendations in the national strategic framework, Developing people – improving care.

The plan also says more will be done to develop and embed cultures of compassion, inclusion and collaboration across the NHS. Specific actions include programmes and interventions to ensure a more diverse leadership cadre, a focus on increasing staff understanding of improvement knowledge and skills, and new pledges to better support senior leaders (including improving the approach to assurance and performance management). NHS England will also extend the work of the Workforce Race Equality Standard, funding it to 2025. As part of this, every NHS organisation will set a target for black, Asian and minority ethnic (BAME) representation across its leadership team and workforce by 2021/22, aiming to ensure that senior teams more closely represent the diversity of the communities they serve. 

More broadly, the plan commits to do more to support current staff, including increasing investment in CPD (although this will depend on the outcome of the Spending Review), taking steps to promote flexibility and career development, and tackling bullying and harassment. The forthcoming workforce implementation plan will provide details of a ‘new deal’ for frontline staff. 

System priorities

Role of patients and carers

The long-term plan calls for a ‘fundamental shift’ in the way that the NHS works alongside patients and individuals. Highlighting the need to create genuine partnerships between professionals and patients, it commits to training staff to be able to have conversations that help people make the decisions that are right for them. There is also a commitment to increasing support for people to manage their own health, beginning in areas such as diabetes prevention and management. This forms part of a broader cultural change, moving towards what we have described as ‘shared responsibility for health'.

Shared responsibility
The plan includes a commitment to increasing support for people to manage their own health and highlights the need to create genuine partnerships between professionals and patients.

As part of this shift, the plan focuses on personalisation. There is a commitment to rolling out the NHS comprehensive model of personalised care (which brings together 6 programmes aimed at supporting a whole population, person-centred approach), so that it reaches 2.5 million people by 2023/24, with an ambition to double that figure within a decade. Referrals to social prescribing schemes will increase, broadening the range of support available, and the roll-out of personal health budgets will be accelerated, so that these are in place for up to 200,000 people by 2023/24.

The plan also includes a welcome focus on supporting carers. This includes introducing quality markers for primary care, highlighting best practice in identifying carers and providing them with appropriate support. It also encourages the national roll-out of carer’s passports, which enable staff to identify someone as a carer and involve them in the patient’s care and promises a more proactive approach to supporting young carers.

Integrated care and population health

The plan confirms the shift towards integrated care and place-based systems which has been a defining feature of recent NHS policy. ICSs will be the main mechanism for achieving this – the plan says that ICSs will cover all areas of England by April 2021 – and will increasingly focus on population health.

Population health
The plan confirms the shift towards integrated care and place-based systems, with an increasing focus on population health.

The plan outlines several core requirements for ICSs (such as the establishment of a partnership board comprising representatives from across the system) but stops short of setting out a detailed blueprint for their size or structure. Systems will be required to ‘streamline’ commissioning arrangements, which will ‘typically involve’ a single CCG across each ICS. It also recognises that NHS organisations will need to work in partnership with local authorities, the voluntary sector and other local partners to improve population health.

From 2019, population health management tools will be rolled out, enabling ICSs to identify groups at risk of adverse health outcomes and inequalities and to plan services accordingly. ICSs will also be supported by changes to funding flows and performance frameworks. A new ICS accountability and performance framework will consolidate local performance measures and a new integration index will measure patient and public views about local service integration. Existing approaches to bringing together health and social care budgets are also encouraged, with an expectation that the social care Green Paper will set out further proposals. There will also be a review of the Better Care Fund.

The move towards a more interconnected NHS will be supported by a ‘duty to collaborate’ on providers and commissioners, while NHS England and NHS Improvement will continue efforts to streamline their functions. The plan suggests that progress can continue to be made within the current legislative framework but also puts forward a list of potential legislative changes that would accelerate progress, in response to requests from the Health and Social Care Select Committee and the government. The proposed changes include allowing joint decision-making between providers and commissioners and reducing the role of competition in the NHS.

Prevention and health inequalities

The plan signals a clear focus on prevention, recognising that the NHS can take important action to ‘complement’ – but not replace – the role of local authorities and the contribution of government, communities, industry and individuals. A ‘renewed’ NHS prevention programme will focus on maximising the role of the NHS in influencing behaviour change, guided by the top five risk factors identified by the Global burden of disease study: smoking, poor diet, high blood pressure, obesity, and alcohol and drug use.

