The NHS Long Term Plan (in a nutshell)

This week NHS England published its long term plan outlining its priorities for the NHS over the next 10 years. It’s focus is on retaining the things that are good about the NHS but also tackling head on the areas where there are concerns and pressures. Things like funding, staffing, increasing inequalities and pressures from a growing and ageing population.

The plan is presented in seven chapters as outlined in the graphic below.

A NEW SERVICE MODEL FOR THE 21ST CENTURY

The plan outlines initiatives to provide more options for patients, better support with joined up care at the right time, in the right setting. Today there are many challenges across the health system ranging from an Ambulance Paramedic who can’t respond to the next 999 call because they are stuck on a hospital ramp through to a patient with a long term condition who is called back for a pointless outpatient appointment every 6 months.

To respond to challenges like this, five practical changes have been outlined.

1. Boost “out of hospital care” — dissolve the divide between primary and community health service. To do this there will be increased investment in primary medical and community health services — at least £4.5b in 5 years, which may be increased by Clinical Comisioning Groups and Integrated Care Systems. This will be achieved through the following measures…
   a). Creating primary care networks comprised of local GP practices and community teams, creating fully integrated community based healthcare.
   b). Providing guaranteed support for people living in care homes
   c). Supporting people to age well through better support for careers, connected home based monitoring devices and proactive population health
2. Redesign and reduce pressure on emergency hospital services — this will be achieved through a variety of measures including those listed below;
   a). Providing a fully implemented and consistent Urgent Treatment Centre model by the Autumn of 2020. UTCs will work alongside other parts of the urgent care network including primary care, community, ambulance and other services to provide a locally accessible and convenient alternative to A&E for patients who do not need to attend hospital
   b). Reforming hospital emergency care using new diagnosis and treatment practices to adopt a Same Day Emergency Care model, allowing patients to spend fewer hours in hospital and only being admitted to a ward when absolutely necessary.
   c). Cut delays in patients being able to go home, though the use of SAFER patient flow bundles, MDT reviews on all wards every morning and an agreed Clinical Care Plan within 14 hours of admission.
3. Personalised Care — giving people more control of their health when they need it, supplemented by experts. As part of a move to a “Shared Responsibility for Heath” model there will be rollout of personalised care, reaching 2.5m people by 2023/24, and double that within a decade. As part of this work there will the creation of personal health budget to give people greater control and choice.
4. Digitally enabling Primary and Outpatient care — the starting point to enable this is data and system interoperability. In addition to this, a digital NHS ‘front door’ through the NHS App will provide advice, check symptoms and connect people with healthcare professionals — including through telephone and video consultations. Within 5 years every patient across the country will have the right to have an online consultation. Outpatient services will be redesigned so that over the next 5 years patients will be able to avoid up to a third of face-to-face appointment, removing the need for 30m outpatient visits a month.
5. Population Health — Through new Integrated Care Systems, which will grow out of the existing STP networks, there will be a streamlined commissioning process that will enable local systems to make decisions on how to best use resources, design services and improve the health of their population. By April 2021 ICS’s will cover the entire country

MORE NHS ACTION ON PREVENTION AND HEALTH INEQUALITIES

The plan outlines new commitments to improve both prevention and provide stronger action to address health inequality.

Wider action on prevention will help people stay healthy and also moderate demand on the NHS with specific new evidence-based NHS prevention programmes, including some of those outlined below;

1. Smoking — 6.1m people still smoke in the England and the NHS is committed to make England a smoke free society. By 2023/24 all smokers admitted to hospital will be provided with NHS funded tobacco treatment services. In addition, new smoke free pregnancy pathways will be provided and a smoking cessation offer will be provided as part of mental health services.
2. Obesity — Access will be provided to weight management services in primary care for people with Type 2 Diabetes or hyper tension with a BMI of 30+.
3. Alcohol — Creation of Alcohol Care Teams for hospitals with the highest rate of alcohol dependant related admissions.
4. Air Pollution — The NHS is commuted to reducing business mileage and fleet air pollution by 20%by 2023/24
5. Antimicrobial Resistance — The NHS will continue to support the implementation and delivery of the governments new 5 year plan on antimicrobial resistance

There will also be stronger action on inequality with a higher share of funding made available to geographies with high health inequality. Specific measurable goals will be defined to narrow inequality and identify those related to poverty. This will cover a range of areas including some of those listed below;

1. Helping women quite smoking during pregnancy
2. Ensure people with learning difficulties, autism or both can live a happier, healthier and longer live.
3. Carers will continue to be supported, especially those from vulnerable societies
4. Invest in specialist clinics to help with gambling.

