What is the NHS Long term plan?
It is a key strategy document setting out plans, ambitions and priorities for the NHS over the next 10 years, including a major new reorganisation.
The 130-page strategy was produced by NHS England and was much anticipated amid nation-wide pressure on the NHS.
How does the plan describe itself?
“the Long Term Plan is ambitious but realistic,
It will give everyone the best start in life; deliver world-class care for major health problems, such as cancer and heart disease, and help people age well.”
NHS England says a new 10-year plan could save up to 500,000 lives by focusing on prevention and early detection. Promises to improve cancer outcomes, raise access to mental health and move funding to community services were generally well received.
However, the plan has also been widely criticised for not tackling what is seen as the number one problem: a national staffing crisis in the NHS.
Trade unions, charities, campaigners and think tanks have all pointed out that a lack of staffing and funding will undermine the plan’s proposals.
The NHS is short of over 100,000 staff according to its own figures, but the plan contains no comprehensive strategy to address this. The plan sets out its intention to invest £4.5bn in community services over the next five years, but omits to say what increases in staff numbers there will be and in turn, how this will improve capacity. There is much more detail in the plan about managing the flow of patients, however NHS England say workforce plans will be published later in the year.
Other stress points?
Progress will also be dependent on a number of other polices falling into place or changing.
Despite promises of an announcement there is still no solution to the social care funding crisis, 25% less adults are accessing care, adding to the demand on the NHS.
The core public health grant has fallen by a quarter (25%) per person since 2014-15, making harder to address issues like obsesity. The government say they will be addressed in different ways in future.
One billion pounds worth of debt has mounted up across the NHS. It threatens the ability of the NHS both to cope with demand and to implement the Long Term Plan, according to an assessment by the National Audit Office.
The NAO report also highlights that the extra funding promised to the NHS over the next five years does not cover key areas of health spending such as education, public health and capital investment.
In contrast to the fanfare after the £20bn NHS funding announcement the NAO report offers a sober assessment that the NHS is not yet on a sustainable financial footing. It echoes of the conclusions of leading health economists that the rise in NHS funding will not be enough to fund improvements.
What else is behind the Plan?
Apart from explaining how the extra NHS money will be spent the plan is an attempt to relaunch a large reorganisation of the NHS.
The NHS England CEO, Simon Stevens has been encouraging NHS providers and commissioners to work more closely alongside councils and experiment with new ways of working. Pilot projects were set up. Local areas were asked to come up with their own versions of the new models of care. However this project ran into trouble as many of the local plans carrying this forward – known as Sustainability and Transformation Plans, were dominated by cuts and undermined by existing debts.
The core idea, of more integration – local organisations working more closely together, was to culminate in the formation of Accountable Care Organisations. Controversy quickly followed this announcement, as these new bodies were seen to open the door to more private sector control. Attempts to stop ACOs through the High Court failed, but NHS England were forced to consult with the public and the debate has continued.
The Long-Term plan is a therefore, in part a relaunch of the integration project after this controversy, but it is unclear how far the 44 local STPs will have to go in revising their existing plans.
The plan Local areas should be more realistic in their planning, but putting in place new financial controls is also goal of the plan.
Suggestions to relieve the pressure on the NHS?
The plan puts a greater focus on prevention and out-of-hospital care and thereby aims to reduce demand on the NHS and hospitals.
One in three patients are to receive care from newly enhanced community-based services rather than going to their local hospital for an outpatient appointment; this accounts for 30m clinic visits a year.
The plan promotes innovation and wants to use more digital technology such as video consultations with GPs. By 2022-23 all patients in England should have access to a “digital first primary care offer”
To pay for this, GPs, mental health and community care will receive £6.8bn of the extra £20bn promised to the NHS over the next five years – currently they account for less than a quarter of spending, while hospitals take up around half of the £114bn frontline budget.
Will the plan lift the pressure?
However, doubts have been cast about what can be achieved through the Plan. Nursing unions have pointed out that the capacity of community services has fallen sharply in recent years. There has been a 50% fall in the number of district nurses between 2010-17.
Current trends are no better as the number of nurses qualifying as district nurses in the UK has dropped by more than 10% over the last year.
There are a fifth less health visitors since 2015 and a 12% drop in mental health nurses over the last decade. So there is a very steep hill to climb if community based services are to take on more work from hospitals.
New arrangements will take time to introduce and in the meantime hospitals are under extreme pressure. Many trusts missed all three key waiting time targets for A&E, cancer care and routine operations, and are struggling with growing deficits.