Commitments include the provision of alcohol care teams in a quarter of hospitals with the highest rate of alcohol dependence-related admissions, and a promise that by 2023/24, NHS-funded tobacco treatment services will be offered to all smokers admitted to hospital. There are also plans to introduce new programmes for specific diseases and conditions, and to scale up existing ones. For example, the number of places on the Diabetes Prevention Programme will double over the next five years. Acknowledging the contribution the NHS can make to action on air pollution, the plan also commits to reducing the mileage and air pollutant emissions from the NHS fleet by 20 per cent by 2023/24.

ICSs will have a key role in helping to deliver these programmes and in working with local authorities, the voluntary sector and other local partners to improve population health and tackle the wider determinants of ill health. Significantly, the plan indicates that the NHS and government will consider whether the NHS should have a ‘stronger role’ in commissioning sexual health services, health visitors and school nurses (currently commissioned by local government). Spending in these areas is not covered by the plan as it is routed through local authorities.

Health inequalities

The plan commits to a ‘more concerted and systematic approach to reducing health inequalities’, with a promise that action on inequalities will be central to everything that the NHS does. To support this ambition and to ensure that local plans and national programmes are focused on reducing inequalities, specific, measurable goals will be set. Local areas will need to set out how they will achieve this, drawing on a menu of evidence-based interventions developed by NHS England, Public Health England and others. Changes to commissioning allocations for CCGs will ensure that a higher share of funding is targeted at areas with high inequalities and a review of the inequalities adjustment to funding formulae will be undertaken.

The plan includes specific goals for particular groups – for example, greater continuity of midwife care for black, Asian and minority ethnic women and women from deprived groups; an increase in physical health checks for people with severe mental health. The plan also identifies £30 million worth of investment in meeting the needs of rough sleepers and ensuring better access to specialist mental health support.

Implementation

Further detail on how the commitments in the long-term plan will be implemented will be set out in a national implementation framework, due to be published in spring 2019. However, there are a number of other plans and reviews will have an impact on how the plan is implemented. These include the following:

  • a clinical review of standards setting out expectations on operational performance, including a review of waiting time targets, due to be published in spring 2019 
  • a workforce implementation plan, overseen by a cross-sector national workforce group, due to be published later in 2019 
  • a review of the Better Care Fund, due to be completed in early 2019.

The Spending Review will outline funding for areas of NHS spending not covered by the plan such as workforce training and capital investment, as well as for social care and local authority-funded public health services. The social care Green Paper is expected to set out options for social care funding and proposals for health and social care integration. The prevention Green Paper, also expected in 2019, will focus on delivering the vision for prevention published in November 2018.

The plan is intended to provide a ‘framework for local planning’ over the next five years. Local areas have received indicative financial allocations for 2019/20 to 2023/24 and, in the short term, will be expected to develop plans for implementing the long-term plan’s commitments in 2019/20, a transitional year, as well as developing five-year system plans by the autumn. These plans will be ‘brought together in a detailed national implementation programme’ in the autumn of 2019.

Reflecting on the plan

Overall, the long-term plan amounts to an ambitious set of commitments within the constraints of the funding available. It is firmly focused on the future, rather than simply shoring up current models of care, and sets the right direction for the NHS by focusing on delivering joined-up, personalised, preventive care, and expanding primary and community services.

The plan signals both evolution and revolution

In many respects, the plan signals continuity rather than change. The focus on ICSs and expanding new models of care builds on the agenda set by the Forward View. Many of the chosen clinical priorities, including mental health and primary and community services, have also been singled out for attention in recent years. This reflects a constancy of purpose that has often been missing in health policy and should allow the NHS to build on recent progress.

Although the level of detail in the plan is variable, it differs from the Forward View by focusing more on delivery and implementation. There are measures to accelerate progress towards integrated care, for example by aligning regulation and providing funding for primary and community care. It signals a shift in gear from the bottom-up, iterative approach that followed the Forward View, while retaining a balance between national prescription and local autonomy. However, there is now no doubt that the NHS is moving rapidly away from the focus on organisational autonomy and competition that characterised the Lansley reforms.

