Promises, promises The NHS Long Term Plan makes welcome pledges on tackling the sources of ill health and promoting integration but, with the funding likely to be swallowed by existing demands, can it really make a difference? Peter Blackburn reports

‘This is a historic moment. Our vision is clear. Our commitment is assured. So let’s deliver the NHS of the future.’

Cynicism may have been the overwhelming feeling for many at prime minister Theresa May’s speech last month, unveiling the future vision for the NHS in England.

After all, this is a government that has given little regard to the health service, NHS staff and patients during Brexit negotiations, that promises much and delivers little – 5,000 more GPs springs to mind – and it follows a government led by many of the same parliamentarians who claimed to have ‘fully funded’ the NHS, despite presiding over an era of record-breaking strain on frontline services and wholesale cuts to budgets.

It is also the second plan aimed at revolutionising the health service this decade. The previous iteration, the ‘five-year forward view’, hailed as an opportunity to revitalise the way care is planned and delivered, was undermined by profound cuts to budgets, soaring demand and catastrophic failures in recruitment and retention of staff.

‘The investment in the NHS Long Term Plan will still leave the UK falling behind comparative nations’

So what are the odds on the Government and NHS England’s latest plan delivering ‘the NHS of the future’ – one which the prime minister claims will deliver radical improvements to technology, workforce and infrastructure and will deliver a ‘more integrated’ health service focused on ‘prevention and early diagnosis’?

The Government’s NHS Long Term Plan makes tackling the causes of ill health a priority – but in recent years it has spent less and less (SOURCE: The Health Foundation)

Unlike the five-year forward view, NHS England chief executive Simon Stevens’s latest plan is actually backed with some sort of finance; rather than requiring cuts of around £20bn, this iteration is backed by year-on-year real-terms funding rises of around 3.4 per cent.

The result of that pledge is that NHS spending will increase by £20.5bn in real terms, from £114.6bn in 2018/19 to £135bn in 2023/24. While something of a departure from the recent trend, it’s a smaller increase than the average 3.7 per cent increase which the Health Foundation calculated the NHS received between its formation in 1948 and 2016/17.

Treading water

If the health service wants to do more than ‘stand still’ in keeping up with an ageing population and other cost pressures, and actually genuinely transform services, it is reckoned that it would need considerably more.

As BMA council chair Chaand Nagpaul (pictured below) says: ‘Ultimately, there is a need for honesty about how far the £20.5bn over five years will stretch.

'A need for honesty'

‘World-class care requires world-class funding and the investment in the NHS Long Term Plan will still leave the UK falling behind comparative nations such as France and Germany.’

‘It’s duplicitous to be cutting public health funding at the same time’

While evidently not a genuinely transformative amount of funding, the Government’s commitment does mean there are conversations to be had about what the health service can do and where it should change, rather than simply where the axe must fall. And this is where the plan comes in.

At the top of Mr Stevens’s agenda is prevention. For many doctors it may be galling that this intention is outlined after seemingly endless warnings from public health leaders and 17 years after the publication of Derek Wanless’s health review, which said poor levels of health in the population would see considerable pressure on the NHS, swamping Government investment in services. Sir Derek’s report urged prevention to be placed at the centre of health policy.

‘This was all predicted, so it’s not a surprise that we find ourselves needing to rediscover the lessons previous generations have taught us,’ BMA public health medicine committee local authority lead Sohail Bhatti says.

‘I would welcome greater integration but it shouldn’t be about saving money’

With regard to prevention, the plan focuses on the top five lifestyle factors leading to premature death in England: smoking, poor diet, high blood pressure, obesity, and alcohol and drug use. It also references air pollution and lack of exercise.

In a bid to tackle these problems it suggests offering NHS-funded tobacco treatment to people admitted to hospital, doubling funding for the NHS diabetes prevention programme and establishing alcohol-care teams in hospitals where need is greatest.

Percentage falls in real-terms public health grant spending between 2014/15 and 2018/19 (SOURCE: The Health Foundation)

For Dr Bhatti, the NHS Long Term Plan is a positive step but one which fails to address the mistakes of the past – and those mistakes could threaten its success.

He says: ‘There is lots of good stuff in there, no doubt there’s some really good ideas. People should take more responsibility for their health and if we encourage people to keep themselves healthy that’s all for the better – but it’s duplicitous to be cutting public health funding at the same time. You can’t say one thing and do the other.’

Funds slashed

Research from the Health Foundation last year found that £3.2bn a year would be required to reverse the effects of the cuts Dr Bhatti talks about – with funding falling by £700m since 2014/15, a fall of almost a quarter per person in the country, owing to austerity measures placed on local authorities.

Dr Bhatti (pictured below) says: ‘The guillotine fell on the big budgets – drugs and alcohol, sexual health and zero to 18 children’s services. As they have the biggest budgets they have the most obvious cuts. My experience is people in local authorities tried really hard to get the same level of service for less money but if you suck as much out as you can, eventually you fail because fundamentally you don’t have enough money. In the long run services fall over.’

'If you suck out as much as you can, eventually you fail'

While it must be a positive step for prevention to be in vogue, these are ideas likely to be confounded by the brutal cuts that have been before – and an unwillingness to look to effective population-wide measures, such as a minimum unit price for alcohol; reducing sugar levels in food; and greater restrictions on junk-food marketing.

For Dr Bhatti, talk of prevention is cheap, and action would speak much more loudly. ‘There’s no point fiddling while Rome burns,’ he says.