NHS bosses say they need a plan to raise NHS capacity. Understaffing is there number one issue. NHS vacancies are running at record levels, not helped by the collapse of recruitment from EU countries that have been a crucial source of staff.
7 things they say the plan will do
NHS England said that it will help pay for:
- Deliver community based physical and mental care for 370,000 people with severe mental illness a year by 2023/24
- Deliver the best treatments available for children with cancer, including CAR T and proton beam therapy.
- New testing centres for cancer patients to ensure earlier diagnosis which they claim will help 55,000 more people per year survive five years after a cancer diagnosis – from 2028.
- Digital access to health services, including online GP booking and remote monitoring of conditions such as high blood pressure
- Extra support in the community so patients can be discharged quickly from hospital and reduce the number of outpatient appointments by a third
- More social prescribing to give GPs a range of options to tackle social problems like loneliness through connecting people to activities such as choirs and arts groups
- Healthy living programmes for patients struggling with ill-health
What is the reaction to the plan?
Although commentators have welcomed the aims of the long-term plan, they have also pointed out the lack of detail in the plan and that without more funding, more staff and a credible workforce strategy then it will be undeliverable.
Chris Hopson, the chief executive of NHS Providers, said: “This plan cannot be delivered whilst trusts still have 100,000 workforce vacancies. We need urgent action to solve what trust leaders currently describe as their biggest problem. It’s a major concern that we will have to wait longer to get the comprehensive plan that is needed here.”
Sara Gorton, head of health at Unison, said: “Finding the NHS more staff, and holding on to those it already has, is key to the success of the government’s plan. The plan is honest about the scale of the staffing challenge. But nothing will happen without more money to attract new recruits and train existing employees. The government must act now, or its plan will fall at the first hurdle.”
Richard Murray, the chief executive of the King’s Fund, said: “Whether the plan can be delivered relies critically on tackling workforce shortages. While the plan recognises this, commitments to increase international recruitment depend on decisions about immigration policy and we will need to wait for solutions until a new workforce plan is published later this year.”
Nigel Edwards, chief executive of the Nuffield Trust, said: ”There are several big pitfalls ahead. The extra funding will actually be below the historic average and what experts thought was needed. It’s 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. The reforms we all know are needed to the way we pay for care have been kicked into the long grass again and again. If this goes on, the NHS will be stretched still further as it looks after more people who couldn’t find the help they needed.”
Dr Jennifer Dixon, chief executive of the Health Foundation, said: ”The NHS’s ability to deliver the long-term plan will also depend on wider political choices. Without a solution to the growing crisis in social care, people will continue to suffer unnecessarily, and more pressure will be piled on the NHS. Yet the government’s green paper on social care funding is still yet to appear, and current funding is not enough to meet rising pressures.”
Labour health spokesman Jonathan Ashworth said: “The reality is the NHS will continue to be held back by cuts and chronic staff shortages….the Tories have spent nine years running down the NHS, imposing the biggest cash squeeze in its history, with swingeing cuts to public health services and the slashing of social care services. They have failed to recruit and train the staff desperately needed, leaving our NHS struggling with shortages of over 100,000 staff….While the aspirations for improving patient care NHS England has outlined today are welcome, the reality is the NHS will continue to be held back by cuts and chronic staff shortages.”
Dame Donna Kinnair, acting chief Executive and General Secretary of the RCN, said: “This is undoubtedly the right direction, yet with 40,000 nurse vacancies in England, cancer centres are struggling to recruit specialist cancer nurses, we have lost 5,000 mental health nurses since 2010, and district nurse numbers fell almost 50% in the same period….It is strange then that this plan offers no money for nurses to develop the specialisms and skills patients need.”
Gill Walton, chief executive and general secretary of the RCM, said: “There is much in the plan to welcome…..However, there is right now a gap between the ambitions for our maternity services and the reality on the ground. This plan adds yet more aspirations but we need to know how the government will bridge this gap and give us the services they have promised. The issue of funding services also rears its head. There are some commitments in the plan to postnatal care yet this is an area that has long been underfunded. Key elements of the plan also talk about prevention of poor health such as reducing the numbers of people smoking. But we are seeing budgets for public health services such as smoking cessation cut.”
