Alastair Whitington, Consultant Editor for Specialised Commissioning, welcomes the new NHS plan’s ambitions, but questions how it can be delivered
The festive lull in the Brexit civil war was just sufficient to finally publish the catchily titled ‘NHS long term plan’ and as half-plans go it’s alright. The vision may be for 10 years, but as the Government only guaranteed 5 years’ money, Simon Stevens has cannily produced a 5-year plan, with all target dates for delivery set to 2023/4; having ‘long term’ in the title makes it appear to be a lot more. Then again, for a government currently staggering from day to day, 5 years must seem like an eternity.
The plan is what it should be—strategic, realistic, and deliverable—and its component parts fulfil the NHS doctrine, established by Beveridge 70 years ago: ‘from the cradle to the grave’. The ambition is to improve a child’s start in life, add years to that life, and ensure those in their twilight years are supported and cared for.
The investment priorities remain the diseases that kill or significantly impact upon the majority of the population—heart disease, stroke, diabetes, and cancer. However, there is also the timely investment of at least £2.3 billion more per year in mental health services, the required shift in focus from acute care to primary and community care (at least £4.5 billion per annum extra), and emphasis on the importance of preventing disease, reducing health inequalities, and improving early diagnosis so treatment is commenced when medical intervention is likely to deliver the best outcome.
The plan is deliverable in that almost everything within it is already being implemented successfully somewhere within the NHS. The aim of the next 5 years is simply to roll out this good practice across the NHS. The aim for greater integration, keeping people out of hospital, and embracing new technology is in the right direction, and if politicians resist the urge to tinker and meddle it has a fair chance of making a difference. However, success is dependent on two big challenges—will the funding be sufficient and is there the workforce to deliver it?
The total budget for the NHS in 2018/19 is £114 billion. The funding through to 2023/24 will increase in real terms by £20.5 billion, averaging 3.4% average real terms growth per annum against the 2.2% rise of recent years, and only 1.1% growth in the years of the coalition government. However, it is significantly less than the 5–6% average for the Blair/Brown years,1 and below the average of 3.7% since the NHS was founded.1
The new money has to be stretched a long way. In 2017/18, 44% of NHS Trusts (65% of acute trusts) were in debt to the tune of £960 million,² so the first £1 billion goes on rebalancing the books, and it is worth bearing in mind that every 1% of pay inflation will reduce the pot by a further half a billion pounds.³
The new money has to be stretched … the first £1 billion goes on rebalancing the books
The expectation of at least 1.1% cash-releasing productivity growth is certainly more achievable than the unrealistic £20 billion savings target that was set in the first half of this decade.⁴ The agreement that the NHS holds onto any saving for reinvestment is also sensible in providing the necessary incentive to get delivery.
The NHS employs 1.2 million full-time equivalent staff to deliver current services. Current challenges include the 100,000 vacant posts within NHS Trusts (including 10,000 doctors and 36,000 nurses),³ and staff leaving the workforce early to pursue employment elsewhere or early retirement. According to a report from three health think tanks⁵ these staff are not being replaced fast enough, either through people training (the removal of the nursing bursary may be a factor here), or by people coming into the country from the EU and beyond. Add to that the level of satisfaction and stress that existing staff feel,⁶ and the starting point to implement the long term plan is not good. The solution is not only improving recruitment and training but also improving the environment in which staff work, and whether they feel valued and motivated. The 2017 staff survey suggests that there is still some way to go.⁷ Refreshing the long-term vision for the NHS is welcome, and the objectives for the next 5 years are clear and attainable. However, long term success will depend on the funding being sustained and a workforce of sufficient size and capability to deliver it.
- Charlesworth A, Johnson P, Firth Z et al. Securing the future: funding health and social care to the 2030s. Institute for Fiscal Studies, NHS Confederation, 2018. Available at: www.ifs.org.uk/uploads/R143.pdf
- Full Fact. Spending on the NHS in England. fullfact.org/health/spending-english-nhs/ (accessed 23 January 2019)
- NHS Improvement. Performance of the NHS provider sector for the year ended 31 March 2018. NHSI, 2018. Available at: improvement.nhs.uk/documents/2852/Quarter_4_2017-18_performance_report.pdf
- Nicholson D. The year: NHS Chief Executive’s annual report 2008/09. Department of Health, 2009. Available at: webarchive.nationalarchives.gov.uk/20130105045611/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_099700.pdf
- The Health Foundation, The King’s Fund, Nuffield Trust. The health care workforce in England—make or break? The Health Foundation, The King’s Fund, Nuffield Trust, 2018. Available at: www.kingsfund.org.uk/sites/default/files/2018-11/The%20health%20care%20workforce%20in%20England.pdf
- NHS Survey Coordination Centre. NHS Staff Survey 2017—national briefing. NHS Survey Coordination Centre, 2018. Available at: www.nhsstaffsurveys.com/Page/1064/Latest-Results/2017-Results/
- NHS Survey Coordination Centre. 2017 results. www.nhsstaffsurveys.com/Page/1064/Latest-Results/2017-Results/ (accessed 24 January 2019).