News and views
A bow to the inevitable, a dose of common sense, and a streak of the radical – our comment on the NHS Ten Year Plan
Earlier this week saw the publication of the long-awaited NHS ten year plan. Originally due in the autumn, it picks up the torch from the 2014 Five Year Forward View and explains how the NHS will change over the next decade. This includes how it will use the extra £20bn a year of investment committed by the Prime Minister last June.
News headlines focused on a shift of investment away from urgent care towards prevention, perhaps the most eye-catching of the announcements. However, there are also a number of less heralded changes which will change the way the NHS does business. Below I’ve picked out five key themes, and commented on what they might mean in practice:
1. Moving emphasis to GP and community care
More strongly than ever before, the plan signals the intention for the NHS to become more proactive at encouraging better health, rather than just being a service that treats sick people.
For the first time in its history, funding for primary and community health services is guaranteed to grow faster than the overall budget, reflecting a desire to move the emphasis close to patients’ homes. A larger proportion of the £20bn funding will be directed to GPs and community providers, with the aim being to stop more people getting to the point that they need hospital care. Primary Care Networks will align multi-disciplinary community teams with groups of GP surgeries, covering a population of 30,000-50,000.
Bravo. This is a significant step and a definite push against an entrenched culture that wrongly prioritises hospital care. This shift is all well and good but also relies on corresponding changes to the payment and incentives regime (see the point below). Once the investment begins it will then be up to clinical leaders to change how and when they interact with patients, and implement pathways in which hospital genuinely is the last resort.
2. A shot in the arm for integration
The announcement that has caused most excitement among policy wonks is that all of England will become part of an Integrated Care System by 2021. The plan goes on to say that each of these systems will ‘typically involve’ one CCG.
There is more than a whiff of top-down reorganisation about this, something that NHS England has been careful to dodge since the Lansley reforms. It smacks of the centre getting impatient with the pace of integration so far – and who can blame them.
To make it easier for NHS organisations to integrate, there will be a shift to a population based payment regime, rather than an activity-based one. This should remove some of the perverse incentives that can make it more beneficial for NHS providers to treat sick people than to encourage them to be healthy. The plan also outlines a desire to introduce ‘further financial reforms’ that give local health systems greater control over resources on the basis of their track record. We await more detail on this.
3. Prevention is better than cure – but who is in charge?
For all the emphasis on preventing ill health, I don’t find the plan convincing in terms of how this will be delivered in practice. Chapter 2 is devoted to those issues that are ruinous to the nation’s health – smoking, obesity, alcohol and air pollution, for example. These are the issues that require a full-on multi-agency response, led by a clear focus on public health.
But the question of leadership is left hanging. Public health remains the statutory responsibility of local authorities, with budgets slashed in recent years. One reading of the plan is that NHS could take over public health functions from local authorities, with the Government committing to ‘consider whether there is a stronger role for the NHS… and what best future commissioning arrangements might therefore be’. If this turns out to be the case then it is the return shot in the game of public health ping-pong that successive governments seem to like to play.
4. Unanswered questions over social care
The biggest gap in the plan is in relation to social care. The NHS and social care are dependent on each other and so reform to one requires reform to the other. There are plenty of warm words on working together but no clear strategy. The plan wobbles as it makes the mighty assumption that funding for social care will keep pace with what the NHS needs. With the delayed social care green paper due later this year we can only sit on our hands to wait and see.
5. A digital revolution at the NHS’s front door
The stamp of the Health Secretary is all over the promises around digital technology. In particular, GPs are being asked to embrace new technology in their interactions with patients, rather than just for making the back-office more effective. All of us will have the ‘right’ to switch from our existing GP to a ‘digital first’ provider and access to online consultations by 2022-23. This sounds great and we already know that this approach is popular, particularly with younger patients. A note of caution though. Effort must be made to engage GPs so that they buy-in to change otherwise we risk wasting this golden chance.
Apps also get a mention as a way of increasing patients’ engagement with their own health and improving self-management of conditions. As digital health products proliferate, getting the level of regulation right will be critical – in order to protect the public without stymying innovation. Our colleagues at ORCHA are at the forefront of assessing the nascent market in digital healthcare.
The Long Term Plan sets a framework for change, combining a bow to the inevitable, a dose of common sense, and a streak of the radical. It sounds the starting gun: more is to come in the form of the Social Care Green Paper, a comprehensive workforce plan, and, later in the year, individual plans for local health systems.
Context is also important. These are unpredictable times and we have to hope that reform doesn’t have its wings clipped by our political masters. The plan admits that implementation will be easier with legislative change but with Brexit, Brexit and Brexit on the agenda it would be foolish to rely on that. We will learn more in the next couple of months.
As the plan sinks in, there will be lots more comment in the coming days and weeks as its implications become clearer. We will be keeping an eye on that. Watch this space.
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