The government has published its 160 page vision for an NHS that will be more local, more personal, and more tech-enabled. But what’s in it, and what should health tech suppliers take away from it?
The 10 Year Health Plan for England opens with prime minister Sir Keir Starmer telling the NHS it must “reform or die” and closes with health and social care secretary Wes Streeting exhorting readers to “be the change.”
Between these two points, Fit for the Future runs to more than 160 pages of ideas, assertions, and vignettes of what the health and care system could be like in 2035. Yet the immediate reaction from think-tanks and representative groups is that the plan lacks detail, particularly when it comes to delivery.
“The plan contains a litany of initiatives and the belief that they will be the NHS’ saviour, with little detail on how the ailing health service is to deliver these changes,” said Nuffield Trust chief executive Thea Stein, who went on to point out the health service has little headroom for radical thinking, amid rising demand and constrained finances.
Worse, she added, “the plan, like so many before it, assumes that preventing ill health and technological advancement will save money” when care closer to home is certainly not “care on the cheap” and “technology has a long history of costing health services more, not less.”
The plan, key points
Three shifts: As expected, the plan argues that reform will be delivered through three key shifts: from treatment to prevention, from hospital to community, and from analogue to digital.
New operating model: To realise these shifts it sets out a new, NHS operating model, with a smaller centre, seven regions, a smaller number of integrated care boards focused on “strategic commissioning”, “reinvented” foundation trusts operating under a system of “earned autonomy,” and new neighbourhood health services.
New financial regime: These organisations will be expected to operate within a tough new financial regime. The plan underlines the message given at ConfedExpo that trusts will be expected to manage without bailouts and repeats the spending review demand for productivity savings of 2% a year.
Over time, Fit for the Future also envisages the return of payment by results, with the caveat that trusts will be paid not just for activity, but for outcomes and patient satisfaction. Eventually, it says, there will be a new system in which money will “follow patients throughout their lifetime.”
The return of transparency: The plan says the NHS will have a new regulatory regime, with a revamped role for the CQC, a new AI early-warning system, and penalties for “persistent poor quality care.” This will operate alongside a reboot of the transparency agenda, with “easy to understand league tables” and features in the NHS App to encourage patients to use them to make treatment choices.
Public health: The idea of lifetime funding is presumably intended to give providers an incentive to keep people well and treat them promptly. But most of the factors that lead to ill health are outside providers’ control. The plan says it wants to see ICBs working with local authorities and metro mayors on “total place” initiatives.
Otherwise, its public health ideas are modest: restricting junk food advertising to children, making obesity drugs more widely available, a retread for that policy perennial a “health reward scheme,” and support for vaccinations.
Reaction:
Although the plan is vast in scope, many of its ideas are familiar. This may not be surprising when many of its contributors and authors have come from the New Labour era or think-tanks. But it’s odd to see ideas that have failed resurface with no indication of why they should work this time.
The neighbourhood health services that featured in the launch press release, for example, look a lot like the polyclinics championed by Lord Ara Darzi in the 2000s. Yet they had largely vanished by the time the coalition government arrived because they were expensive, duplicated existing services, and weren’t particularly popular with patients.
In a blog post, Dr Becks Fisher from the Nuffield Trust, notes that some of the plan’s Cook’s Tour of policy is also contradictory. It says there will be “no top-down reorganisation of the NHS” yet one is clearly underway. It says it wants patients to have more voice, yet Healthwatch England has just been abolished.
On this point, the surprisingly consumerist plan may expect individual patient action to do the job, via those league tables, and the My Choices feature of the NHS App. However, league tables were popular with both New Labour and the coalition’s Andrew Lansley, and all the studies conducted at the time showed patients valued good, local services over shopping around.
In general, though, the reaction was that of Thea Stein: nice ideas, but where’s the model for delivering them? Sarah Woolnough, chief executive of The King’s Fund, said: “There is nowhere near enough detail about how [the plan] will be implemented [and] without this detail it is hard to judge how the ambitions on the page will make a difference to the reality of the care we receive over the next few years.
“There [also] has to be realism about how the financial situation impacts the ability to deliver all the reforms proposed today, and how this will impact existing services.”
For the Health Foundation, chief executive Jennifer Dixon said: “Making the plan happen with the resources on offer will be tough.” For the British Medical Association, new council chair Tom Dolphin made the same point: while warning that staff will need to be on board with the reforms when, right now, residents are voting on new industrial action.
“The plan talks a lot about autonomy and empowering frontline staff, but then says there will be name-and-shame league tables and performance related pay,” he added. Another contradiction that will, eventually, have to be worked through with the unions.
Digital and technology, keypoints:
A single patient record: The big tech idea in the 10 Year Health Plan is the development of a single patient record, an idea heavily promoted by the Tony Blair Institute for Global Change over the past 18 months. The plan says this will be a “single, secure and authoritative” source of health data, that patients will control, and that can be used by services and for research.
