Summary from Highland Marketing
The funding gap and responses: A decade ago, the then-chief executive of the NHS, Sir David Nicholson, warned the health service it was likely to face a period of flat funding, while costs increased and demand rose as a result of population ageing and the increasing number of people living with long-term conditions and mental health problems.
He urged the NHS to adopt quality, innovation, productivity and prevention (or QIPP) programmes to address the resulting funding gap; but in the event health services focused most on productivity, which was improved by holding down management costs and wages.
By 2014, this approach had run out of steam, and the new chief executive of NHS England, Simon Stevens, published the Five Year Forward View to try and refocus attention on innovation and prevention. The plan said “decisive measures” would be taken to break down barriers between health and social care services in the hope of reducing friction and so improving efficiency.
This led to a raft of ‘vanguard’ integration projects, the publication of 44 sustainability and transformation plans to take forward ideas locally, and the creation of a small number of accountable care organisations (now called integrated care services) to try-out population-level planning and budgeting.
However, progress has been limited, as the acute sector has continued to suck-up attention and funding. Last year, NHS Improvement estimated hospitals were running an in-year deficit of £1 billion and an underlying deficit of £4 billion.
In addition, new issues have emerged. One of the most significant is staffing, since the health service has 100,000 unfilled vacancies. Public health has deteriorated on some measures, with both life-expectancy and years spent in healthy life stalling. And council-funded social care is facing its own crisis; one that a repeatedly delayed green paper has so far failed to address.
The birthday present: Against this background, think-tanks, professional bodies and unions lobbied successfully for a further injection of cash into the NHS, to mark its 70th anniversary last July. Prime minister Theresa May said an additional £20.5 billion a year would be given to the NHS in England by 2023-24, with similar uplifts for the health services in Scotland, Wales and Northern Ireland.
The increase of 3.4% a year on average was less than the lobbyists were asking for, since an influential report from the King’s Fund, Nuffield Trust, and Health Foundation had said that 4% a year would be required. It is also likely to be eroded by pay increases, inflation, and Brexit costs, and by cuts to training and public health budgets.
Most commentators warned that the decision would leave the NHS facing ‘hard choices’ and the long-term plan was supposed to set out the choices that have been made.
The NHS Long Term Plan, key points:
Performance, headlines, and the funding gap: There has been an obvious tension between the Treasury, Downing Street, the Department of Health and Social Care, and NHS England over how the “birthday present” should be spent.
The Treasury has wanted to see the NHS back in balance and hitting targets, Downing Street has wanted big programmes to announce, new health and social care secretary Matt Hancock has wanted to push GP at Hand-style services, and NHS England has wanted to focus on the Five Year Forward View agenda of prevention, integrated care, and population-level planning and budgeting.
This, Stevens has argued consistently that is the only way to get the NHS onto a long-term, sustainable footing; although NHS Providers, which represents acute trusts, has argued that hospitals simply need more money, and they should start over with a clean-sheet, as has happened in Scotland. The plan visibly gives something to all these groups.
Finances and efficiency: Chapter six, titled ‘taxpayer’s investment will be used to maximum effect’, nods to the Treasury by saying that “putting the NHS back onto a sustainable financial path is a key priority” (page 100). However, it acknowledges the concerns of the provider lobby by saying, in effect, that this is not going to happen particularly quickly.
The plan says there will be an “accelerated turnaround process” for the 30 worst performing trusts in the country (page 102), that the provider sector as a whole will be expected to return to balance by 2020-21, and that all NHS organisations will be expected to return to balance by 2023-24 (page 101).
There will be a new ‘financial recovery fund’ for struggling organisations to draw on (page 102), but plan assumes that most of this recovery will be achieved through efficiency.
The NHS will be expected to deliver cash releasing productivity growth of at least 1.1% a year over the next five years (page 100), and there will be a “strengthened” ‘efficiency and productivity programme’ focused on ten areas, including pathology, medicines, and patient safety (pages 104 to 108).
As journalists noted, the plan does not commit the NHS to hitting existing waiting time targets: only to “grow the amount of planned surgery year-on-year, to cut long waits, and to reduce the waiting list” (page 74).
Headline programmes: mental health, primary care, maternity: The government was able to release details of some of its key spending commitments to selected media outlets ahead of the plan’s publication. In the October Budget, Chancellor Philip Hammond announced that mental health’s share of the money (£2.3 billion a year), would be spent on crisis services.
In November, prime minister Theresa May announced that primary and community care’s share (£3.5 billion a year, increased to £4.5 billion a year in the plan) would be focused on community-based rapid response teams and clinical support for nursing homes. And in December, the Department of Health and Social Care unveiled a package of measures to improve maternity care that included national roll-out of the eRedbook.
Digital first GP and outpatient care: Matt Hancock’s agenda of giving patients access to monitoring, GP and outpatient services via technology is picked up in chapter one, which says that “digital-first primary care will become a new option for every patient” (page 26).
