The Government published the NHS Long-Term Plan on the 7th January. This follows the Government’s commitment in the 2018 Budget to increase health funding above inflation by £20.5 billion over five years to 2023/24. The Plan indicates the health service’s priorities and proposes reforms to how the service will deliver world-class care in a financially sustainable way.
Now we have the long-awaited Plan, what do we know, what questions remain, and what happens next? This article provides some answers to these questions.
You can read the Plan in full here and a summary here.
What do we know?
At over 120 pages, the Plan is wide ranging, from specific clinical priorities to system reform. Here are seven key themes
A funding boost for primary and community health services
The Plan aims to shift activity out of hospital and into community settings. Inevitably, this means that these parts of the NHS will need more money. It guarantees that “investment in primary and community services will grow faster than the overall NHS budget” and creates a “ring-fenced local fund worth an extra £4.5 billion a year in real terms by 2023/24”.
Re-design health systems around places and people rather than organisations
To shift activity into community settings, health and care organisations need to work together to manage the health needs of their population, particularly those with comorbidities. The Plan contains a series of proposals to encourage organisations to work together. These include:
- Ensuring every part of England is part of a single Integrated Care System (ICS) by 2021 – albeit the Plan acknowledges that how advanced ICS’ are will vary. Commissioners and providers will have a duty to collaborate within their ICS footprint;
- Requiring GPs to sign up to ‘Network Contracts’ to work together on system-wide priorities. These contracts will be an extension of each provider’s existing contract with their commissioner. The Government plans to give Network Contracts greater traction by funnelling part of the £4.5 billion of extra funding (see above) through them, and using Network Contracts to share savings from reductions in local emergency department activity.
Changes where legislation blocks joint working
Existing legislation can hinder rather than help joint working between commissioners, providers and non-NHS organisations. NHS leaders have used the Plan to draw up a wishlist of potential legislative changes to facilitate joint working. These include:
- Exempting the NHS from wholesale inclusion in the Public Contracts Regulations;
- Introducing shared legal duties on delivering outcomes and financial commitments for commissioner and providers;
- Removing the Competition and Market’s role in NHS mergers and acquisitions.
Direct commissioning of public health services (potentially)
Common sense dictates that the best way to make people healthier and restore the NHS to financial balance is to stop them getting ill in the first place. The majority of spending on prevention is currently managed by local authorities through ring-fenced public health budgets. The Long-Term Plan considers the possibility of the NHS taking national responsibility for certain aspects of public health spending – eg sexual health, smoking cessation – to ensure these services are better targeted at national prevention priorities.
Reforms to the provider financial regime
The £20.5 billion investment in the NHS, coupled with the reforms set out above, are designed to reduce hospital activity and place the NHS on a sustainable financial footing. The Long-Term Plan proposes to restore the provider sector to financial balance by 2020/21 and each individual organisation to financial balance by the end of 2023/24.
However, with a collective provider deficit of £1.23 billion in 2018/19, the Plan acknowledges that certain Trusts will need considerable support to do this. The 30 Trusts in the worst financial state will be subject to a new “accelerated turnaround process” and a new Financial Recovery Fund will be created to help Trusts with structural deficits.
Investment targeted at clinical priorities
The Long-Term Plan contains a shopping list of clinical priorities for the NHS. It is safe to assume that services supporting these priorities will receive a favourable hearing as the Government’s additional funding is distributed to the front-line. Priorities include:
- Children and young people’s health;
- Stroke service;
- Diabetes care;
- Support for people with respiratory conditions;
- Mental health services.
The priorities are underpinned by a range of targets which providers will have to meet. As the Kings Fund has commented, individually there is much to recommend in the priorities but collectively they pose a daunting task for an already stretched service. Whilst the Long-Term Plan is accompanied by an average yearly 3.4% real terms increase in funding, estimates suggest a 3.3% increase was required just to service growing demand due to demographic changes. Therefore the pot of money to fund additional commitments may be smaller than anticipated.
Focus on digital transformation
Since taking up the post of Health Secretary, Matt Hancock has been passionate about using technology to solve healthcare’s biggest problems. Therefore, it is not surprising that the Long-Term Plan has a digital focus. Proposals include:
- A patient right to request online consultations with their GP;
- A patient right to request to switch GP to a ‘digital first’ provider;
- Plans to cut hospital outpatient attendances by one-third (3 million per year) through use of new technology and digital consultations.
What questions remain?
The Plan is both extensive and ambitious. However, it does leave some big questions unanswered – some within the control of the NHS, others less so. Here are five key forces which will shape the success of the Long-Term Plan.
The Plan is light on detail about workforce issues. The Kings Fund, Health Foundation and Nuffield Trust estimate that the NHS’ workforce gap will grow to 250,000 over the next decade. The Government’s Immigration White Paper will condition the NHS’s ability to recruit the workers it requires to deliver the Plan and fill this workforce gap. The White Paper proposes a new single system - applied equally to EU and non-EU countries. The system, which would be phased in by 2021, would prioritise ‘skilled’ migration over ‘un-skilled’ migration. The government proposes to use a salary threshold of £30,000 to distinguish between skilled and unskilled workers. This has caused concern across the health and care sector given the starting salaries of nurses, junior doctors, paramedics, midwives, healthcare assistants and others. The proposals are out to consultation and the Government has recognised a system of one-year visas for unskilled migrants may be required in shortage sectors. The outcome of that consultation will have a significant bearing on the deliverability of the Long-Term Plan. The NHS’ own Workforce Implementation Plan, due later this year, will need to cover this and wider issues.
An under-resourced social care system places pressure on the NHS. The Government’s Social Care Green Paper - which aims to mitigate weaknesses of the current social care system - is months overdue. The success of the NHS Long Term Plan will be influenced by the NHS’ ability to accommodate the policy changes which flow from that Green Paper.
HM Treasury will publish the outcome of its cross-Government Spending Review in autumn 2019. This will set the spending limits of each Government department over the following three years - including investment in public health (key to the Plan’s prevention agenda) and capital allocations to the Department of Health (key to estates investment to enable the Plan’s transformation aspirations).
Meanwhile the NHS still has a day job and a set of targets to meet – from referral to treatment to waiting times in A&E. The Plan does not propose any changes to current targets, which providers routinely miss due to growth in demand, workforce shortages and (historic) real-term shrinking budgets. The targets are currently being reviewed as part of the NHS’ Clinical Review of Standards. If relaxed (or rather swapped with new stretching condition-specific targets) this may change provider behaviour going forward.
Finally (and almost needless to say), Brexit will impact the pace and scale with which the Long-Term Plan is delivered. Primarily, the smoothness of the UK’s exit from the European Union will condition the time (not to say the money) the Government has to spend on the Long-Term Plan’s wide-ranging agenda.
What happens next?
These broader questions notwithstanding, the ball is now in the court of Sustainability and Transformation Partnerships and Integrated Care Systems to produce their own, local, strategy to implement the Long-Term Plan. This will happen in two stages - a local plan for 2019/20 (by April 2019) and a five-year local plan (by autumn 2019).
The Long-Term Plan is an ambitious reform agenda but in some places poses more questions than answers. Due to the length of time the Plan covers it is likely to outlast the politicians and senior management who are responsible for it, therefore, as with the plans that preceded it, accountability for delivery will be hard to achieve. The NHS would admit itself that the Plan represents the continuation of a reform journey, not the start of, or end of one. Nonetheless, the Plan is a key milestone, which will shape the NHS, and all other public services it touches, for years to come.
For further information on this subject, contact James Nicholls or Greg Rubins