The NHS Long Term Plan

NHS England has finally found a gap between Brexit crises in which to publish what was in danger of becoming its Long Awaited rather than Long Term Plan (LTP). While the preceding plan, the Five Year Forward View (5YFV), had the feel of a new leadership setting out its vision, the LTP unsurprisingly feels a bit more box-ticking: it followed NHS England securing £20bn in additional funding over five years from a government which then wanted to know what it was going to get for that ‘extra’ money. I put ‘extra’ in inverted commas, because the settlement only takes the level of funding back up towards more typical rates of NHS funding increase after years in which most health economists regarded the NHS as under-funded, and in which social care funding has fallen.

The 130-plus rather dense pages though, are full of specific actions, including some very positive indications of how the NHS’s thinking about communities, and community organisations, has evolved from the 5YFV. That plan set out a compelling vision for communities, but it was light on tangible actions in that area. The prose here is less lyrical, but the actions are there, and they should make a difference.

Most important are the headlines taken from the forthcoming Comprehensive Model of Personalised Care. It’s not a very snappy title and it’s a programme still under the radar for much of the NHS, but it should prove to be as big a change for long term health care as the personalisation reforms have been in social care, and it uses some of the same mechanisms. By 2024,

• 200,000 people will have a personal health budget, meaning they, rather than doctors, can decide how they want to be supported with a long term health condition
• 900,000 people will have access to over 1,000 social prescribing link workers. These workers will be part of local primary care networks, which will bring together GP practices with, the plan says, councils and community groups.

These are large numbers of people – and represent a different way to spend large amounts of NHS money, which could help to change local health economies. These reforms may have learned from the personalisation of social care, where personal budgets were found to be more effective ways to change things for groups most able to advocate for themselves: the social prescribing link workers should help a wider range of people to make informed choices. We’re expecting a lot more detail on personalised care next week.

In the Joint VCSE Review, we argued that VCSE organisations need to be at the heart of both planning and delivering health and social care. We said that this was essential if care was ever to be redesigned around people’s lives, getting people out of hospital, and keeping people out of care homes for as long as possible. In particular, co-designing services with communities and community organisations is the only way to reduce the inequalities which people from black and minority ethnic communities, and other marginalised groups, encounter when they try to use health services which are still designed by commissioning teams in which white men remain over-represented. (See our concise action plan).

The Long Term Plan says that NHS England will develop better measures of inequalities and unmet need in local areas (2.25): the NHS will need to work with its local community organisations to do that effectively. Importantly, it says (2.26), the NHS will set out “specific, measurable goals for narrowing inequalities, including those relating to poverty” and that “all local health systems will be expected to set out … how they will specifically reduce health inequalities”. Those getting extra funding to tackle inequalities will have to be specific about how it is targeted. The NHS “and our partners in the voluntary and community sector and local government, will develop and publish a ‘menu’ of evidence-based interventions that if adopted locally would contribute to this goal.”

We argued for exactly that kind of clarity of expectations and use of hard evidence, so I’m excited to see those goals taken forward during 2019.

In the Joint VCSE Review, we said that if people start to co-design health and care services, they will ask for a stronger role for VCSE organisations of all kinds and sizes in providing more holistic and human-shaped support. So it’s great to see (2.37) such a clear commitment “to commission, partner with and champion local charities, social enterprises and community interest companies” including the smallest social enterprises, with our colleagues at Community Catalysts earning a name check for their pioneering work. This requires more than good intentions: it will only happen where funding moves away from one-size-fits-all contracting cultures, to what we described as ‘simplest by default’ funding, using grants, personal health budgets and intermediary models like (good) social prescribing, alongside contracts where the size and technicality of the work demands it. We have been arguing that use of existing Social Value Act powers – which allow public bodies to ask for added social value such as volunteering or benefiting the local community – should become used by default in all NHS commissioning. This would cost nothing and add value to the public pound. As Don Redding of National Voices has argued in HSJ (paywall), without specific commissioning changes, you can’t have new relationships with communities: change doesn’t happen for free. So I’m disappointed that the Plan doesn’t go as far as this, although the Appendix on the NHS’s impact upon society includes a number of social value goals, such as using NHS organisations as ‘anchor’ organisations which employ local people and creating NHS employment opportunities for people with learning disabilities.

I’ll end with a couple of specific examples of both the Plan’s potential, and how far we have to go. It is good that the Plan recognises our lives don’t fit neat boxes. It sets out goals for the mental health care of people with learning disabilities for instance, although initial reaction from Learning Disability England and others is that we shouldn’t need to be waiting another four years – 13 years after the Winterbourne View abuse scandal – for a 50% reduction in the 2350 people still being held as patients in so-called Assessment and Treatment Units. The glacial pace of change in this highlights the need for both personal health budgets and better links with community provider organisations, which, combined with investment in decent advocacy, could help people get their lives back much more quickly. In mental health support more broadly, the Plan announces “a new community-based offer” including “access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use.” This will include addressing “racial disparities”. Mental health support is a good example of where the NHS, however ‘community-based’ and ‘personalised’ cannot achieve its goals alone: mental illness can be treated by a service, but we have to create our mental health ourselves, even if we need help with forming the connections and relationships with others that that nearly always requires. This is the kind of goal where areas need to look at all of their resources – their communities and community resources as well as those NHS community-based services – and to see investing in their communities as core business, not an add on to IAPT. The Plan creates some reasons to start thinking in this radically different way, but there is a vast mindset shift implicit in that short section. There is also a potentially huge change wrapped up in a couple of lines (1.51) which say that, using the Integrated Care Systems model, “CCGs will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and Long Term Plan implementation”. If this is followed through, those slimmed-down CCGs will need to invest some of their freed-up resources in community organisations to co-commission integrated care.