I was sitting in the audience at the Royal Free Hospital on 18 June when the Prime Minister gave her speech about the NHS for its landmark 70th birthday. All ears were tuned to how much more money would be promised (£20.5bn real terms by 2023/24), where the money would come from (as yet unclear) and what priorities the government favoured for the service for the next ten years.
Here, the Prime Minister set out five priorities: putting the patient at the heart of how we organise care, a workforce empowered to deliver the NHS of the future, harnessing the power of innovation, a focus on prevention not just cure, and true parity of care between mental and physical health. She also said that a 10-year plan for the NHS must enjoy the ‘support of NHS staff across the country – not be something dreamt up in Whitehall and centrally imposed.’
Feverish work is now underway to put together such a plan, looking at clinical priorities and life course programmes, ‘enablers’ such as workforce and technology, a review of the financial ‘architecture’ (as promised by Stevens and Dalton at the Public Accounts Committee in March), and various forms of stakeholder engagement (including design of a NHS Assembly).
So, what should be in it? The direction of travel set out by the NHS Five Year Forward View in 2014 and again in the ‘next steps’ report of 2017 still makes a lot of sense, and the new plan should stick to it. The main thrust is a focus on developing integrated care (within the NHS, between NHS and social care), upgrading prevention and public health, making progress on selected clinical areas, and enhancing efficiency. However, we think four key gaps need filling, as outlined below.
A long-term strategy
First, the NHS needs the certainty of a robust long-term strategy spanning 10–15 years as well as a five-year plan, out of which should fall a concrete operational delivery plan for the next two years.
At the least, a long-term strategy should include the following elements:
- A reaffirmation of the NHS offer to the population, and analysis of what the public should expect to see.
- A description of the broad challenges and opportunities facing the health of the population and the health care system over the next 10–15 years, with supply and demand modelling.
- An assessment of how the health care system is performing to date (for example, based on international comparisons and the experience of patients).
- Key areas for improvement and suggestions for what is likely to help achieve improvement. This should encompass the core infrastructure that requires a long-term approach to planning, such as workforce, building provider capability to make change and adopt innovation and investments in capital, as well as investments in prevention. Details of how the health care system will respond in broad terms and a rationale for the specific approaches, should also be included.
- An overview of how the NHS will be able to assess progress and course correct regularly, reporting back to NHS staff and the public, as well as to government.
- A strong research and evaluation strategy, particularly for new initiatives, is critical if the NHS, key national arm’s length bodies (ALBs), and local sites pioneering the initiatives are to fully understand whether or not there is progress and continue learning. The Improvement Analytics Unit (IAU) – a partnership between NHS England and the Health Foundation to evaluate significant new national initiatives – is a case example, as is the Health Improvement Studies (THIS) Institute which is trialling citizen science techniques to assess change more rapidly.
The five-year plan: plugging gaps
Second, a five-year plan should include specific priorities, and the current focus on clinical and service priorities (or ‘vertical programmes’) such as cancer and primary care, as well as horizontal ‘enablers’ such as workforce, is right. But there is also a strong argument for a distinct ‘vertical’ programme to be created for people living with multiple health conditions – a group using nearly two-thirds (63%) of NHS resources, according to our estimates. New analysis by the Health Foundation, due to be released soon, also shows that 82% of patients with cancer, 92% of patients with cardiovascular disease, 92% of patients with chronic obstructive pulmonary disease and 70% of patients with a mental health condition, have at least one additional condition. Our findings highlight that people with multiple health conditions are more likely to live in deprived areas, meaning that tackling multiple conditions also means tackling health inequalities.
Our proposed NHS workstreams are wider than those currently being developed in the long term plan:
Another enabler: building capacity and capability in quality improvement
Third, a critically important ‘enabler’ currently missing is the building of provider capability to deliver key activities such as integrated care systems, manage winter pressures, tackle variation, and adopt innovations faster. Based on over a decade of experience at the Health Foundation of funding quality improvement, building capacity and capability among staff is clearly needed. Without it, kiss goodbye to rapid change, including uptake of new innovation. Part of the solution to this challenge involves understanding what characterises those health care organisations already delivering outstanding care efficiently. The work of the Care Quality Commission (CQC) has developed a comprehensive picture of quality nationally, and has identified several organisations that they judge to deliver outstanding quality. Many of these, such as Salford Royal, East London and Western Sussex NHS Trusts, use a structured quality improvement approach as part of a strategic approach to delivering high-quality care. It should be remembered, too, that the additional funding of £20.5bn by 2023/4 – while substantial – is actually limited given the demands on the service. Astute targeting of new investment is key, but more so will be eking out every benefit from the other odd £140bn. This must mean mobilising the talents of staff to make continual improvements as part of the day job, which in turn means getting serious about training and supporting staff to do this. Skimping on this won’t work.
Finally, the ‘radical upgrade’ promised in the NHS Five Year Forward View hasn’t yet happened, but the aim is absolutely right. To support this, the ways in which the NHS can maximise primary and secondary prevention of ill-health in each vertical programme, as well as working with public health staff in local authorities, has got to be much more clearly spelt out using the latest evidence. There are also powerful opportunities for tackling upstream determinants of health by mobilising NHS organisations as ‘anchor’ institutions in the community; for example, through procuring more supplies, staff and services locally. But there are limits to what the NHS can achieve on its own, and the sustained cuts to public health funding undertaken in recent years must be reversed – alongside other measures – if we are serious about prevention.
This time round, it is vital that more headway is made on these issues; an agreed longer term strategy with specific focus on people with multiple co-morbidities as a distinct programme, building capacity and capability in quality improvement and an embedded focus on prevention.
Jennifer Dixon is Chief Executive at the Health Foundation.