The NHS has been marking its 70th anniversary, and the national debate this has unleashed has centred on three big truths. There’s been pride in our Health Service’s enduring success, and in the shared social commitment it represents. There’s been concern – about funding, staffing, increasing inequalities and pressures from a growing and ageing population. But there’s also been optimism – about the possibilities for continuing medical advance and better outcomes of care.
In looking ahead to the Health Service’s 80th birthday, this NHS Long Term Plan takes all three of these realities as its starting point. So to succeed, we must keep all that’s good about our health service and its place in our national life. But we must tackle head-on the pressures our staff face, while making our extra funding go as far as possible. And as we do so, we must accelerate the redesign of patient care to future-proof the NHS for the decade ahead. This Plan sets out how we will do that. We are now able to because:
- first, we now have a secure and improved funding path for the NHS, averaging 3.4% a year over the next five years, compared with 2% over the past five years;
- second, because there is wide consensus about the changes now needed. This has been confirmed by patients’ groups, professional bodies and frontline NHS leaders who since July have all helped shape this plan – through over 200 separate events, over 2,500 separate responses, through insights offered by 85,000 members of the public and from organisations representing over 3.5 million people;
- and third, because work that kicked-off after the NHS Five Year Forward View is now beginning to bear fruit, providing practical experience of how to bring about the changes set out in this Plan. Almost everything in this Plan is already being implemented successfully somewhere in the NHS. Now as this Plan is implemented right across the NHS, here are the big changes it will bring:
Chapter One sets out how the NHS will move to a new service model in which patients get more options, better support, and properly joined-up care at the right time in the optimal care setting. GP practices and hospital outpatients currently provide around 400 million face-to-face appointments each year. Over the next five years, every patient will have the right to online ‘digital’ GP consultations, and redesigned hospital support will be able to avoid up to a third of outpatient appointments – saving patients 30 million trips to hospital, and saving the NHS over £1 billion a year in new expenditure averted. GP practices – typically covering 30-50,000 people – will be funded to work together to deal with pressures in primary care and extend the range of convenient local services, creating genuinely integrated teams of GPs, community health and social care staff. Now expanded community health teams will be required under new national standards to provide fast support to people in their own homes as an alternative to hospitalisation, and to ramp up NHS support for people living in care homes. Within five years over 2.5 million more people will benefit from ‘social prescribing’, a personal health budget, and new support for managing their own health in partnership with patients’ groups and the voluntary sector.
These reforms will be backed by a new guarantee that over the next five years, investment in primary medical and community services will grow faster than the overall NHS budget. This commitment – an NHS ‘first’ – creates a ringfenced local fund worth at least an extra £4.5 billion a year in real terms by 2023/24.
We have an emergency care system under real pressure, but also one in the midst of profound change. The Long Term Plan sets out action to ensure patients get the care they need, fast, and to relieve pressure on A&Es. New service channels such as urgent treatment centres are now growing far faster than hospital A&E attendances, and UTCs are being designated across England. For those that do need hospital care, emergency ‘admissions’ are increasingly being treated through ‘same day emergency care’ without need for an overnight stay. This model will be rolled out across all acute hospitals, increasing the proportion of acute admissions typically discharged on day of attendance from a fifth to a third. Building on hospitals’ success in improving outcomes for major trauma, stroke and other critical illnesses conditions, new clinical standards will ensure patients with the most serious emergencies get the best possible care. And building on recent gains, in partnership with local councils further action to cut delayed hospital discharges will help free up pressure on hospital beds.
Chapter Two sets out new, funded, action the NHS will take to strengthen its contribution to prevention and health inequalities. Wider action on prevention will help people stay healthy and also moderate demand on the NHS. Action by the NHS is a complement to – not a substitute for – the important role of individuals, communities, government, and businesses in shaping the health of the nation. Nevertheless, every 24 hours the NHS comes into contact with more than a million people at moments in their lives that bring home the personal impact of ill health. The Long Term Plan therefore funds specific new evidence-based NHS prevention programmes, including to cut smoking; to reduce obesity, partly by doubling enrolment in the successful Type 2 NHS Diabetes Prevention Programme; to limit alcohol-related A&E admissions; and to lower air pollution.