There are some notable omissions from the plan. Multi-morbidity is barely mentioned despite the growing number of people living with multiple long-term conditions. In contrast to the Forward View, the plan is relatively silent on how the NHS will work with communities and engage patients and the public in shaping services. Also significant is the absence of any commitments to current waiting time targets - these are on hold until the clinical review of standards is published later in the year.

If delivered, the plan could make a positive difference to patients

The ambition to deliver more personalised, joined-up and proactive care – if it can be delivered – could make a significant difference to patients and change how they interact with health services. Potential benefits include: fewer handoffs and referrals for patients receiving care in the community; more NHS support for people in care homes; better access to services spanning mental health, general practice and community crisis response teams; fewer trips to outpatient appointments; more services and information available online; and more opportunities for people to make decisions about their own care.

By assuming that demand for acute services will continue to increase at roughly its current rate, the plan provides a welcome dose of realism and avoids the mistake made in predecessor plans of assuming that strengthening primary and community services will result in reduced demand for hospital care. Changes to acute services include significant reforms to urgent and emergency care, a major overhaul of outpatient services, more hospitals splitting services between hot and cold sites, further consolidation of stroke services and possible changes to service configurations if more hospitals take up the green light to merge. Taken together, this adds up to an ambitious agenda for change that could provide significant benefits for patients. Delivering it will require skilful leadership and a concerted effort to involve patients and communities.

The plan seeks to balance national direction and local autonomy

A consistent lesson from previous attempts at NHS reform is that central directives on their own often fail to deliver the improvements envisaged. To overcome this, the approach to delivering the plan balances national direction with local autonomy. National expectations are made clear and local systems will be accountable for contributing to national programmes on a ‘comply or explain basis’. At the same time, the plan promises that local implementation will be led by clinicians and leaders who are directly accountable for patient care.

This means that much is riding on the ability of local systems to deliver. ICSs are singled out as being central to the delivery of the plan. However, their development is currently much more advanced in some areas than others, and even the most advanced systems are in their early stages. ICSs have no formal powers or accountabilities (the plan does not suggest any change to this) and progress is dependent on the willingness of individuals and strength of local relationships. There are also high expectations on primary care networks as the key mechanism for delivering the expansion in primary and community services outlined in the plan. However, these are a long way from existing in the form or on the scale envisaged. Providing support for ICSs and primary care networks and building local leadership capacity and capability should therefore be key priorities.

National bodies have an important role in removing barriers to local implementation. This is recognised in the plan and reflected, for example, in the commitment to align regulation through a new ‘shared operating model’ across NHS England and NHS Improvement, and the emphasis placed on the performance of systems as well as organisations. This will also need to be reflected in the behaviours of regulators on the ground. The potential changes to the legislative framework also seek to remove barriers and accelerate change but the prospect of parliament passing new legislation remains unlikely in the short term. In the meantime, the plan is right to stress that the immediate priority is to continue making progress within existing legislation.

This is the NHS’s plan but the NHS does not operate in isolation

NHS leaders have done what was asked of them by delivering a forward-thinking plan that sets out how the NHS will spend the additional money promised by the government. It is essential to view the plan within this context, and to recognise its limitations. Critical interdependencies exist between the NHS and local government, wider public services and communities. A plan for the NHS cannot fully address this wider context, particularly when there is so much uncertainty about the future of social care and public health budgets are being cut.

The decision to delay publication of the social care Green Paper is a missed opportunity to tackle the issues facing and health and social care in a joined-up way. Delivery on many of the plan’s flagship commitments will depend on closer integration between health and social care, but the plan says relatively little about how NHS bodies and local authorities will work together to achieve this. The plan highlights the importance of a well-functioning social care system and notes the government’s commitment to ensure that decisions about social care funding do not impose any additional pressure on the NHS. However, the funding settlement for social care will not be known until the Spending Review later this year.