FURTHER PROGRESS ON CARE QUALITY AND OUTCOMES

The plan outlines clear and costed improvement priorities for the biggest killers and disablers, for both young people and major health condition affecting the population.

For children and young people the plan outlines improvements for a number of services, including those outlined below.

1. Maternity and Neonatal — The plan will accelerate acton to achieve 50% reduction in still birth, maternal mortality, neonatal mortality and serious brain injury by 2025.
2. Children and Young Peoples Mental Health Services — The plan outlines a new commitment that funding for children and young people mental health services will grow faster that both overall NHS funding and total mental health spending
3. Learning Disability and Autism — Action will be taken to tackle the causes of mobility and preventable health in people with learning difficulties and autistic people.
4. Children and Young people with Cancer — From 2019 all children with cancer will be offered whole genome sequencing to enable from comprehensive and personalised treatments,

The latest Global Burden of Disease study shows that the top five causes of early death for the people of England are: heart disease and stroke, cancer, respiratory conditions, dementias, and self-harm. NHS England have used these GBD findings to help frame the improvement priorities in the Long Term Plan. The plan outlines the following action.

1. Cancer — A new ambition is outlined that by 2028 the proportion of cancers diagnosed at stage 1 and 2 will rise from a half to three quarters. In addition to this there a number of short terms targets including faster diagnosis by 2020, access to personalised care by 2021 and stratified follow-up pathways by 2023.
2. Cardiovascular Disease — Early detection can help save lives and this is single biggest area where the NHS can saves lives over the next 10 years. Through a range of preventative and early detection measures the plan outlines a target of preventing 150k heart attacks, strokes and dementia cases over the next 10 years.
3. Stroke — another preventable disease and the 4th leading cause of death in the UK. The NHS will work with Health Education England to modernise the stroke workforce with a focus on cross-specialty and in some cases cross-profession accreditation of particular ‘competencies’. By 2025 the NHS will have amongst the best performance in Europe for delivering thrombolysis to all patients who could benefit.
4. Diabetes — The plan outlines measures to support people who are newly diagnosed to manage their own health by further expanding provision of structured education and digital self-management support tools. Through continuing investment in supporting delivery across primary care the NHS will enable more people to achieve the recommended diabetes treatment targets and drive down variation between CCGs and practices.
5. Respiratory Disease — The NHS will do more to detect and diagnose respiratory problems earlier. From 2019 the NHS will build on the existing NHS RightCare programme to reduce variation in the quality of spirometry testing across the country. PCNs will support the diagnosis of respiratory conditions. More staff in primary care will be trained and accredited to provide the specialist input required to interpret results.
6. Adult Mental Health Services — The Long Term Plan makes a renewed commitment to grow investment in mental health services faster than the NHS budget overall for each of the next five years. NHS England’s renewed pledge means mental health will receive a growing share of the NHS budget, worth in real terms at least a further £2.3 billion a year by 2023/24.

NHS STAFF WILL GET THE BACKING THEY NEED

Like any organisation its success ultimately depends on its people and the NHS is no different. The plan outlines a commitment to give NHS staff the backing they need. To make this a reality, the NHS will need more staff, working in rewarding jobs with a more supportive culture.

The plan sets out a number of specific workforce actions developed by NHS Improvement and others that they propose can have a positive impact now.

1. A new workforce implementation plan — NHS Improvement, HEE and NHS England will establish a national workforce group to ensure that such workforce actions agreed are delivered quickly.
2. Expanding the number of nurses, midwives, AHPs and other staff — an extra 5,000 places will be funded from 2019/20, a 25% increase. From 2020/21, there will be up to a 50% increase.
3. Growing the medical workforce — grow medical school places from 6,000 to 7,500 per year.
4. International recruitment — new national arrangements to support NHS organisations in recruiting overseas.
5. Supporting current NHS staff — expand multi-professional credentialing to enable clinicians to develop new capabilities formally recognised in specific areas of competence 6. Enabling productive working — Ensuring staff are making the most of their skills and expertise will form a critical component of the NHS workforce implementation plan.
6. Leadership and talent management – the NHS will do more to nurture the next generation of leaders by more systematically identifying, developing and supporting those with the capability and ambition to reach the most senior levels of the service.
7. Volunteers — The NHS will back the Helpforce programme with at least £2.3 million of NHS England funding to scale successful volunteering programmes across the country, part of our work to double the number of NHS volunteers over the next three years.