Developing the NHS App: Fit for the Future goes big on the NHS App, which it says will become a “doctor in the pocket of every patient.” It promises a plethora of new services: a My GP tool that will use AI to answer health queries and direct patients to the right care; a My Choices tool to help patients choose services based on league tables and feedback; a My Specialist tool to allow them to self-refer to specialists; a My Consult tool for remote consultations.
Also, a My Companion tool to help patients prep for consultations and manage treatment; a My Medicines tool to advise them on drug interactions; a My Children tool for parenting advice; a My Carer tool for caring advice. There will also be a new HealthStore for apps, to replace the NHS App store that shut amid security and quality concerns.
Infrastructure, enterprise systems and national platforms: The plan has nothing to say about NHS infrastructure, the roll-out of electronic patient records, or the deployment of enterprise systems in pathology and radiology, even though these have consumed central attention and funding in recent years.
It does promise to address some IT pain points. For example, it says single sign-on will be rolled out across the NHS and clinicians will be encouraged to use ambient scribing technology to reduce administration. It also suggests the DHSC would prefer to work with single providers where possible. Most notably, it says there will be a national platform for virtual wards.
Five big bets: The plan says the government has identified five “transformative” technologies that it wants to push – data, AI, genomics, wearables, and advanced robotics. Some of its specific commitments include: the creation of a Health Data Research Service with money from the Wellcome Trust; a new regulatory framework for AI devices, an AI roadmap, and training for staff; and genotyping from birth.
Reaction:
If the 10 Year Health Plan has an answer to where the money will come from, it is that shifting care into the community and swapping in technology will do the job, by delivering efficiency gains. In a section on “securing the financial sustainability of the NHS,” it argues that booking appointments, attending physical appointments, collecting information during appointments, preparing patients for treatment and following up all have significant costs.
All of which, it says, can be reduced by getting patients to do their own booking, attend consultations virtually, send AI scribes into the consulting room, and deliver advice, letters, pre- and re-hab through the app. However, this idea has been met with considerable scepticism.
Dr Becks Fisher from the Nuffield Trust, for example, said: “There is little robust evidence to suggest that moving care into communities will save money, and a recent OBR report featured a range of studies showing that technological developments in the health sector tend to push up costs.”
There is also concern that Fit for the Future focuses on shiny tech ideas, and not the infrastructure, systems, standards, and indeed people needed to make them work. For the King’s Fund, Sarah Woolnough said: “While the possibilities of AI are exciting, there is an urgent need to get the basics right first, when much of the health service is plagued by basic IT woes and outdated equipment.
“[In addition] historical announcements on NHS tech have been big on promise but lacking in delivery as money has been diverted to other areas [while] another clear lesson from the past is that the benefits will not be realised unless staff and patients are involved in design and implementation.”
The danger of digital exclusion, she noted, is barely mentioned in a plan with a vision of tech-enabled, savvy health consumers shaking up the system. Again, though, the big concern is the lack of detail and a credible roadmap for how this vision will be realised.
Jeremy Nettle, chair of the Highland Marketing advisory board, said: “I hope that we will see some detailed, funded and realistic strategies for delivery, now it has finally been published.”
Take aways for suppliers
There are a lot of good things in the 10 Year Health Plan for health tech suppliers. The NHS may be facing a difficult few years, as the government cracks down on deficits, drives through a reorganisation, looks to deliver its waiting list commitments, and sees off public concern over A&E and access to GPs.
But it has set a clear direction of travel for the medium to long term that companies can plan against, and suppliers with technology to support its ambition for a more local, more personalised health service ought to get a hearing. Fit for the Future also makes some big bets on developing technology, particularly AI.
And there should be some funding. The spending review said there would be a cumulative £10 billion for NHS IT and transformation over the next three years, tied to productivity gains. And the plan suggests this will be supplemented by local money.
It says trusts will be expected to put aside 3% of their budget for one-off transformation projects each year, which should be very good news for vendors (if it can be delivered). In another interesting development, the plan also says the National Institute for Health and Care Excellence will be able to recommend the removal of outdated treatments and technologies in the future, to free up resources for new ideas.
A further welcome line is that the government is looking to work with developers. The shift towards once for England procurement and national platforms will drive consolidation in some areas. But the plan says: “We recognise the NHS does not have a monopoly on good digital technology… and we want to work in partnership with those creating exciting new technologies, to make sure patients have access to [their] products.”
What is needed now is a digital strategy and timed, costed roadmaps for big developments like the NHS App. As these come on stream, the trick for suppliers that want to make the most of the new opportunities will be to have good public affairs, PR and marketing in place, to shape the conversation, influence the right people, and gain customers that want to be at the forefront of delivering the plan’s vision.