In fact, it goes further, and says that within five years, patients will have a “right” to choose this option, thanks to a three part plan that will: provide a platform on which suppliers can operate; ensure safety; and review existing GP payment mechanisms “to ensure fair funding without inequitably favouring one type of GP provider over another” (page 26). Similar ideas will be applied to outpatient care.
Prevention and inequalities: Stevens’ pre-occupations are more visible in chapter two, which focuses on public health and reducing health inequalities. The plan says NHS England will adjust the allocations that it makes to clinical commissioning groups, so more money goes towards areas with high inequalities.
It will also set new targets for reducing these that national and local programmes will be expected to meet (page 40). The plan sets out out specific action for smoking, obesity, alcohol and air pollution (pages 34 to 39).
The Forward View agenda: integrated care systems: The plan really gets into rebooting the Forward View agenda in chapter seven, ‘next steps’. It says that although the current financial year, 2019-20, will be treated as a transition year, trusts and commissioners will be expected to work together on a single, “health system-level plan” that can segue into a five-year implementation plan in due course (page 110).
It says integrated care services “will be central to delivery”, that ICSs will cover the country by April 2021 (page 110), and that the number of CCGs will be reduced to one per ICS in most instances (page 113).
As ICSs come in, the plan says organisations will be expected to adopt a whole-system mindset, and “not to pursue actions that, while potentially improving their institutional financial position, would result in a worse position for the system overall” (page 112).
To support this, the chapter proposes a number of legislative changes that would effectively unpick the competitive elements of former health secretary Andrew Lansley’s 2012 reforms (pages 113 and 114). These would also make it easier for acute trusts to become ‘integrated care trusts’ running community and primary care services.
A new service model: One of the distinctively new aspects of the long-term plan is that, alongside this shift towards more joined up care, it recognises that the NHS needs a ‘new service model’ that makes significant use of digital technology (page 12 and chapter one).
The long-term plan says the NHS “needs to become more proactive in the services it provides” by making use of population health management techniques and to “become more differentiated in its offer to individuals” by shifting towards a “digital first” offer for most and using technology to help people take “more control of their health and wellbeing (page 12).
Specifically, the plan sets out ‘five, major practical changes’ to bring this about, saying it will: “boost out of hospital care”; reduce pressure on emergency hospital services by introducing new 24 A&E and urgent care centres; introduce “personalised care”; mainstream “digitally enabled primary and outpatient care”; and “focus on population health” at an ICS level.
The long-term plan had a curiously low-key launch at Alder Hey Children’s Hospital in Liverpool, and national press reaction was limited by interest in May’s battle to get her Brexit proposals through Parliament. Initial reaction from think-tanks and NHS bodies tended to focus on things that are not in the plan but that are likely to determine whether it can be delivered.
The King’s Fund: “NHS leaders have done what was asked for them within the constraints of the funding settlement provided by the government. We strongly support the ambition to establish integrated care systems in every part of the country by 2021 [but] while today’s plan is a significant step forward, a number of questions remain unanswered [and] there should be no illusions about the scale of the challenge ahead.”
The Nuffield Trust (chief executive Nigel Edwards): “The goals of this plan look right – carrying on with joining up care and improving services for older people, while pushing vital issues like heart attack survival and children’s health up the agenda. What worries me is how difficult it will be such wide-ranging changes when there are several big pitfalls ahead.
“The extra funding will be below the historic average and what experts thought was needed. It is enough to move forwards, but with little room for manoeuvre. If we face a no deal Brexit, the extra costs and tasks required would eat up the first instalments, stopping progress dead in its tracks.
“The last few years have seen repeated cuts to public health and social care. Success will depend on extra effort and initiative from staff, but relations have been frayed by shortages and burnout. And the biggest obstacle is the lack of key staff. Workforce planning has failed us and needs deep reform.”
NHS Confederation (chief executive Niall Dickson): “We very much welcome the increased funding for the NHS and the vision to strengthen and improve services. But the plan cannot escape the harsh reality that the NHS will face tough decisions on what it can and cannot do.
“The next few years will be about balancing the need to keep the NHS going, overcoming the large deficits in hospitals, delivering some improvements, and preparing for new ways of delivering care that will make the NHS sustainable. This is not about miracles – money will be tight, staffing will remain a headache for years to come [and] the government must find a solution to the social care crisis.”
NHS Providers: “Successful delivery will depend on four factors: ruthless prioritisation and effective implementation; a rapid solution to current workforce shortages; a clear path to recovering performance in areas like urgent and emergency care and routine surgery; and the resolution of other issues central to the success of the NHS through the spending review – social care, public health and NHS training budgets.”
Technology in the NHS Long Term Plan:
‘A plan that is technology enabled at its heart’: The Five Year Forward View was supported by an IT strategy, Personalised Health and Care 2020. This promised patients more information about the health service as part of the Cameron government’s ‘transparency’ agenda, “read-write” access to their medical records, and some transactional services, such as appointment booking and repeat prescription pick-up.