DIGITALLY-ENABLED CARE WILL GO MAINSTREAM ACROSS THE NHS

Digitally-enabled care will go mainstream across the NHS. Virtually every aspect of modern life has been, and will continue to be, radically reshaped by innovation and technology — and healthcare is no exception

Good progress has been made in achieving the ambitions set out in the Five Year Forward View and the Wachter report, with many new or enhanced digital and technology systems and services delivered over the last three years, including Electronic Prescription Service and Electronic Referral Service.

However, wholesale transformation of the NHS is not yet complete. Technology will play a central role in realising the Long Term Plan, helping clinicians use the full range of their skills, reducing bureaucracy, stimulating research and enabling service transformation

People will have more control over the care they receive and more support to manage their health, to keep themselves well and better manage their conditions, while assisting carers in their vital work.

The NHS is made up of hundreds of separate but linked organisations, and the burden of managing complex interactions and data flows between trusts, systems and individuals too often falls on patients and clinicians. Digital services and data interoperability provide the opportunity to free up time and resources to focus on clinical care and staying healthy.

In ten years’ time, the existing model of care is expected to look markedly different. The NHS will offer a ‘digital first’ option for most, allowing for longer and richer face-to-face consultations with clinicians where patients want or need it. Primary care and outpatient services will have changed to a model of tiered escalation depending on need. When ill, people will be increasingly cared for in their own home, with the option for their physiology to be effortlessly monitored by wearable devices. People will be helped to stay well, to recognise important symptoms early, and to manage their own health, guided by digital tools.

Empowering People

People will be empowered, and their experience of health and care will be transformed, by the ability to access, manage and contribute to digital tools, information and services.

The NHS Apps Library, NHS App and NHS login will enable easy access to personalised content and digital tools and services. The NHS App will create a standard online way for people to access the NHS. The app will work seamlessly with other services at national and local levels and, where appropriate, be integrated into patient pathways.

Support for people with long-term conditions will be improved by interoperability of data, mobile monitoring devices and the use of connected home technologies over the next few years. By 2020, every patient with a long-term condition will have access to their health record through SCR accessed via the NHS App. This will also be available to all urgent and emergency care services, with appropriate permission. By 2023, the SCR functionality will be moved to the Personal Health Records held within the Local Health and Care Record systems, which will be able to send reminders and alerts directly to the patient.

Patients’ Personal Health Records (PHRs) will hold a care plan that incorporates information added by the patient themselves, or their authorised carer. The PHRs will also hold data that the patient chooses to share with the NHS, including from monitoring devices. Patients who choose to join a condition monitoring programme will be able to benefit from insights from these data and will be monitored for combinations of symptoms that may indicate clinical events and result in contact from a health adviser or clinician to help the individual stay well. Patients and clinicians will also be able to add information about living circumstances which may require reasonable adjustments to be made.

Supporting health and care professionals

At present, too much of the technology in the NHS is a burden on staff — slow to log in, clunky to use and unreliable in moments of crisis. The NHS will ensure that health and care professionals have the tools they need to efficiently deliver safe and effective patient care, and require vendors to meet usability standards to match those expected in the rest of our lives. Staff will be enabled to capture all health and care information digitally at the point of care, and optimise clinical processes to reduce administrative burden.

Supporting clinical care

Patients, clinicians and the carers working with them will have technology designed to help them. They will have a digital service for managing their interactions with the NHS, a view of their record, care plan, expectations, appointments and medications, to enable care to be designed and delivered in the place that is most appropriate for them.

