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The NHS’s £20.5 billion birthday present was announced amidst much fanfare last year, with many waiting expectantly for an early Christmas present in its publication alongside the social care green paper. Anticipated as a solution to all ills, it fast became all things to all people: putting an end to the cycle of winter crises; overcoming the obstacles to adopting innovation; resolving the workforce crisis. The truth is inevitably more complicated.

A further delay to the workforce plan which – although integral to the delivery of the Long Term Plan – is ‘expected later this year’. No word on the much-delayed social care green paper and no guarantee that waiting targets will be addressed, having not been met since David Cameron’s time in Number 10.

In reality, the Long Term Plan was always going to benefit some sectors over others. The cash injection only amounts to a real terms increase of 3.4 per cent per year which is less than the 3.7 per cent average over the NHS’s 70 years, and even less than the 4 per cent the Institute for Fiscal Studies and other organisations argued was necessary to sustain and transform the NHS. As a result, it will inevitably limit the extent to which NHS organisations are empowered to deliver the transformative care laid out today. Niall Dickson, chief executive of the NHS Confederation, has already warned that “the greatest danger we face with this plan is unrealistic expectations”.

The challenge
Although the Government emphasises that public spending on healthcare has increased by more than ten times since the inception of the NHS, the number of people using the NHS has grown too. And while advances in treatments and technologies mean they’re living longer, they’re spending more years in ill health and accessing more expensive care. These demand pressures – coupled with the shift towards longer-term (and more expensive) conditions like cardiovascular disease, cancer and respiratory – mean that while spending has increased, it is not enough to keep up with the significant demographic shift that has changed the face of society.

Prevention, not cure
The Long Term Plan is fundamentally wrapped up in Matt Hancock’s long-term vision for the NHS: reduce financial pressure by asking the public to take responsibility for their health. After Hancock made prevention one of his top three priorities in his first speech as Secretary of State for Health and Social Care last year, it wasn’t a surprise to see it at the heart of the Long Term Plan. His focus on individual responsibility and low cost ‘nudging’ to incentivise people to adopt healthier lifestyles is well known.

However, the focus on prevention could be considered overly narrow. It does not place significant weight on the impact of wider environmental factors and indices of multiple deprivations, like housing, employment and education, on individual choice. Notably, although NHS England will now base local funding on assessment of health inequalities, there is no mention of increased funding for public health. Moved to local authorities following the 2012 Health and Social Care Act, public health is the main agency empowered to tackle primary prevention. However, with 40% of real terms cuts to the public health budget, the areas of greatest deprivation will still see the most substantial cuts to prevention.

So, while Hancock vows to prioritise prevention and tackle unhealthy behaviours such as smoking with targeted adverts on Facebook88 councils across the country will spend £3.4 million less on smoking cessation, 87 have already removed £7.9 million for services tackling alcohol abuse and 72 are cutting £758,000 worth of services for children living with obesity.

What it means for industry
A renewed focus on prevention and out-of-hospital care signals a distinct shift from an acute care model to pre-empting the development of a disease. So, although Theresa May alleged the plan would enable the NHS to pay for ‘world class treatments’, it is unlikely that new money will not be used to expand the treatment budget. Instead, by tackling the causes of obesity, the plan also seeks to tackle type 2 diabetes, coronary heart disease, breast and bowel cancer and stroke. NHS spending on diabetes alone is expected to reach £16.9 billion by 2035 so the market for secondary prevention is strong. Brands should refocus their communication around health and wellness, and harness the power of mobile and digital health to shift the narrative from treating disease to preventing disease. Wearable devices play a key role in the Long-Term Plan so opportunities to promote health monitoring – from heart rate and blood pressure to blood sugar and cholesterol – will become increasingly important for a digital-first Health and Social Care Secretary.

What it means for local health economies
The NHS is in a constant state of flux and the Long Term Plan provides fresh momentum for further change. The plan announces the creation primary care networks, which will see an expanded role for primary care in pharmacy, district nursing, dementia and into other allied health professional roles. The plan also sets out an expectation that all Sustainability and Transformation Partnerships (STP) evolve into Integrated Care Systems (ICS) by 2021. This risks placing significant strain on already tense local relationships, and risks recalibrating already agreed priorities.

STPs were the first manifestation of local council and NHS leaders working together to make decisions on the health and care of their local populations. But these partners come from two different worlds and speak two different languages. And, where the sense of shared enterprise remains weak across the country, achieving the Long Term Plan outcomes will be challenging. Coupled with concerns about workforce and recruitment, it is clear that there are challenges facing the realisation of the ambitions within the plan.

What comes next
To provide a framework for local planning over the next five years, NHS leaders are developing a new operating model which will be published in Spring, prior to implementation of local plans from October 2019.  An NHS Assembly, due to be established in early 2019, will play an advisory role to NHS England and NHS Improvement in the implementation of the Long Term Plan at a local level.

In the meantime, each local health system will engage with their local communities and partners to produce individual plans to implement the commitments set out in the Long-Term Plan in 2019, alongside proposals for how they will deliver the outcomes.

Although the Long Term Plan does not require legislative change to be implemented, a “provisional list” of amendments for changes to legislation has been developed, and includes the removal of the role of the Competition and Markets Authority in NHS merger and acquisitions and facilitating more joint working between NHS England and NHS Improvement.

Rebecca recently joined Lexington as a Senior Consultant. A specialist in health policy and advocacy, she is also a councillor in the London Borough of Merton, and is currently chairing a task group into transitions for children with special educational needs. She is on the Board of a local Healthwatch where she leads on children’s mental health, and acts as a deputy representative on the South West London Sustainability and Transformation Board. She is also a Governor at St George’s Hospital, Tooting.

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