To help tackle health inequalities, NHS England will base its five year funding allocations to local areas on more accurate assessment of health inequalities and unmet need. As a condition of receiving Long Term Plan funding, all major national programmes and every local area across England will be required to set out specific measurable goals and mechanisms by which they will contribute to narrowing health inequalities over the next five and ten years. The Plan also sets out specific action, for example to: cut smoking in pregnancy, and by people with long term mental health problems; ensure people with learning disability and/or autism get better support; provide outreach services to people experiencing homelessness; help people with severe mental illness find and keep a job; and improve uptake of screening and early cancer diagnosis for people who currently miss out.
Chapter Three sets the NHS’s priorities for care quality and outcomes improvement for the decade ahead. For all major conditions, results for patients are now measurably better than a decade ago. Childbirth is the safest it has ever been, cancer survival is at an all-time high, deaths from cardiovascular disease have halved since 1990, and male suicide is at a 31-year low. But for the biggest killers and disablers of our population, we still have unmet need, unexplained local variation, and undoubted opportunities for further medical advance. These facts, together with patients’ and the public’s views on priorities, mean that the Plan goes further on the NHS Five Year Forward View’s focus on cancer, mental health, diabetes, multimorbidity and healthy ageing including dementia. But it also extends its focus to children’s health, cardiovascular and respiratory conditions, and learning disability and autism, amongst others.
Some improvements in these areas are necessarily framed as 10 year goals, given the timelines needed to expand capacity and grow the workforce. So by 2028 the Plan commits to dramatically improving cancer survival, partly by increasing the proportion of cancers diagnosed early, from a half to three quarters. Other gains can happen sooner, such as halving maternity-related deaths by 2025. The Plan also allocates sufficient funds on a phased basis over the next five years to increase the number of planned operations and cut long waits. It makes a renewed commitment that mental health services will grow faster than the overall NHS budget, creating a new ringfenced local investment fund worth at least £2.3 billion a year by 2023/24. This will enable further service expansion and faster access to community and crisis mental health services for both adults and particulary children and young people. The Plan also recognises the critical importance of research and innovation to drive future medical advance, with the NHS committing to play its full part in the benefits these bring both to patients and the UK economy.
To enable these changes to the service model, to prevention, and to major clinical improvements, the Long Term Plan sets out how they will be backed by action on workforce, technology, innovation and efficiency, as well as the NHS’ overall ‘system architecture’.
Chapter Four sets out how current workforce pressures will be tackled, and staff supported. The NHS is the biggest employer in Europe, and the world’s largest employer of highly skilled professionals. But our staff are feeling the strain. That’s partly because over the past decade workforce growth has not kept up with the increasing demands on the NHS. And it’s partly because the NHS hasn’t been a sufficiently flexible and responsive employer, especially in the light of changing staff expectations for their working lives and careers.
However there are practical opportunities to put this right. University places for entry into nursing and medicine are oversubscribed, education and training places are being expanded, and many of those leaving the NHS would remain if employers can reduce workload pressures and offer improved flexibility and professional development. This Long Term Plan therefore sets out a number of specific workforce actions which will be overseen by NHS Improvement that can have a positive impact now. It also sets out wider reforms which will be finalised in 2019 when the workforce education and training budget for HEE is set by government. These will be included in the comprehensive NHS workforce implementation plan published later this year, overseen by the new cross-sector national workforce group, and underpinned by a new compact between frontline NHS leaders and the national NHS leadership bodies.
In the meantime the Long Term Plan sets out action to expand the number of nursing and other undergraduate places, ensuring that well-qualified candidates are not turned away as happens now. Funding is being guaranteed for an expansion of clinical placements of up to 25% from 2019/20 and up to 50% from 2020/21. New routes into nursing and other disciplines, including apprenticeships, nursing associates, online qualification, and ‘earn and learn’ support, are all being backed, together with a new post-qualification employment guarantee. International recruitment will be significantly expanded over the next three years, and the workforce implementation plan will also set out new incentives for shortage specialties and hard-to-recruit to geographies.
