The new NHS Long Term Plan Implementation Framework document published by NHS England and NHS Improvement was published well after Treasury Secretary Liz Truss confirmed that the spending review, expected to be completed in the autumn, has been delayed by the chaos in the Tory Party, and will not now report until the new year.
NHS England’s hopes of agreeing five year plans by the end of the year were all conditional on the outcome of the spending review deciding how much revenue and capital might be available. Until ministers’ decisions are known, many NHS plans will remain no more than wishful thinking.
However this problem is simply ignored in the Framework, giving the document an immediate air of unreality.
Once again, as with Sustainability and Transformation Plans three years ago, the Framework sets out a hugely ambitious and probably impossible timetable for rapid decision making and top-down change.
Draft plans need to be submitted by 27 September and finalised by November 15 (p32) – so expect a repetition of the secretive process that hatched up 44 largely useless STP plans in 2016. The Framework sets out the approach through which STPs and Integrated Care Systems (ICSs) should create “five-year strategic plans covering the period 2019/20 to 2023/24.”
Despite having only the sketchiest of “interim” workforce plans so far in place nationally, local health chiefs are told that their plans “should be based on realistic workforce assumptions” (“which must be delivered within the local financial allocation,” p31) and “deliver all the commitments within the Long Term Plan.”
To make the local task even more impossible the financial pressures on trusts and CCGs are being increased rather than relaxed: “Local plans will need to include the financial recovery plans for individual organisations in deficit against specified deficit recovery trajectories, with actions to achieve cash releasing savings including through the reduction of unwarranted variation and how they will moderate growth demand.”
Local managers are required to guess the outcome of future government decisions: “Plans should set out capital investment priorities for capital budgets being agreed through the forthcoming Spending Review.”
The Framework itself reveals that some of the so-called “priorities” in the Plan have now been elevated into “critical foundations” – which all areas must try to do at once.
This means a series of other priorities have been relegated to lesser importance, and effectively kicked into the long grass.
The priorities that have remained prioritised include primary care and community services (which are set to receive the largest allocations of additional funding up to 2023); mental health (receiving the next largest allocation of extra cash); urgent and emergency care; cancer; increasing numbers of elective operations; ‘personalised’ care (which always seems to be laid down in a one size fits all formula) and digital primary care and reduction in numbers of outpatient appointments – in line with the “digital first” mania in the Long Term Plan.
The remaining list of “priorities” that have been downgraded includes prevention; maternity and neonatal services; children and young people; learning disabilities and autism; cardiovascular disease; stroke care; diabetes and respiratory disease.
Clearly some of these are potentially complex policy problems, and will inevitably also feature in any serious discussion of restricting demand, urgent and emergency care, primary and community care, cutting out 30 million outpatient appointments and increasing provision of elective operations.
The requirement to expand elective services is also complicated by attempts to rein in spending by CCGs and trusts, and by NHS England’s own insistence that commissioners adhere to the controversial “Menu of Evidence Based Interventions” (EBI) which last year singled out 17 treatments for exclusion from routine referral.
This has in many areas been exceeded by much longer lists of exclusions drawn up by CCGs – as Health Campaigns Together warned a year ago. The Framework expects the EBI Menu alone would result in a reduction of 128,000 elective operations a year (p30), but planned to expand it.
So the postcode lottery is not only alive and well, it is growing in scope. NHS England has taken no steps to ensure that CCGs with excessively long and unjustified lists, such as those which exclude routine referral for cataract operations, hip and knee replacements and other proven effective treatments, are forced to think again.
There is once again a gulf between words and deeds on the ground.
In words the Framework commits to tackling inequalities: “System plans should demonstrate the key areas of inequality they will tackle and how additional funding is targeted” (p5)
In deeds, when Warrington & Halton hospital trust offered to allow patients who could afford it to pay for access to many “low value” treatments no longer routinely funded by local CCGs, Simon Stevens criticised the way they presented it rather than the two tier NHS they were threatening to open up.
Crisis response … or not?
In words the Framework commits to ensuring that “as a minimum” plans must focus on four things including “iii. improving the responsiveness of community health crisis response services to deliver the services within two hours of referral …” (p8)
However even as it was published it turns out that crisis-ridden Cambridgeshire & Peterborough CCG was discussing desperate cuts to reduce spending, including their emergency rapid response team for older people and patients with long-term conditions – which the CCG admits has “provided excellent patient facing care for patients”.
There is no explanation of what the Framework means by “digital and online services” as options for quick elective surgical care (p13). It seems the fictional future technology of Star Trek is already a part of NHS England’s plans.
For campaigners and health unions the Framework is a reminder of the scale of the challenge ahead to ensure services, and the funding for them are defended, and that the values and principles of the NHS are protected.