In 2014 the NHS England, the central executive body of the English health service, published its Five year forward view. The latest Long Term Plan represents a broad continuation of the policy direction.
The document has a dual role. Firstly, it is designed as a commitment to Government departments, Parliament and the general public that the substantial additional money announced for the NHS will be used to deliver ambitious and meaningful improvements.
The planned increase of £20.4 billion by 2023 – a real terms increase of 3.4% - comes after almost 10 years of very small funding increases, giving rise to a concern especially in the Treasury (finance ministry) that extra funding would be largely used simply repairing financial damage. In fact, it is indeed likely that the first 1-2 years of the period covered by the plan will largely be spent addressing this legacy.
Secondly, it represents a long list of instructions and ambitions aimed at the NHS system itself, designed to signal where investment should be targeted.
Chapter 1 sets out ‘A new service model for the 21st century’ with significant changes to outpatient care (substitution by digital and other redesign), digital GP consultations and further progress towards integration of primary, secondary and social care. Primary and out of hospital care will be strengthened through an increased proportion of the health budget being directed to these areas, largely through a greater rate of growth than hospital care, and the development of primary care networks.
This will be underpinned by a new GP contract which will incentivize practices to work together and to proactively identify people at risk in the population. The exact legal form of these is to be determined.
There will also be further development of ambulatory emergency care and the emergency care system more generally including the integration of out of hours GP services, the 111 telephone advice service and ambulances. A standardized model of urgent treatment centres will be created building on the very variable pattern of local provision.
The NHS Comprehensive Model of Personalised Care will be extended with an ambition to increase the number of people with Personal Health Budgets from 32,000. It is intended that the new model will cover 2.5 million people by 2023 and twice that by the end of the plan. Social prescribing will be extended with over 1,000 trained social prescribing link workers be in place by the end of 2020/21 rising further by 2023/24, with the aim that over 900,000 people are able to be referred to social prescribing schemes by then. There will also be increased support for nursing and care homes and for carers.
Digital-first primary care will become a new option for every patient improving fast access to convenient primary care. Outpatient services will be redesigned so that patients will be able to avoid up to a third of face-to-face outpatient visits, removing the need for up to 30 million outpatient visits a year.
The plan also marks a shift away from the English model of an internal health system market based on local payers – latterly known as “Clinical Commissioning Groups” – and separate local provider bodies. Instead it requires the participants in local systems to create ‘Integrated Care Partnerships’ (ICPs) bringing the two together.
These are required to have governance arrangements in place and where possible have one clinical commissioning group per ICP. The ICPs are likely to follow the foot print of the 44 strategic planning STPs (sustainability and transformation partnerships), and some of the early developments in this area have been a subset of the STP. These plans appear to be the precursor of some structural changes and are linked to arrangements for these partnership bodies to be accountable to the centre. This seems to represent something of a reassertion of central control over local areas although devolution experiments continue in a number of areas.
Chapter 2 signals increased emphasis on those areas of prevention within the ambit of the NHS (most public health functions are delivered by local authorities or Public Health England). These include smoking, alcohol, obesity and air quality
Chapter 3 contains proposals for improvements in disease areas where the UK’s outcomes are poor relative to other high income countries. The areas targeted are maternity and neonatal, child health, learning disability and autism, cancer, cardiovascular disease, stroke, diabetes, respiratory, mental health and waiting time for procedures. There will be investment in new rapid diagnostic centres to support this. Resources are also committed to research to improve outcomes in these and other areas. The CQC – the quality regulator –will place more emphasis on how the whole local delivery system works.
Chapter 4 commits to expansion of the workforce, more medical school places, improving staff retention and investment in leadership. There will be further work on staff retention. One interesting proposal is the expansion of multi-professional credentialing to enable clinicians to develop new capabilities formally recognised in specific areas of competence.
Chapter 5 states a number of bold ambitions about the deployment of digital tools to support improved patient engagement, support professionals in their work, improving safety and clinical efficiency and population health management.
The document has relatively little to say about change will be delivered and while choice is still seen as an important instrument in driving change in elective surgery there are proposals that would significantly weaken the use of market type mechanisms. Subject to legislation and government approval, provisions in chapter 7 suggest removing the requirement to automatically tender some services and curtail the powers of the competition regulator in healthcare.