Colenzo Jarrett-Thorpe, Unite national officer for health, said: “This new cash is, in reality, putting in the funding that the government removed a decade ago…..How can this long-term plan be implemented if the government gives with one hand and takes away with the other? This plan is doomed to failure if ministers do not reverse cuts to local authority budgets or give incentives to councils not to cut public health or community health budgets.”
Duncan Stephenson, director of external affairs at Royal Society for Public Health said: “There is much within the forthcoming NHS Long Term Plan to welcome…However, while there is much to welcome from NHS England, in terms of secondary prevention, improving diagnosis and embracing new technologies, the best laid plans can go to waste if not backed up by sufficient funding.
Rachel Power, chief executive of the Patients Association, said: “The long-term plan has undoubted strengths….So, it’s highly unfortunate that failures outside the plan itself mean that on its own it cannot safeguard the future of the health and social care system. The government still lacks any sort of strategy for health and wellbeing, and has not even published its green paper with proposals to end the ongoing social care crisis. Last year’s funding announcement promises another five years of below-trend growth for the NHS, on top of the eight it has just endured, and excluded key areas of expenditure. The serious and growing shortages in the health and care workforce are a major threat, and could even make the plan undeliverable.”
Dr Chris Moulton, vice president of the RCEM, said: “On face value, the NHS long-term plan is ambitious, optimistic and considered. However, we fear that there are incompatibilities with expectation and reality; particularly when considering the gap between what is being promised and what is being provided. As others have rightly pointed out, the viability of this plan will not only be conditional on tackling workforce shortages – and ensuring that those staff that we have do not leave the NHS – but also on adequate funding for both public health and social care.”
The long-term plan contains a request by NHS leaders to the Government to scrap legislation introduced by the Conservative Health Secretary Andrew Lansley in the 2012 Health and Social Care Act that effectively forces NHS organisations to run a full procurement and tendering process for many contracts within the NHS. This is the legislation that many feel is responsible for an increase in privatisation of the NHS.
Instead, NHS leaders want the NHS to be able to decide whether a full procurement process is needed based on circumstances, rather than be forced to run one regardless.
BMA chair Dr Chaand Nagpaul said: “At a time when the NHS can least afford it, too much time and money is currently spent on tendering processes for contracts.’ Dr Nagpaul suggested CCGs “should have the flexibility to commission services to suit local need, not to suit competitive tendering regulation and without the fear of having to pay out millions to private providers for falling foul of existing legislation, as has been the case in recent years.”
Jonathan Ashworth, Labour’s shadow health and social care secretary, said: “the fact NHS bosses are now proposing significant changes to the Health and Social Care Act confirms what a wasteful, bureaucratic disaster it was in the first place. Labour has long called for this Act to be binned and will study legislative proposals carefully. The Tories must apologise for wasting billions of taxpayers’ money on the privatisation, constant tendering of contracts, top-down reorganisation and demoralisation of staff this Tory Act ushered in.”
The changes to the 2012 legislation are included in “a provisional list of potential legislative changes for parliament’s consideration”, which also includes changes that are needed for integrated care systems to work effectively. The Guardian notes that the long-term plan including the section on legislative changes has been endorsed by Downing Street, indicating that the Prime Minister could possibly support the scrapping of this particular part of the legislation.
It turns out, however, that changing the regulations on procurement might not even need legislative changes. A letter from Peter Roderick, Principal Research Associate in the Institute of Health & Society at the University of Newcastle, published in the Guardian (8/1/2019), notes: “The act only empowers the government to require tendering and the requirement is imposed under secondary legislation – the National Health Service (Procurement, Patient Choice and Competition) (No 2) Regulations 2013.”, which he writes can be “revoked with the stroke of a ministerial pen.”
The regulations in the 2012 act are widely thought to have contributed to a significant increase in privatisation of the NHS, including allowing companies such as Virgin Care to take over large NHS contracts.
However, things are not so straightforward – privatisation was happening before this act was put in place. Indeed, in April 2012, Virgin Care began a multi-million pound contract for community care in Surrey lasting five years. The development of the contract and the procurement process began long before the 2012 act, and the actual contract began a full year before the 2012 act was enforced in April 2013. Furthermore, there were already plenty of other much lower value contracts in place before 2012 as well.
The requirement for tendering can be removed, but it can still take place and private companies can still be awarded contracts in the NHS. The document states that NHS organisations should still be allowed to use a full procurement process under certain circumstances, which will be subject to what NHS England term a ‘best value’ test to secure the best outcomes for the patients and taxpayer.
Can the long-term plan be funded?
