NHS England published a long-term plan to drive fundamental change in its services in January 2019. One year later, a coordinated focus on the following seven areas remains vitally important in order to continually improve the NHS.
1. Primary care
Primary and community care is a headline commitment. This is an obvious area for fundamental change to bring about improvements in out-of-hospital care. General practitioners (GPs) and primary care clinical staff are critical because they provide the gateway for patients to access the NHS.
Careful and appropriate changes in primary care can shift emphasis away from the hospital, exerting a profoundly positive impact on both compromised resources and access to all-important hospital beds. The long-term plan encourages GP practices to join together to form integrated primary care networks (PCNs). These networks will need to assess the health of their local population (from 2020 to 2021) to target those who will benefit from focused support.
The PCNs could provide focused care for key patients in the community, removing the need for them to seek treatment in a hospital. To extend the reach of PCNs, the NHS could increase the number of district nurses. Over the last five years, the number of district nurses has been cut by 28%—at a time when obtaining a GP appointment is taking longer due to increased demand from the local population.
Officials must design a strong incentive for primary and community care to reduce the need to send patients to Accident and Emergency (A&E) or for hospital admissions.
2. Secondary care
The ten-year NHS plan intends to forge greater collaboration between primary and secondary care to improve the quality of patient services and experience. The plan outlines a number of promising measures to reduce the overwhelming pressures on A&E departments, including clinical streaming initiatives.
Reorganizing the process for accessing secondary care is key. It includes the notion of urgent treatment centers, which can provide facilities outside A&E. Also, instead of focusing on specialized medicine, there’s a shift to appreciate the benefits of generalists. This broader knowledge is particularly useful for patients that present with more than one long-term condition.
Policymakers will need to keep in mind that conventional wisdom is often wrong. Specialists may resist this move to introduce greater generalists, fearing that it may diminish expertise. Recognizing the services that only specialists can provide may counteract such concerns. Generalists can relieve pressure on the specialists to provide care where their expertise alone is necessary.
3. Social care
Social care is possibly a bigger problem for the NHS than primary care - over the last five years, 900,000 people have lost eligibility. This is a challenge for the NHS as it is not directly responsible for social care, which is run by councils in England.
The NHS will have more success in expanding provisions for care in the community if social care is reformed at the same time. A green paper is expected later this year, which may suggest a long-term plan and a sustainable funding model.
With an aging population, any social care provision must play a significant role in diverting this age group away from hospitals.
The Nuffield Trust has also shown that two-fifths of the NHS budget is spent on patients over 65 years of age. So, to play its part in integrating better with the NHS, social care considers how resources can be blended to support both physical and mental health. Older people and those with long term illnesses often need their symptoms managed rather than immediate medical attention, so preventative outpatient care should be introduced.
While NHS care is free at the point of entry, social care is means-tested. In addition, social care relies heavily on private sector capacity, so profitability challenges are reducing availability. The NHS and social care policy could benefit from being run along similar lines.
4. Volunteers and the voluntary sector
Volunteers are another opportunity for the NHS. Again, this pertains to roles that do not need to be carried out by a specialized workforce.
The plan rightly shifts towards a multidisciplinary approach to providing services. In the 1980s, volunteers were used by Community Service Volunteers to pioneer support for people with severe physical disabilities. It showed that, where people could direct their own care, volunteers could meet their needs—not simply care staff. This enabled greater choice for people with disabilities, who had the chance to live independently rather than within a residential home. Voluntary services could extend to community-based services.
If we assume that primary or secondary care staff and resources are always necessary, we are wrong. Volunteers may be more appropriate in certain situations than healthcare professionals.
Many patients say that they start to make progress towards getting better when someone listens to them and takes their concerns seriously. Volunteers can take on this kind of role and many others to support patients in following directions and treatment plans provided by healthcare professionals. The key is to preserve the roles of professionals for tasks that require advanced medical training.
5. Well-being, self-help, and prevention
Currently, the balance of health resources is significantly weighted against promoting well-being, especially in early life. All government departments also need to work together to tackle the social determinants of many illnesses.
The plan has a distinct focus on the need for prevention, which is laudable. Funding for programs on health promotion and behaviors that can prevent the five top health risk factors (smoking, poor diet, high blood pressure, obesity, and alcohol and drug use) are desirable but need to be sustained.
We also need to ensure that services from multiple agencies are streamlined and coordinated to avoid fragmentation or unnecessary duplication. The system needs some incentivization to make prevention a priority and thus have a greater impact on the effective use of NHS resources. It is much cheaper to fund prevention than the cost of medication and treatments after people become ill due to one or more of the five key risk factors.
6. System operations and streamlined clinical pathways
The plan emphasizes steps to improve services. One prominent and bold commitment relates to clinical priorities. It aims to counteract the concern that we are beginning to lose our reputation as world leaders in healthcare and demonstrating poorer outcomes than our peers from other advanced health systems.
The plan sets out priorities for cancer, cardiovascular disease, maternity and neonatal health, children and young people’s health, mental health, stroke, diabetes, and respiratory care. These are the areas that will potentially have the most impact.
To maximize success, we need more effective systems working. Currently, clinical services that straddle multiple health organizations lack coordination. This is because clinical services aren’t systematically planned across the entire clinical pathway. In addition, the transition between health and social services isn’t smooth in many areas of the UK.
There are promising care models and a permissive approach that is already starting to bridge the gaps. Sustainability and transformation partnerships (STPs) will play an essential role in planning and harmonizing services and work with integrated care systems (ICSs). They should also play a paramount role in sharing and spreading the benefits of new care models. Incentivization would bolster the adoption of new care models.
7. Digital enablement
Traditionally, the health service has underinvested in digital services. Digital projects thus far have been aimed at replicating analog working practices rather than working as a catalyst for transformational change. In the ambitious new plan, however, it is a cornerstone of patient-related targets.
Electronic records and a range of digital capabilities need to be put in place by 2024. Digital enablement may prove to be a useful way to break down some of the perceived barriers between primary and secondary care and health and social care.
For example, the use of a telehealth hub—backed by a dedicated team—can provide a 24-hour consultation service via a secure, encrypted video link. This has a wealth of benefits for clinicians, patients, and caregivers in nursing and residential homes across the country. It has the potential to cut down on waiting times, reduce costs, intervene quickly for more favorable outcomes, and increase efficiencies.
The plan has bolstered previous commitments such that NHS organizations will need to include, at board level, a chief clinical information officer or a chief information officer by 2022. Also, controls introduced in 2019 will ensure that technology suppliers to the NHS comply with standards designed to promote consistency and interoperability.
Enhancing services through digital enablement seems an obvious use of resources, especially given its ability to provide population health techniques with powerful preventative tools. Much will depend on appropriate funding, but this constructive approach has the potential to add value on so many levels within the systems used by the NHS and its patients.
Once again, incentivization would encourage strong digital enablement. The use of analytical tools and comprehensive evaluation will be important.
So far, so good
"Of course, the long-term plan is an indication of where the NHS wants to go with its changes to equip the system over the next decade. The translation into practice will be critical, and implementation must support frontline NHS staff."
The plan offers exciting and promising signposts to help on the NHS’s journey, embracing the needs of patients in the future. Policymakers and leaders have their work cut out for them—‘one size’ won’t fit all, and approaches that work for one area of the country may not in another.
Creativity and new ways of working are paramount for translation from plans into practice to succeed. Consistent evaluation needs to inform all pilot initiatives to make sure that they constitute best practices and will work in other areas of the UK.
The path from plan to implementation won’t be easy, but there’s every reason to hope that the NHS will retain the core principles at its heart that staff and patients alike hold dear.