The Secretary of State has announced that NHS organisations will from 2020 no longer use fax machines to communicate with other NHS organisations or patients. All providers, across acute, community and mental health settings, will be expected to advance to a core level of digitisation by 2024. To support this, the NHS will accelerate the roll out of Electronic Patient Record (EPR) systems and associated apps, including a spectrum of Software as a Service (SaaS)/Cloud- based variants. Provider digitisation will be implemented to nationally agreed standards to enable integration with the LHCR to provide patient-centric and clinician-centric digital user journeys across all health settings

Technology will enable the NHS to redesign clinical pathways. Easy access to referral decision trees, referral templates and direct access to investigations that reflect evidence-based best practice and universal access to ‘one click away’ specialist advice and guidance for GPs, will avoid many patients from requiring referral for an appointment

Improving Population Health

During 2019, the NHS will deploy population health management solutions to support ICSs to understand the areas of greatest health need and match NHS services to meet them. Over the coming years these solutions will become increasingly sophisticated in identifying those groups of people who are at risk of adverse health outcomes and predict which individuals are most likely to benefit from different health and care interventions, as well as shining a light on health inequalities

The use of de-personalised data extracted from local records, in line with information governance safeguards, will enable more sophisticated population health management approaches and support world-leading research. The NHS will make frictionless APIs available to industry and the developer community to stimulate innovation and support integration with other products. This will enable the NHS to work with suppliers to develop user journeys, supplemented with data and insights, that help clinicians to do their jobs more effectively and more efficiently. The initial API and workflow integration initiatives will develop towards full integration with smart home and wearable devices.

Improving clinical efficiency and safety

Digital technology can support the NHS to deliver high quality specialist care more efficiently.
Decision support and artificial intelligence are developing all the time. These technologies need to be embraced by the NHS, but also subjected to the same scrutiny that we would apply to any other medical technology. In the coming years AI will make it possible for many tasks to be automated, quality to increase and staff to focus on the complexity of human interactions that technology will never master.

TAXPAYERS’ INVESTMENT WILL BE USED TO MAXIMUM EFFECT

The new funding settlement announced by the Prime Minister in June 2018 promised NHS England’s revenue funding would grow by an average of 3.4% in real terms a year over the next five years178 delivering a real terms increase of £20.5 billion by 2023/24

Putting the NHS back onto a sustainable financial path is a key priority in the Long Term Plan and is essential to allowing the NHS to deliver the service improvements in this Plan. This means:

1. the NHS (including providers) will return to financial balance
2. the NHS will achieve cash-releasing productivity growth of at least 1.1% a year, with all savings reinvested in frontline care;
3. the NHS will reduce the growth in demand for care through better integration and prevention;
4. the NHS will reduce variation across the health system, improving providers’ financial and operational performance;
5. the NHS will make better use of capital investment and its existing assets to drive transformation.

NEXT STEPS

2019/20 will be a transition year, with every NHS trust, foundation trust and CCG expected to agree single year organisational operating plans and contribute to a single year local health system-level plan.

To support local planning, local health systems will receive five-year indicative financial allocations for 2019/20 to 2023/24 and be asked to produce local plans for implementing the commitments set out in the Long Term Plan in 2019. They will be expected to engage with their local communities and delivery partners in developing plans, which will be based on a comprehensive assessment of population need and will deliver the outcomes set out in the Long Term Plan

The approach to delivering the Long Term Plan will balance national direction with local autonomy to secure the best outcomes for patients. Local implementation will be led by the clinicians and leaders who are directly accountable for patient care and making efficient use of public money. This will ensure local health systems have the ability and accountability for shaping how the Plan is implemented.

ICSs will be central to the delivery of the Long Term Plan and by April 2021, NHS England wants ICSs covering all of the country. As local systems are in different states of readiness, the NHS will support each developing system to produce and implement a clear development plan and timetable.
The collaborative work which will need to underpin the development of local plans, and the detailed understanding of the services that each provider will need to deliver to meet the trajectory of outcomes, will be supported by the new regional teams. In particular, these teams will play a key role in ensuring the system is securing the best value from its combined resources to deliver the Long Term Plan.

The NHS will build on the open and consultative process that this Plan is built on, and strengthen the ability of patients, professionals and the public to contribute, by establishing an NHS Assembly in early 2019. The NHS Assembly will bring together a range of organisations and individuals at regular intervals, to advise the boards of NHS England and NHS Improvement as part of the ‘guiding coalition’ to implement this Long Term Plan. The Assembly membership will bring insight and frontline experience to the forum where stakeholders discuss and oversee progress on the Long Term Plan.