The commitment of the NHS to play its part in improving prevention and reducing health inequalities should be applauded but these aims cannot be achieved by the NHS in isolation. Partnerships between the NHS and local government will be key to delivering improvements in population health. ICSs should ensure that local authorities are equal partners and engage with the voluntary sector, patients and communities. Central government must also play its part by following through on the recent vision for prevention and using the forthcoming Green Paper on prevention to set out an ambitious agenda for improving the population’s health. This should include reversing cuts to public health budgets and being bolder about using other mechanisms at their disposal including tax and regulation to drive improvements in population health.

From planning to delivery

The long-term plan marks a significant step forward in setting the NHS on a sustainable course for the next decade. The main challenge will be to translate this into delivery. Even with exceptional leadership and the continued commitment of staff, delivering the extensive list of commitments outlined in the plan is a daunting task.

While the funding settlement is a significant improvement on the constraints of recent years, it is not a panacea. The NHS will continue to face tough choices about how to prioritise resources. One of the most important of these decisions – what to do about recovering waiting times standards – has been postponed. Patients are likely to continue to face longer waits for treatment for the foreseeable future.

The greatest risk to delivery is workforce shortages. Put simply, the NHS will not be able to achieve its ambitions if it does not have the number and type of staff that it needs. Much is now riding on the workforce implementation plan due later this year. While the long-term plan is an important piece of the jigsaw, the picture is far from complete.

With thanks to the policy leads and other colleagues for their contribution to this explainer.

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Comments

Michael Sharpe

Position
Professor and lead for integrated psychological medicine,
Organisation
Oxford University Hospitals NHSFT
Comment date
24 January 2019

As you comment the plan has little to say about arguably the biggest problem the NHS faces- multimorbidity, especially in the elderly. This needs truly integrated medical psychiatric and social care.

Treating 'mental health' seperately from 'physical health' is a major missed opportunity.

Lets hope it is grasped soon.

Harry Longman

Position
Chief Executive,
Organisation
askmyGP
Comment date
24 January 2019

I do wonder why the plan makes patients wait until 2024 to have a "right" to digital access to their GP. We're doing it now, over half of episodes now starting digitally. And in any case, patients have been able to order repeat prescriptions, see their records and allegedly book appointments online for some years now.
It hasn't worked, and rather than print more vague promises, NHS England would do better to understand why it hasn't worked. We'll tell them for nothing if they ask.

Richard Spicer

Position
Retired consultant surgeon,
Organisation
NHS
Comment date
24 January 2019

As highlighted by the King's Fund and others the biggest single problem is clinical staff shortage. The government seems to think that this can be overcome by 'technology'. It can not. Until politicians recognise that they have caused this problem it is never going to improve. If staff feel valued and their working conditions are satisfactory they will be recruited and retained.

Fabien Wecker

Position
RN,
Comment date
24 January 2019

It is a plan with great prospect. However, it is astonishing that education is not part of this "forward-looking" vision that merely seems to lay the foundation for a theoretical paradigm. Education should not be reduced to the mere dissemination of information. Rather, its overarching goal is to support learners in the process of being taken out of what they already (believe they) know in order to be led into one of newfound realization, whilst simultaneously making them aware of their learning journey to allow for knowledge crystallization. This process prevents patients and staff to mindlessly go through the motions just for being told to do so.

Rhuosa Ehimatie

Position
student nurse,
Organisation
Wolverhampton University
Comment date
29 January 2019

