NHS Long Term Plan ‘guarantees’ shifting resources from hospitals to community

'Historic' publication promises to reshape health service around the ‘changing needs of patients’

At 134 pages long, and setting out a vision for the next ten years, The NHS Long Term Plan covers a lot of ground.

From embracing digital technologies to setting out the future of care for everything from learning disabilities and cancer to mental health, it pulls together the wide spectrum of NHS services in a way that has not been done since 2000, when The NHS Plan: A Plan for Investment, a Plan for Reform was published.

Prime minister Theresa May hailed the long-awaited launch of the plan a historic moment for the health service in England, promising it would reshape it around the ‘changing needs of patients’.

Most clearly this reshaping will involve shifting resources from hospitals to the community.

Of course, this direction of travel has been suggested before. But this time the government sets out a ‘guarantee’ that the budgets for non-hospital care will rise at a quicker rate than they will for hospitals.

One third of the extra £20 billion the NHS should receive by 2023 will go to primary care, community services and improving mental health, while £4.5 billion of the total is expected to be set aside to create fully integrated community-based healthcare ‘for the first time since the NHS was created’.

To achieve this, the plan calls for a series of redesigns in every corner of the country, overseen by integrated care systems (ICSs).

Networks

The plan draws on evidence from work done through the vanguards and ICSs after publication of the Five-Year Forward View in 2014.

While emergency admissions per head in areas that have pioneered new ways of working have risen by 1.6% over the past three years, they are up by 6.9% in the rest of the NHS.

At the heart of the new system will be primary care networks aligned to geographical areas with populations of between 30,000 and 50,000.

These networks will set up multidisciplinary neighbourhood teams with a range of staff, including district nurses, GPs, social care staff, pharmacists, community geriatricians and physiotherapists.

These teams will be tasked with promoting independence, enabling speedy discharge, reducing avoidable outpatient visits by one third and preventing emergency admissions.

They will also need to offer a guarantee of support to people living in care homes, while staff should have access to NHSmail so they can communicate effectively and securely with health service colleagues.

Staff shortages

RCN professional lead for long-term conditions Amanda Cheesley says the vision is right, but she has concerns about its delivery.

‘As we know, district nursing and other community services have not trained sufficient staff.

‘We cannot do this with junior roles alone. These are highly skilled roles that require nurses to make complex decisions on their own; there is not the support around that there is in a hospital.

‘It is not just in district nursing where there are gaps. There are shortages with practice nurses, social care nursing staff and those working in public health, such as school nurses. This presents a problem. Hospitals are under so much pressure that there is a limit to how much they can do to support the community.’

For the shift in resources to work, the plan makes clear that the NHS must embrace digital technologies. It advocates online GP booking, prescriptions management and home-based wearable monitoring equipment.

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But the shift will also require access to good public health services, and this is where other concerns are being expressed.

Funding

According to the plan, multidisciplinary teams must work with local falls prevention services, exercise classes, home adaptation services and befriending projects, achieved through an expansion of social prescribing.

But such projects are funded through the public health grant given to local authorities, which is due to be cut by more than 4% next year after inflation is taken into account.

Local Government Association community well-being board chair Ian Hudspeth says, as a result, essential services will be put at risk.

He is also critical of the continued delay of the social care green paper, first promised in 2017, and calls the failure to publish it alongside the plan a missed opportunity.

‘The ambition set out can be fully realised only if adult social care and public health services are properly funded.’

Hospitals are also being asked to embrace change. The plan praises the emergency care system for doing its best to cope with rising numbers of patients, and states that continued improvements to GP out-of-hours services, the multidisciplinary community teams and the 111 service will play crucial roles in managing pressures.

But the plan also states that hospitals can do more. It advocates same-day emergency care, setting an ambition to increase the proportion of admissions that do not involve overnight stays from one fifth to one third. The key to this, it suggests, will be the development of ambulatory care and frailty units.

Delayed discharges

Hospitals will also need to play their part in ensuring delayed discharges are kept to a minimum.

Patients who are admitted will be expected to have an agreed clinical care plan, including an expected date of discharge, within 14 hours of admission.

It is also clear that there is much more to come. NHS England chief executive Simon Stevens hinted that new legislation could follow to allow greater collaboration rather than a culture of competition.

He added that the four-hour emergency care four-hour operational standard may need to be changed because it does not differentiate between a ‘sprained finger or a heart attack’.

North Middlesex University Hospital NHS Trust assistant director of nursing Nichole McIntosh says some form of relaxation of the target would be a ‘sensible and pragmatic approach’.

But she also highlights the need for a staffing plan, saying shortages that have led to one in 11 posts in the NHS being vacant are adversely affecting patients.

‘Privacy, dignity and preventing harm will need to be made priority areas,’ she says.

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Leadership

A workforce implementation plan is due in the coming months, according to the government.

This is being led by NHS Improvement and Health Education England and follows the draft strategy published a year ago.

It will focus on increasing the number of nurses in training, with the workforce plan stating that online degree training will be introduced.

RCN nurses in management and leadership forum chair Sally Bassett says the workforce plan is essential, but adds: ‘Ensuring we have enough staff will be a challenge, especially with the uncertainty of Brexit.’

She says it is not just about front-line staff. ‘The plan talks about the need to support leaders; that is good and very welcome.

‘But we’re concerned that good management gets overlooked and forgotten when all the talk is about leadership. Leadership is sexy at the moment, but it will take managers as well as leaders to implement these plans.’