To support current staff, more flexible rostering will become mandatory across all trusts, funding for continuing professional development will increase each year, and action will be taken to support diversity and a culture of respect and fair treatment. New roles and inter-disciplinary credentialing programmes will enable more workforce flexibility across an individual’s NHS career and between individual staff groups. The new primary care networks will provide flexible options for GPs and wider primary care teams. Staff and patients alike will benefit from a doubling of the number of volunteers also helping across the NHS.
Chapter Five sets out a wide-ranging and funded programme to upgrade technology and digitally enabled care across the NHS. These investments enable many of the wider service changes set out in this Long Term Plan. Over the next ten years they will result in an NHS where digital access to services is widespread. Where patients and their carers can better manage their health and condition. Where clinicians can access and interact with patient records and care plans wherever they are, with ready access to decision support and AI, and without the administrative hassle of today. Where predictive techniques support local Integrated Care Systems to plan and optimise care for their populations. And where secure linked clinical, genomic and other data support new medical breakthroughs and consistent quality of care. Chapter Five identifies costed building blocks and milestones for these developments.
Chapter Six sets out how the 3.4% five year NHS funding settlement will help put the NHS back onto a sustainable financial path. In ensuring the affordability of the phased commitments in this Long Term Plan we have taken account of the current financial pressures across the NHS, which are a first call on extra funds. We have also been realistic about inevitable continuing demand growth from our growing and aging population, increasing concern about areas of longstanding unmet need, and the expanding frontiers of medical science and innovation. In the modelling underpinning this Long Term Plan we have therefore not locked-in an assumption that its increased investment in community and primary care will necessarily reduce the need for hospital beds. Instead, taking a prudent approach, we have provided for hospital funding as if trends over the past three years continue. But in practice we expect that if local areas implement the Long Term Plan effectively, they will benefit from a financial and hospital capacity ‘dividend’.
In order to deliver for taxpayers, the NHS will continue to drive efficiencies – all of which are then available to local areas to reinvest in frontline care. The Plan lays out major reforms to the NHS’ financial architecture, payment systems and incentives. It establishes a new Financial Recovery Fund and ‘turnaround’ process, so that on a phased basis over the next five years not only the NHS as a whole, but also the trust sector, local systems and individual organisations progressively return to financial balance. And it shows how we will save taxpayers a further £700 million in reduced administrative costs across providers and commissioners both nationally and locally.
Chapter Seven explains next steps in implementing the Long Term Plan. We will build on the open and consultative process used to develop this Plan and strengthen the ability of patients, professionals and the public to contribute by establishing the new NHS Assembly in early 2019. 2019/20 will be a transitional year, as the local NHS and its partners have the opportunity to shape local implementation for their populations, taking account of the Clinical Standards Review and the national implementation framework being published in the spring, as well as their differential local starting points in securing the major national improvements set out in this Long Term Plan. These will be brought together in a detailed national implementation programme by the autumn so that we can also properly take account of Government Spending Review decisions on workforce education and training budgets, social care, councils’ public health services and NHS capital investment.
Parliament and the Government have both asked the NHS to make consensus proposals for how primary legislation might be adjusted to better support delivery of the agreed changes set out in this LTP. This Plan does not require changes to the law in order to be implemented. But our view is that amendment to the primary legislation would significantly accelerate progress on service integration, on administrative efficiency, and on public accountability. We recommend changes to: create publicly-accountable integrated care locally; to streamline the national administrative structures of the NHS; and remove the overly rigid competition and procurement regime applied to the NHS.
In the meantime, within the current legal framework, the NHS and our partners will be moving to create Integrated Care Systems everywhere by April 2021, building on the progress already made. ICSs bring together local organisations in a pragmatic and practical way to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care. They will have a key role in working with Local Authorities at ‘place’ level, and through ICSs, commissioners will make shared decisions with providers on population health, service redesign and Long Term Plan implementation.