The long-term plan has been drawn-up based on an extra £20.5 billion being given to the NHS – although this sounds a lot, once split over a five year period, it is actually only a rise each year of 3.4%.
Expert consensus, however, is that a rise of at least 4% per year is needed for the next 5 years to maintain the current level of care, and to make meaningful progress on staff shortages, mental health provisions and waiting times, the NHS will need funding growth of around 5% a year over that same period.
There are several reasons why it is highly unlikely that the long-term can be carried out at the current level of funding settlement.
First the projected increase in demand: the new settlement is significantly lower than the 4.3% annual growth in the Office for Budget Responsibility’s projection of future cost pressures due to rising demand. This is an estimate that the IFS, think tanks and most economists agree is a fair measure of how much money the NHS needs just to keep up with demand, let alone improve standards.
Secondly, the long-term plan has a focus on prevention and improving health to reduce demand on the NHS, but the primary services focusing on these areas, public health services, were not included in the funding settlement. Indeed, public health was not just excluded from the funding even though it provides services that can prevent ill health and reduce future spending, this area continues to experience severe cuts to funding by cash-strapped councils. The only positive is if, as requested, the NHS takes back control of these services and receives sufficient funding for them to have a meaningful impact on society.
Finally, the long-term plan fails to mention funding to increase the capacity of the NHS: there has been no extra funding for the cost of new buildings and training staff. Seven years of underfunding has left the UK unprepared for rising demand with below average numbers of doctors, nurses, hospital beds, MRI machines, and CT scanners per head. There is a now large mismatch between the capacity of the service and the health needs of our society. In terms of staff, the NHS needs an extra 100,000 staff and funding is needed to recruit, train and retain these staff.
Commentators have picked up on the mismatch between the long-term plan and funding:
Dame Donna Kinnair, Acting Royal College of Nursing (RCN) Chief Executive, said: “the NHS’s biggest asset is its staff. It is strange then that this plan offers no money for nurses to develop the specialist skills patients need. ”
The Royal College of Midwives (RCM) noted the issue of a lack of funding and a lack of staff. Gill Walton, RCM chief executive said: “The issue of funding services also rears its head. There are some commitments in the plan to postnatal care yet this is an area that has long been underfunded. Key elements of the plan also talk about prevention of poor health such as reducing the numbers of people smoking. But we are seeing budgets for public health services such as smoking cessation cut. It is therefore vitally important that sufficient funding is made available and that we have the right numbers of midwives and other staff in place.”
Chair of the British Medical Association (BMA), Dr Chaand Nagpaul, noted in a statement the lack of detail on how the aims of the plan were going to be realised and the lack of sufficient funds: “Given that there are 100,000 staff vacancies within the NHS, the long-term sustainability of the NHS requires a robust workforce plan that addresses the reality of the staffing crisis across primary, secondary and community care. This will require additional resources for training, funding for which has not been mentioned in the long-term plan.”
UNISON head of health Sara Gorton said: “The plan is honest about the scale of the staffing challenge. But nothing will happen without more money to attract new recruits and train existing employees. The government must act now, or its plan will fall at the first hurdle.”
Unite national officer for health Colenzo Jarrett-Thorpe said: “This new cash is, in reality, putting in the funding that the government removed a decade ago. ‘Smoke and mirrors’ is the name of the game. The money that is now coming on stream is not enough to meet the ambitious targets to save the almost 500,000 lives outlined in the long term plan….The NHS requires an immediate cash injection to meet increasing demand. That’s the grim reality.”
The Health Foundation notes that “without a solution to the growing crisis in social care, people will continue to suffer, and more pressure will be piled on the NHS. Without additional funding for public health, which runs services that are essential for keeping people healthy and reducing health inequalities, NHS plans in these areas risk stalling. The Health Foundation has calculated that an additional £3.2bn a year is required to reverse the impact of cuts to the public health grant and ensure that it is re-allocated according to need.”
“The goals of this plan look right…..what worries me is how difficult it will be to roll out such wide ranging changes. There are several big pitfalls ahead. The extra funding will actually be below the historic average and what experts thought was needed. It’s 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. The reforms we all know are needed to the way we pay for care have been kicked into the long grass again and again. If this goes on, the NHS will be stretched still further as it looks after more people who couldn’t find the help they needed……The biggest obstacle of all is the lack of key staff. Our calculations with The King’s Fund and Health Foundation show a shortfall of 250,000 by 2030, which would make delivering even current services near impossible.”
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