I appreciate the size of the task for the NHS cohort, but if things are to start improving and working well again in this country we need to approach challenges like we mean business as it is obtainable in other progressive, none- English speaking European nations where they really contemplate problems critically and come up with workable solutions instead of just mere posturing and waiting for a pat on the shoulders for fair attempt. Perhaps, it is the language, and they spend more emphasis on colourful, high -sounding, intelligent and cooperate words and terms that signify or do not amount to much to the ordinary man on street. Perhaps this is how they win their contracts, so that year on year, you have the same or similar group of old boys and girls being commissioned to review high profile situations with big promises and short on delivery, waste of public fund, waste of time. Like Harry Longman (Chief executive askmyGP) said, why don`t they ask the real people who are involved in the real life situation of human difficulties who know better? If they do, they will soon realize why some of their ideas are not working or will just not plug the holes. Take nursing for example, the country continue to look further afield to recruit nurses from abroad who have to spend more time understanding the language and culture of their patients to adequately care for them and yet, you have thousands of British citizens and residents who are willing to train as nurses and healthcare professionals but have no adequate support especially in the hostile environment like placement where students are treated poorly to the point of wanting to leave the profession altogether, yet the government announced 25 per cent increase in nurse undergraduate placements, and the plan commits to funding a 25 per cent increase in clinical nursing placements from 2019/20 and an increase of up to 50 per cent from 2020/21 plan, pushing more students into placement. Let me be clear, placement is good but my goodness, does the government realize the difficulties most student face whilst in placement? A majority of students on placement are disillusioned about the profession by the time they complete their placement. This is not because the placement is hard but because it has been made unpleasant due to the attitude of qualified staff and leadership in the ward hence students fail or quit the profession altogether. The government should be spending more time trying to find out why such a high drop out rate for nursing students and newly qualified nurses and how to support them and make their working environment suitable so that students want to stay, when student stay it leads to more qualified nurses and this in turn makes the profession more attractive, (word of mouth) more people taking up the profession, less dependency on foreign nurses, less money spent on foreign recruitment and retraining for nurse recruits.
The other point is about digitalization in care. This sound good, but as already mentioned it is already operational with little result why spend more especially when some GP cannot type, cannot make out time to learn to type and have no time to listen to the patient in front of them so is it when they are on line that they will have the time to listen to them? The list goes on. So, are they going to waste this money and waiting for couple of years to review it after it has failed to achieve its goal and then reconstitute a special committee out of the old group to do the same thing all over again after 3 or 4 years? This is not the way forward.

John Keyes

Position
Chair of Public Sector,
Organisation
Cushman & Wakefield
Comment date
29 January 2019

I am constantly frustrated at why the NHS estate - its bricks and mortar - is not recognised as a key part of the NHS "resource". I understand that there may be greater, more pressing priorities but the estate is fundamental to a more effective service. We need more community facilities, in the right place, and more care beds. We also need to re-model hospitals to deliver new systems of care and need to address backlog maintenance which is a long term drain on funding and delivery.

Revd Paul Brothwell

Position
Retired Hspital Chaplain (Kidderminster),
Organisation
Kidderminster & Worcestershire Prostate Cancer Support Group
Comment date
30 January 2019

Over the past years successive Governments have spoken on, the integration between the NHS organisations and how they need to work in partnership with local authorities, and the voluntary organisations. We do not see this happening. When will these ideas be taken more seriously and implemented? Do you think C.C.Gs and STP should be trained on how to integrate with voluntary and support groups like ours?

Tim Houghton

Position
Chief Executive,
Organisation
Communities First Wessex
Comment date
31 January 2019

The plan highlights the importance of social prescribing in helping to tackle the underlying causes, issues and circumstances that impact a person's health. Voluntary and community organisations have a significant role to play and can add great value to helping NHS resources go further. There are many local and regional examples of where this is working. Whilst there are some hints at investment and recognition that voluntary doesn't mean 'free', it's concerning that subsequent announcements suggest that the NHS itself is going to recruit staff to deliver social prescribing. The key to success is working with the sector to ensure resources follow the patient and that the wide variety of advice, social activities and voluntary sector support on which social prescribing is based, can continue to respond to the ever increasing demand and increase in referrals from GPs and other clinicians.

Umesh Prabhu

Position
Was Medical Director for 15 years,
Comment date
13 February 2019

Plan is only a plan and leadership is making the plan a reality. When I was the Medical Director of Wrightington, Wigan and Leigh FT, we reduced harm to patients by 90% simply by transforming culture of bullying, racism and closed culture to an open culture, duty of candour and putting patient safety and staff happiness at the heart of everything we did. It was done by uniting everyone for a common purpose and putting patients and patient safety at the heart. 70 staff came to meet the leaders in confidence as we empowered staff to speak up and we had to dismiss few bad doctors, remove few bad bullying managers and change many leaders. Leadership is honesty, sincerity, integrity, truth, justice, fairness and sheer determination to succeed or to lead successfully or to transform

Transform means to change. Transformational leaders know their purpose and they are value based leaders and they do not compromise their values. NHS long term plan is the only solution but it needs leaders with values, good governance, excellent staff and patient engagement. It also needs good governance and accountability for managers and leaders and also to each and every staff. It is called just culture.