One of the plan’s biggest focuses is on reforming services – particularly boosting primary and community care, personalising care, increasing digitalisation and, perhaps most prominently, local integration.

Integrated care

More care will be expected to be provided at urgent treatment centres, rather than emergency departments, with more being unveiled across the country. Multidisciplinary teams are to be set up in primary care networks which GP practices will be asked to join, and 200,000 more people are to be given a personal health budget by 2023/24. It also suggests every patient will have a right to access telephone and online consultations within the next five years.

Integrated arrangements, where different parts of a local health system are asked to come together to plan care for patients jointly in their area, are now expected to cover the whole country by April 2021 with integrated care systems, which are voluntary partnerships, and integrated care providers, contracted bodies responsible for an area’s services, supported by NHS England.

(SOURCE: The Health Foundation)

The BMA has consistently welcomed greater integration and reduced duplication of services, while insisting the proper investment must be available to achieve it.

Dr Bhatti says: ‘I would welcome greater integration but it shouldn’t be about saving money – it should be about better outcomes and better flow.’

But there is one main stumbling block in the path of this integrated future for the NHS: legislation. The 2012 Health and Social Care Act enshrines competition and procurement regulations – facilitating a bloated internal market and tendering bureaucracy. Until parts of this system are gone, integrated care will go nowhere fast. And NHS England has dropped welcome hints that change could be on the way in the plan – suggesting legislative changes would enable ‘more rapid progress’.

Tender times

The plan suggests impediments to ‘place-based’ commissioning – another term for integrated-care arrangements where services are planned and provided by a body or group of organisations for their local area – could be removed. And it also suggests allowing the creation of ‘integrated care trusts’, the removal of general competition rules and cuts to procurement processes.

Dr Nagpaul says: ‘At a time when the NHS can least afford it, too much time and money is spent on tendering processes for contracts. Given the long waits for treatment and the cash-strapped state of our health service, time and money should be spent on the front line, delivering better care to patients, not on costly tenders.

‘These competition rules have also resulted in a fragmented NHS driven by commercial motives rather than providing patients with seamless care.

‘When Government rhetoric is centred around integration within the health service, independent providers bidding on time-limited contracts sits entirely at odds with this philosophy. Only by removing the requirement to put services out to tender, can local systems work together to ensure cohesive patient-centred healthcare.’

‘The sustainability of the NHS requires a robust workforce plan that addresses the reality of the staffing crisis’

In mental health, the plan renews the previously asserted commitment to grow investment in mental health services faster than the NHS budget overall for each of the next five years, including expanding access to Improving Access to Psychological Therapies services and ridding the NHS of out-of-area placements. However, the promises are vague, according to BMA consultants committee mental health lead Andrew Molodynski (pictured below).

‘What they are doing is good in a way and it is sustaining some improved investment but it’s actually only really holding the position where we are now. This money is not going to be transformative, it’s just looking to keep us where we are,’ Dr Molodynski says.

'The money is not going to be transformative'

‘In all branches of the service – children’s services, which get the most publicity, adult services and older adults’ services – across the country there have been very significant increases in demand in the past five or six years. My service has had an increase from 350 to 600 referrals a year in five years and that’s not unusual.

‘People don’t like to talk about it but the truth is that this has decreased quality of patient care – unless we increase investment to meet demand this will worsen further.’

Dr Molodynski adds: ‘General mental health services need to be properly supported – there has been a lot of policy and financial announcements for small services, crucially important ones, and that’s great, but general services which look after the vast majority of people get neglected.’

No direction

Arguably the most significant aspect of the NHS Long Term Plan is not what it contains, but what it doesn’t contain – a genuine workforce strategy.

A document of some sort is apparently planned for later in the year, but the worry for those working in the NHS is that this workforce crisis – the NHS is short of around 100,000 frontline staff – has been a long time coming and exclusion from a grand plan for the service’s future seems ominous.

Nottingham GP Irfan Malik says: ‘The plan can’t work unless there’s adequate staffing. Certainly, in general practice, the staffing is going lower and lower. There are more vacancies and you can even struggle to get locums in some places now.’

The plan was, however, followed this month with the announcement of a new five-year GP contract in England, which includes a promise to expand the workforce by 20,000, to include physician associates, practice-based physiotherapists and paramedics.

It also enables newly formed primary care networks to employ at least one social prescribing link worker and one clinical pharmacist.

Social care

BMA GPs committee chair Richard Vautrey said the measures, and others in the contract, would begin to address the unsustainable situation of GPs being overstretched, and in many cases choosing to leave the profession.

'GPs in unsustainable position being stretched'

One significant omission, which would have given the long-term plan more credibility, is the long-promised Government green paper on social care – originally due last autumn.

Many would argue that, alongside workforce issues, the decimation of social care is actually the greatest problem facing the NHS.

Community services have been hollowed out and the strain is showing in hospitals where bed occupancy is at dangerous levels – leaving the whole system blocked, at great cost.

Groundhog day?

For Ms May this plan marks a chance to deliver the ‘NHS of the future’. However, for the doctors working in the health service, another change of direction will feel like groundhog day. So can things actually be different this time?

In short, and rather contrary fashion, it seems the answer is yes, and no. This plan often has its heart in the right place – its ambitions are largely positive; they often outline an NHS with better priorities and which could have better outcomes, but without serious movement to address splintered public health and mental health, a decimated workforce and crippled social care these would be foundations built on quickly shifting sand.

If the prime minister’s commitment really is ‘assured’, then the plan will simply mark the start of a serious process and the beginning of the genuine investment. There is much more work to do.

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