A pragmatic plan, but can the NHS make it happen?

What’s the main focus of the new long-term plan?

The plan plots a pragmatic path for the NHS over the next decade, following the route set by the Five Year Forward View in 2014. As we know, the context is extremely challenging: long waiting times for treatment, missed performance targets, and a gap of around 100,000 doctors, nurses, and other staff.

The big emphasis is on shifting the NHS model of care further upstream. The plan aims for more preventive care, closer integration of services in the community – including through new primary care networks, made up of GPs, district nurses, social workers, and other staff – and better coordination of urgent care. Improvements are promised in priority services, including mental health, maternity, and cancer. And treatment is to become more personalised. 

Much of this shift in care relies on implementing new technologies – such as apps and artificial intelligence to support ‘digital first’ primary care, and telehealth to support people with frailty.

The plan also has a welcome emphasis on the NHS’s role in tackling health inequalities. Gaps in life expectancy in England are wide, growing, and unjust. New targets will be introduced for reducing inequalities – and local areas will be asked to show how they plan to meet them.

Is there anything missing from the plan?

There are some gaps and areas of ambiguity. Considering the plan is aimed at future-proofing the health service, it’s strange that it doesn’t more directly address one of the NHS’s biggest challenges: meeting the needs of people living with multiple long-term health conditions, like diabetes and cardiovascular disease. Multimorbidity is common, costly, and socially patterned. My colleagues Sarah Deeny and Rebecca Fisher address these issues in their recent blog for the BMJ. 

Exactly who is accountable for making care improvements is also unclear. Sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) – partnerships of NHS organisations and local government – are expected to lead much of the local change. But STPs and ICSs have no formal authority. The plan suggests legislative changes to help local partnerships function, but time for new legislation, even if appetite for it exists, is scarce.

The plan also raises hard questions. Like how will new digital innovations be evaluated, regulated and, if they work, spread? How will they be used to tackle the NHS’s biggest challenges, like multimorbidity? And what about the risk that new technologies exacerbate health inequalities? There are also important issues about how the NHS shares data with the private sector, to ensure it is patients not shareholders that reap the benefits. Adam Steventon talks more about data sharing in his blog.

Is there enough resource to deliver it all?

Well, that’s the biggest question. Although the extra £20.5bn funding promised for the NHS by 2023/24 is large relative to funding of other parts of the public sector, without big gains in productivity – on which the plan is thin – it is barely enough to keep pace with growing demand. This means trade-offs are inevitable. The plan hints that revised performance standards may soon arrive. 

Just as importantly, the plan relies on an adequately staffed NHS, yet there are major, chronic staff shortages in the health service. While initiatives are being proposed to build the workforce, the NHS’s record on workforce planning is weak – and these initiatives need to be matched with action from central government to secure training budgets and a supportive migration policy to allow international recruitment that is vital to staffing the NHS. 

How will the government ensure progress is made?

Delivering the plan also depends on wider political choices outside the control of the NHS, particularly on Brexit, social care, and wider social policy. 

Further delaying decisions on social care funding will leave vulnerable people without the support they need, and pile even more pressure on the NHS. A no-deal Brexit could threaten the extra investment promised for the NHS and worsen its chronic staffing shortages. And continued cuts to public health and other social services will undermine the NHS’s ambitions to improve health and reduce inequalities. These cuts come at a time when life expectancy improvements are stalling and health inequalities are growing. They could hardly be more short-sighted.

Also in this newsletter

Our newsletter this month looks at the impact of the NHS Long Term Plan more widely, including questions around funding, and how it will affect health and improvement. You may also be interested in: