NHS 10 Year Plan – A Critical Analysis

NHS LONG TERM 10 YEAR FORWARD PLAN EXTRACTS AND COMMENTS

The NHS Long Term 10 Year Forward Plan is a continuation the 5 Year Forward Plan and contains all the features outlined when the Sustainability (now System) and Transformation Plan (STP) was first proposed, producing savings by reducing hospital attendance, moving treatment in primary care, hugely increasing IT and Artificial Intelligence, down-skilling of staff and relying on prevention to reduce the demand for treatment with an increased reliance on the voluntary sector. Below are some extracts and comments (in italics).

These extracts are not in the same order as they appear in the 10 Year Forward Plan document. Our comments appear in Bold Italics.

STRUCTURE
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.

A new ICS accountability and performance framework will consolidate the
current amalgam of local accountability arrangements and provide a consistent
and comparable set of performance measures. It will include a new ‘integration index’
developed jointly with patients groups and the voluntary sector which will measure from
patient’s, carer’s and the public’s point of view, the extent to which the local health service and
its partners are genuinely providing joined up, personalised and anticipatory care.

There is no mention of how ICSs are accountable to the public at large. It is not even clear whether Board Papers will be publicly available or whether the public will be able to attend Board meetings as we can currently for CCGs.

A new Integrated Care Provider (ICP) contract will be made available for use from 2019, following
public and provider consultation. It allows for the first time the contractual integration of
primary medical services with other services, and creates greater flexibility to achieve full
integration of care. We expect that ICP contracts would be held by public statutory providers.

Expecting that ICP contracts would be held by public statutory providers in not the same as saying that they definitely will be.

We will also offer primary care networks a new ‘shared savings’ scheme so that
they can benefit from actions to reduce avoidable A&E attendances, admissions and delayed
discharge, streamlining patient pathways to reduce avoidable outpatient visits and overmedication
through pharmacist review.

This very much sounds like one of the most concerning features of the US Accountable Care model and implies that PCNs will receive a financial incentive to avoid hospital admissions, outpatient visits and overmedication. There is a real danger that this will lead to patients not getting the timely treatment they need and even if it does not, patients may well believe that they are being denied treatment for financial reasons.

REDUCING HOSPITAL ADMISSIONS
In this Long Term Plan, we have not built-in as a core assumption potential offsets in hospital beds from increased investment in community health and primary care. Instead we have provided both for the hospital funding and the staffing as if trends over the past three years continue. So to the extent that local areas are able to do better than recent emergency hospitalisation trends – which if the reforms set out in this chapter are implemented effectively should be possible – that will deliver for them an
additional local financial, hospital capacity and staffing upside ‘dividend’.

On the face of it this should mean current hospitals staying as they are or at least the same number of hospital beds. But centralisation of hospital services is continuing and as we know from stroke services it means less beds.

Although inpatient elective admissions (as against day-cases or outpatients) constitute
under 5% of RTT ‘clock stops’, separating urgent from planned services can make it easier for
NHS hospitals to run efficient surgical services. Planned services are provided from a ’cold‘ site
where capacity can be protected to reduce the risk of operations being postponed at the last
minute if more urgent cases come in. Managing complex, urgent care on a separate ’hot‘ site
allows trusts to provide improved trauma assessment and better access to specialist care, so
that patients have better access to the right expertise at the right time. So we will continue to
back hospitals that wish to pursue this model. In those locations where a complete site shift to
‘cold’ elective services is not feasible, we will also introduce a new option of ‘A&E locals’.

This another aspect of centralisation of services. Separating elective (planned) operations from non-elective in different hospitals makes little sense from a health point of view. If something goes wrong at the ‘cold’ site a patient may need to be transferred at some risk to the ‘hot’ site. Also specialist consultants carry out both planned and emergency operations and so will be having to waste time travelling between the two sites. However elective only hospitals would be a good target for private health companies as they are profitable and emergency care is not.

By 2021, pathology networks will mean quicker test turnaround times, improved access to more complex tests and better career opportunities for healthcare scientists at less overall cost. Mandated open standards in procurement will ensure that these networks are ready to exploit the opportunities afforded by AI, such as image triage, which will help clinical staff to prioritise their work more effectively, or identify opportunities for process improvement. By 2021, all pathology services across England will be part of a pathology network and, by 2023, we will have introduced new diagnostic imaging networks.

Pathology networks means centralisation and possible privatisation of pathology services. This is currently being planned for Kent & Medway with a possible single laboratory networked with small ‘hot’ laboratories in hospitals. The merger of Medway and Darent Valley Hospital Pathology Laboratories has led to delays in test results, some missing results and some re-testing for patients because their samples were too old by the time they came to be tested. This is not just opposed by Unite the Union who represent Pathology Technicians but also by the Royal College of Pathologists who among other objections say that “adverse effects of consolidation include a marked increase in never events”. Never events are events that should never happen.

NHS and social care will continue to improve performance at getting
people home without unnecessary delay when they are ready to leave hospital,
reducing risk of harm to patients from physical and cognitive deconditioning complications.
The goal over the next two years is to achieve and maintain an average Delayed Transfer of
Care (DTOC) figure of 4,000 or fewer delays, and over the next five years to reduce them
further. As well as the enhanced primary and community services response set out earlier in
this Chapter, we will achieve this through measures such as placing therapy and social work
teams at the beginning of the acute hospital pathway, setting an expectation that patients will
have an agreed clinical care plan within 14 hours of admission which includes an expected
date of discharge, implementation of the SAFER patient flow bundle and multidisciplinary
team reviews on all hospital wards every morning.

Both the wellbeing of older people and the pressures on the NHS are also linked to how
well social care is functioning. When agreeing the NHS’ funding settlement the government
therefore committed to ensure that adult social care funding is such that it does not impose
any additional pressure on the NHS over the coming five years. That is basis on which the
demand, activity and funding in this Long Term Plan have been assessed.

This is a fundamental weakness of the Long Term Plan. Social Care is on the point of collapse and needs a huge injection of money but successive Governments have failed to agree how to fund it and the promised Green Paper on the subject has yet to arrive. So a resolution is a couple of years away at best and implementation and training are likely to take longer still. Community care and treatment will require much greater social care resource which is simply not there.

PERSONAL HEALTH BUDGETS
We will accelerate the roll out of Personal Health Budgets to give people
greater choice and control over how care is planned and delivered. Up to 200,000
people will benefit from a PHB by 2023/24. This will include provision of bespoke wheelchairs
and community-based packages of personal and domestic support. We will also expand our
offer in mental health services, for people with a learning disability, people receiving social care
support and those receiving specialist end of life care.

The NHS Comprehensive Model of Personalised Care, developed in partnership
with over 50 stakeholder groups, is now being implemented across a third of England. By
September 2018, over 200,000 people had already joined the personalised care programme
and over 32,000 people had Personal Health Budgets (PHBs) – nearly a quarter of which were
jointly funded with social care. We will roll out the NHS Personalised Care model across
the country, reaching 2.5 million people by 2023/24 and then aiming to double that
again within a decade.

Where possible, people with a learning disability, autism or both will be enabled to have a personal health budget (PHBs).

Personal Health Budgets are building on the personalised budgets already in use in social care where individuals are given money to buy their own care services such as employing their own carers or buying equipment or day care places. This is presented as liberating and giving people control over their care but it can put a greater burden on already vulnerable people. Employing your own carers for instance means taking on an employer’s responsibilities as well as managing your budget. It also opens up more opportunities for private companies to make profits as well as an increased risk of mis-selling and outright fraud. Personal Health budgets will be no different and they are specifically aimed at the most vulnerable people who are least likely to be able cope with that responsibility.

TECHNOLOGY
In ten years’ time, we expect the existing model of care 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. Senior clinicians will be supported by digital tools, freeing trainees’ time to learn. 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. Triaging
(and potentially completing) some specialist referrals such as in dermatology with photos and
questionnaires will allow some patients to be managed entirely digitally.

Use of technology is one of the major planks of the STP and 10 Year Forward Review that they hope will help deliver the financial savings they are looking for. There has been a long and sorry story over 20 years with attempts to build a comprehensive patient records system to cover the entire NHS. Recently the NHS had to pay £millions in compensation to Fujitsu after cancelling the project, having spent many times more trying to get it to work. IT projects have a tendency for escalating costs and the investment required for the technology may be much greater than they think. There is also a problem with reliance on technology that can fail or cannot pick up on things that human contact can. While examining photos sent remotely might work for some aspects of dermatology, the idea of triaging carried out machine or being “managed entirely digitally” is alarming.

STAFFING
We will also increase alternative forms of provision for those in crisis. Sanctuaries, safe havens and crisis cafes provide a more suitable alternative to A&E for many people experiencing mental health crisis, usually for people whose needs are escalating to crisis point, or who are experiencing a crisis, but do not necessarily have medical needs that require A&E admission. They are commissioned through the NHS and local authorities, provided at relatively low costs, high satisfaction, and usually delivered by voluntary sector partners. While these services now exist in a number of areas, we will work to improve signposting, and expand coverage to reach more people and make a greater impact.

