Plan for the best, prepare for the worst?

Prime minister Theresa May and NHS England chief executive Simon Stevens launched the long-awaited NHS Long Term Plan on Monday. There is a lot to like in a document that lays out a new service model for the health service that depends on technology; but many, many pitfalls ahead. Lyn Whitfield reports.

In what must have felt like a welcome break from the ongoing Parliamentary turmoil over Brexit, prime minister Theresa May found time to launch the NHS Long Term Plan on Monday.

Speaking from Alder Hey Children’s Hospital in Liverpool alongside NHS England chief executive Simon Stevens, May insisted the publication of the 134-page plan was a “historic moment” that would “secure the future of the NHS for generations to come.”

Stevens was more circumspect. “The NHS Long Term Plan keeps all that is good about our health service and its place in our national life,” he said. “It tackles head-on the pressures our staff face. And it sets a practical, costed, phased route map for the decade ahead.”

Five-year funding, ten-year plan

The need for another NHS plan became evident as soon as May found a “birthday present” for NHS70 last year. In the face of sustained lobbying, she announced the NHS in England would receive an additional £20.5 billion a year by 2023-24, with matching increases for Scotland, Wales and Northern Ireland.

At 3.4% a-year (or less, once adjustments for inflation, increases to pay and cuts to training and public health budgets are taken into account), this was less than think-tanks and unions had been looking for.

The King’s Fund, Nuffield Trust and Health Foundation had estimated that 4% a-year would be needed to keep pace with demand, invest in mental health, cancer services and primary care, and progress the Five Year Forward View.

Sir Malcolm Grant, the outgoing chair of NHS England, said it was clear that the money would only go “some way towards filling the widely-accepted funding gap” and suggested that “hard choices will have to be made.” Hard or not, the government set five tests for the NHS to meet in making them; and these are duly addressed by the plan.

Waiting time target row delayed

The first two tests were for the NHS to return to financial balance and to generate ongoing, cash-releasing efficiency savings. With the acute sector’s deficit positioning worsening, organisations like NHS Providers have been lobbying for a bail-out, as has happened in Scotland.

The Treasury was never going to wear this, and the plan does not pursue it. Instead, it says there will be an “accelerated turnaround process” for the 30 worst performing trusts in the country, a rebooted efficiency drive, and productivity improvements of 1.1% a year.

In a nod to the provider lobby, however, the plan doesn’t promise to return to balance particularly quickly; its target is for the provider sector to be in balance by 2020-21 and the NHS to be in balance by 2023-24.

Nor does it promise to meet another Treasury demand; to start hitting waiting time targets. As journalists noted as the plan was launched, it says only that there is enough money to “grow the amount of planned surgery year-on-year, to cut long waits, and to reduce the waiting list.”

However, the King’s Fund predicted that this was an issue that would return. “NHS leaders have done what was asked of them, within the constraints of the funding settlement provided by the government,” it said of the plan, “but a number of decisions, most notably on hospital waiting times, have been postponed, indicating that trade-offs and difficult choices lie ahead.” 

Competing stakeholder demands let ICSs fly below the radar

The other tests were to: reduce growth in demand, to reduce unjustified variation in performance, and to make better use of capital assets. The rest of the plan’s text can be read as a response to other, and in some cases competing, stakeholder demands.

So, the Treasury and Downing Street were able to announce major programmes on mental health and primary and community care at the time of the Budget and in the run-up to Christmas.

The Department of Health and Social Care, or its new secretary of state, Matt Hancock, was able to launch a “digital first” approach to GP and outpatient services that captured most of the plan’s headlines on the day.

And Stevens was able to focus substantial sections of the plan on prevention and health inequalities and on rebooting the Five Year Forward View he drew up in 2014. This aimed to reduce friction and improve efficiency through establishing population-level planning and budgeting, creating integrated health and care services, and delivering care as close to home as possible.

The plan says that that what were called accountable care organisations are so important that what are currently called integrated care services will cover the country by April 2021; and that the number of CCGs will be reduced to one per ICS in most instances.

It also proposes legislative changes to effectively unpick former health secretary Andrew Lansley’s 2012 reforms, by reducing their emphasis on competition and tendering and making it easier for acute trusts to run community and primary care services.

This was welcomed by the British Medical Association. Chair Chaand Nagpaul described the quasi-market, with its purchaser-provider split, as an expensive distraction that had led to a “fragmented” service.

“Only by removing the requirement to put services out to tender can local systems work together to ensure cohesive, patient centred care,” he said. However, some commentators still worry that long-term ICS level contracts will lead to private-sector involvement on the American model.

Technology enabled at its heart?

Unusually, the NHS Long Term Plan has its own chapter on technology. This effectively supports the Forward View agenda, by setting out a new model for creating integrated care records (confusingly called personal health records), while completing the digitisation of hospitals.

To do this, the NHS Summary Care Record will be wound down, and turned into a basic integrated care/personal health record at local health and care record exemplar level. The plan seems to envisage that data will be abstracted from these records for population health management, planning, research and other activities.

Patients will be able to contribute to a care plan attached to the PHR, and will otherwise access advice, booking, and other transactional services via the NHS App and linked third-party apps that use the NHS Login.

With many details of architecture, standards, ownership and procurement still to be spelled out, reaction to the technology components of the plan has been relatively muted: although vendors have welcomed a plan that sets out a new service model for the NHS that genuinely depends on technology.

One company CCIO told Highland Marketing that the NHS Long Term Plan should give renewed impetus to health tech initiatives, because if the NHS wants the plan to work, it will have to invest in the IT that it will need to make it work.

Lots missing, lots still to do

It is not just IT that will be critical, though. There are plenty of other obstacles ahead. The government had barely got its plan launched before the release of quarterly figures showed the NHS’ performance was worse than ever in November.

Brexit continues to be a huge distraction for the government and a cost to the health service, which is seeing EU staff quit the UK and spending cash on stockpiling medicines. Some think-tanks argue that a lack of staff is now a greater threat to health and care than a lack of money.

Then again, social care is facing a crisis all of its own; one that the government has failed to address with a green paper, to the disappointment of the Local Government Association, which argued that the NHS Long Term Plan was a “missed opportunity” without one.

For these reasons, much of the initial reaction to the plan focused on what was not in it rather than on what was; and on the scale of the challenge.

Nigel Edwards, the chief executive of the Nuffield Trust, and a veteran commentator on the health and social care system, warned that while “the goals of the plan look right” it will be difficult to achieve them on a below-historic trends funding uplift, when “big pitfalls” lie ahead.

Chris Hopson, chief executive of NHS Providers, said “ruthless prioritisation” would be needed and called for a “detailed implementation plan” to match deliverables to money and staff.

Back at Alder Hey, Stevens was probably right to downplay the moment, while recognising there is a lot at stake. “There will be big changes across the NHS,” he concluded. “Today, we get on with them.”