Without good governance and accountability nothing will change. Integrated care is the right way forward and it needs honest kind caring compassionate leaders with integrity and courage to held everyone to account and to deliver the plan.

Susan Boex

Position
Retired,
Comment date
26 February 2019

It is disappointing that there is barely any mention of dementia but this is going to be a heavy burden on the NHS - will this come under mental health umbrella or multi morbidities where again there is barely any mention of. People with multiple long term conditions are not getting the support they need is it any wonder why they turn to the hospitals for help and why our hospitals are under pressure and can’t cope.
I really do hope there will be support for carers - as a carer for my Mother I had no support even though my own health was at risk. A 6 month wait to have a social worker visit where is this myth of person centred care. My Mother was dying of cancer - it was a Monday when we asked for a bed at the local hospice - she could have an assessment on the Thursday - she died on Friday - we desperately need more co-ordinated care, more care beds and more care

Michael Gocman

Position
Retired,
Comment date
18 March 2019

The primary care networks are a rehash of the Total Purchasing Pilots 1995-1999 audited by the King's Fund. My own pilot the New River TCP determined the minimum size of these Primary Care networks tobe 50000 population as the financial and workforce risks were too great otherwise.

Unfortunately there is here a lot of duplication & crossing boundaries with GP Federations and waste of funding relating to organisational change. These Primary Care Networks are unlikely to work effectively given the severe workforce crisis in the NHS especially in Primary Care.

Andrew Harris

Position
Clinical Psychologist,
Organisation
NHS
Comment date
10 June 2019

Unless local authorities, GP's and Secondary Services recognise how socio-economics are impacting on mental health difficulties and work together, patients are always going to be falling through the gaps and revolving doors. We cannot ever expect patients to recover from trauma if there's no safety net. We're also off-rolling those with long term mental health difficulties and leaving them with no therapy at all or therapy in a year's time or more. Patients are dying needlessly, as a result.

John Finch

Position
Retired senior lecturer in healthcare law,
Organisation
Private
Comment date
15 June 2019

The language of the document reveals the unwelcome recent tendency among healthcare organisations to use a 'quantitative' vocabulary, as well as to confuse words which describe a desirable means and a desired result. 'Good practice' has been replaced by 'benchmarks', and these have been replaced by 'targets'. They are related, but each has a separate and assignable meaning. Healthcare is a value, not a commodity, and the loose use of 'delivery' is inappropriate. 'Delivering on a target' is meaningless. Even the estimable King's Fund uses the inappropriate term 'investment' in health services. Apart from the widely discredited PFI initiative, where the term 'investment' is clearly relevant, healthcare providers do not 'invest'. They spend taxpayers' money. Healthcare provision in the UK faces enough difficulties without the use of language which may sound clever but isn't.

Hedley Piper FRCS

Comment date
15 August 2019

Long on changes in management and all the talk of technology but very short on actual management and treatment of patients. A hospital can be run by less than 80 people ! I worked in one.
Clinical history and actual examination of the patient is still key to diagnosis. So far my wife and I have driven over one hundred miles to see various 'lightly' qualified people and for tests and we still have not got an orthopaedic opinion from a practising orthopaedic surgeon. There are 18 in our local DGH ! There used to be 5 !
I fear that it is a plan drawn up by those with very little practical experience of managing sickness, disease, trauma and elective procedures. Even the length of these "papers" is indicative of much of the guff that you are now producing, sorry.

Marc Farr

Position
Chief Analytical Officer,
Organisation
East Kent Hospitals
Comment date
10 October 2019

Under 'Digital' the word 'data' appears once - wrongly suggesting that the KF referenced the exciting demand for Analytics, instead just referencing the cables and wires section ie IT. The IT 'kit' will naturally improve, industry will account for that; people will have better phones and faster wifi than they have now. What needs more attention is this opportunity that Analytics presents - for patients, clinicians and managers to really understand what's going on. The NHS Digital Academy is also guilty of this - assuming that being able to book a GP or OP appt on line is the only target. That's the easy stuff.

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