The challenge of completing the digitisation of hospitals, left incomplete by the National Programme for IT in the NHS, was addressed by the Wachter Review of NHS IT. This led to the creation of the global digital exemplar programme and, more recently, the local health and care record exemplar programme, which will enable five areas of the country to try integrated care records and advanced analytics at scale.
The long-term plan says both agendas have made good progress, but “we have not enabled the wholesale transformation of the NHS that patients have a right to expect” (page 91). Chapter five sets out proposals for achieving this.
Empowering people: The plan quietly drops existing targets for access to medical records and the idea of read-write access. Instead, it says every patient with a long-term condition will have access to their NHS Summary Care Record and that this will be shared with “all urgent and emergency care services” (page 94).
However, the end looks nigh for the NPfIT-era SCR. The plan says that “by 2023, SCR-functionality will be moved to the personal health record held within the LHCRE systems” and a care plan will be added to which patients and carers can add their own information (page 94).
The plan also says the NHS App will become “the standard online way for people to access the NHS” but an open architecture and NHS Login will allow developers to create apps that work with it (page 93). As discussed above, “Digital first” offers for GP and outpatients are outlined in chapter one.
Digitising hospitals: The plan recognises that the digitisation of hospitals has to be completed and says that “all providers will be expected to advance to a core level of digitisation by 2024.” This is not defined, but it will apparently cover infrastructure and security as well as electronic patient records.
The plan says “we will accelerate the roll-out of electronic patient record systems and associated apps, including a spectrum of Software as a Service/cloud-based variants”. It implies that money will be made available to do this, as long as systems comply with standards and integrate with LHCR set-ups (page 96).
It also promises an extension of the GDE and LHCRE programmes, starting with the announcement of additional fast followers (page 96).
Population health management: The plan puts a big focus on population health management in both its ‘new service model’ and technology chapters. On the tech front, it says that “by 2019, we will deploy population health management solutions to support ICS to understand the areas of greatest health need and to match NHS services to them (page 97); and that it expects population health management solutions to develop from there.
Controversially, in the light of the care.data saga, it suggests that this will involve making “de-personalised” data available to industry and researchers “in line with information governance standards.” Other tech pledges in the plan include an expansion of the NHS Digital Academy and a CIO or CCIO on every board.
Initial responses to the technology aspects of the long-term plan have been published by:
- Digitalhealth.net (short quotes from NHS Digital and some reaction from healthcare IT leaders)
- The Health Tech Newspaper (much more thorough industry reaction from a wide range of vendors)
The NHS has been subject to a number of ten-year plans over the years, and it would be easy to dismiss the chances of this one, given the political uncertainty facing the UK at the moment.
Even as she was trying to bill the plan as a “historic moment” for the health service, journalists were asking prime minister Theresa May about Brexit and whether her government would survive the coming vote on the terms for leaving the EU.
However, the plan does set out a clear direction for the NHS. And that direction is, in some respects, new. If nothing else, the NHS Long Term Plan does go further than previous documents in engaging with technology. It doesn’t talk about IT, or computerising records, or giving patients an online version of existing services (although, in reality, all of these things need to happen).
Instead, it starts with a new service model that puts digital tools for planning and commissioning front and centre and it lays out a “digital first” approach to delivery that reserves face to face interactions for when they are really needed.
There is a even a chapter on technology, and it sets out some digital milestones that, on the face of it, match the new service and delivery model, while dealing with unfinished business in the hospital sector.
If that’s the good news, the less good news is that the plan is clearly the product of many competing agendas. There is unfinished business with the Treasury, which is assured that the provider sector will return to balance, but not that it will start hitting targets again.
A lot of money has been allocated to headline-friendly crisis programmes in mental health and primary care that might have been better spent on existing – even digital – services. Yet government ministers have said little or nothing about NHS England’s commitment to tackling health inequalities; which is certain to cause upset as money shifts from affluent to poorer areas this year.
Perhaps most critically, the plan attempts to reboot the Five Year Forward View’s agenda of joined up health and care and integrated care services, but key details are missing. The plan says the whole country will be covered by ICSs by 2021, but it doesn’t explain how the transition from a quasi-market to an accountable care set-up will be handled, what ICSs will look like, how they will operate, or how they will spend money.
All of those are key questions for suppliers looking for customers. In the same vein, while chapter five tackles the right tech areas, it fudges some key questions. What is a core level of digitisation in a hospital? What constitutes an EPR? Is cloud really the only game in town?
And, at the ICS level, how will the summary care record be wound down? What model will be used to replace it with integrated/personal health records? And how will local and national data demands be reconciled? All of these questions will have to wait for national and local implementation plans (say it quietly, even an IT strategy).
Meanwhile, as think-tanks have pointed out, any number of factors, from trusts failing to get back into balance, to the workforce crisis intensifying, to social care completing its near-collapse, could stop the plan in its tracks. As long-term observer Nigel Edwards from the Nuffield Trust pointed out, vision is one thing: and delivery quite another.