These services are indeed provided at “relatively low cost” precisely because they are delivered by the voluntary sector partners who compete with each other for contracts. This means paying low wages and relying on volunteers. This again is a key component of expected savings but is likely to result in high staff turnover and may not be sustainable in the long term.

We also need to make training more accessible. We will establish a new online
nursing degree for the NHS, linked to guaranteed placements at NHS trusts and
primary care, with the aim of widening participation. This could be launched from 2020
depending on the speed of regulatory approvals. And to both minimise student debt and
incentivise mature applicants, it will be offered for substantially less than the £9,250-a-year
cost to current students.

‘Earn and learn’ support premiums for students embarking on more flexible undergraduate degrees in mental health or learning disability nursing, who are also predominantly mature students will be explored, with the aim of having an additional 4,000 people training by 2023/24, supported by the increased funding for clinical placements. In the meantime, we will also seek to grow wider apprenticeships in clinical and non-clinical jobs in the NHS, with an expectation that employers will offer all entry-level jobs as apprenticeships before considering other recruitment options. We will continue to
discuss a fair pay framework for apprenticeships with the Social Partnership Forum, balancing affordability against the need to grow these roles as quickly as we can and provide greater opportunities for people from less advantaged backgrounds to get a first foot on the NHS career ladder.

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’. This will include work with the medical Royal
Colleges and specialty societies to develop a new credentialing programme for hospital
consultants from a variety of relevant disciplines who will be trained to offer mechanical
thrombectomy.

Much of the STP savings are planned to come from the pay bill but not only will these plans require more staff but there is also a desperate need to fill the very many vacancies that exist. Obviously the expected reduction in hospital admissions are intended to mean fewer expensive staff. That may not work out as well as they hope, but the other leg is to ‘up-skill’ specialist staff to become generalists so that they cover more work and to introduce new roles and grades for staff that will pay less.

There will be a new compact with our most senior leaders. We will better support them, particularly those undertaking the most challenging roles; ensuring they have both the time and space to make a difference, and appropriate ‘air cover’ when taking difficult decisions.

No comment necessary.

Many trusts are now meeting the cost of applying for settled status for their staff from the EEA.

Medway Foundation Trust are doing this and other trusts should be doing it if they are not already.

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

Changes to payment arrangements and allocations will take better account of the costs of delivering efficient services locally. This will be achieved by phasing in an updated Market Forces Factor over the next five years.

Reforms to the payment system will move funding away from activity-based payments and ensure a majority of funding is population-based.

We will reduce the prescribing of low clinical value medicines and items which are readily available over
the counter to save over £200 million a year.

Every year for the next 10 years the NHS will be expected to produce at least 1.1% “cash-releasing’ productivity savings. Saying this will be invested in frontline care makes it sound innocuous but what it means is another 10 years of so-called ‘efficiency savings’ intended to reduce the overall cost of the NHS. Moving from activity-based payments to payments based on population may mean that the NHS in areas of deprivation where health is worse may lose out. This would contradict the pledge elsewhere in the plan to reduce health inequality. There is no mention I could see of the plan to give ICSs a fixed budget and allow them to decide how to use it which is a feature of ACOs in the US. This would leave the responsibility for cuts to the ICSs and away from the Department of Health and NHS England.

NHS Improvement will deploy an accelerated turnaround process in the 30 worst financially performing trusts that, between them, account for all the net total of the trust provider deficit.

We will also create a new Financial Recovery Fund (FRF) to support systems’ and organisations’ efforts to make all NHS services sustainable. As a result of this funding, we expect the number of trusts reporting a deficit in 2019/20 to be reduced by more than half, and by 2023/24 no trust to be reporting a deficit.

Kent Trusts will be among the 30 worse financially performing trusts. The scale of trust deficits nationally is very large, the result of years of underfunding. These are not going to be written off but instead forcing the Trusts to cut costs.

We will ensure that an increasing share of the NHS budget is invested in frontline services by simplifying costly and overly bureaucratic contracting processes, supported by reforms to the payment system as we progressively move away from episode-based payments.

Cut delays and costs of the NHS automatically having to go through procurement processes. We propose to free up NHS commissioners to decide the circumstances in which they should use procurement, subject to a ‘best value’ test to secure the best outcomes for patients and the taxpayer. We also propose to free the NHS from wholesale inclusion in the Public Contract Regulations.

If it means less contracting out of services it is welcome, although we want an end to contracting out all together.

We 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. Its members will be drawn from, among others, national clinical, patient and staff organisations; the Voluntary, Community and Social Enterprise (VCSE) sector; the NHS Arm’s Length Bodies (ALBs); and frontline leaders from ICSs, STPs, trusts, CCGs and local authorities.

Patient and staff organisations will be very much a minority. This is not the accountability that we need.

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