Questions, questions...

The NHS long-term plan provides clarity about the direction the NHS is moving in. Integrated care systems are the future and there must be a rebalancing of services – both from treatment to prevention and from acute to the community and primary care settings.

Few, if any, would argue against these ambitions. But stating them is one thing, realising them is an altogether bigger challenge.

There are huge questions looming over the plan. The obvious high-level ones remain to do with funding and workforce. Despite commitments to increase clinical placements for nursing and expand medical school places – the first steps in three- and five-year journeys to increase home-grown capacity in these vital areas – we don’t yet know the training budgets for the years ahead. We will have to wait for the spending review later in the year to address these major uncertainties.

Long-term capital budgets are similarly unknown. Some challenges bring together these two issues – staff and capital – that are so vital to the plan’s delivery. The plan acknowledges we have fewer MRI and CT scanners per head than most OECD countries. And vacancy rates for radiologists and radiographers are 12.5% and 15%. Yet referrals for diagnostic tests have risen by over 25% in five years.
Imaging networks are the plan’s response – and investment in a ‘new digital diagnostic imaging service’. As with most aspects of the plan, the NHS is not starting from scratch. Four early adopter imaging networks were selected last year (from 22 expressions of interest, which shows the local enthusiasm to improve). But getting from the current underprovided service to one where diagnostics meet demand and support revised pathways is a huge transformation in its own right.

The acceleration of integrated care systems also raises questions. Promising that ICSs will cover the whole country by April 2021 shows a welcome commitment to managing on the basis of population health. But moving beyond the current sustainability and transformation partnerships – where progress is at very different stages – will need much more than setting a deadline. The most advanced ICSs have a history of system collaboration that doesn’t exist everywhere.

The plans to return all NHS providers to financial balance by 2023/24 also appear ambitious in the face of the current financial position, providers’ underlying deficit of £1.85bn and significant continuing demand and activity pressures. The service needs to understand much more about how the new proposed financial recovery fund – aimed at deficit providers – will work, given that the more broadly focused provider sustainability fund is being phased out.

There are wide-ranging questions at more detailed levels too. As part of 10 areas prioritised for special attention in driving efficiency, the plan wants all providers deploying clinical staff using an electronic roster or e-job plan by 2021. Again, this is nothing new – there have been frequent calls for this, perhaps most recently in the Carter report on provider productivity. But the plan envisages trusts doing more than investing in systems – many trusts already have them – and starting to use them in a meaningful way for medical as well as nursing staff.

There is an undoubted value to be had in this area – but such changes will not be switched on overnight.

Also in the efficiency section, the plan talks about realising £700m savings in administrative costs. This will come from an overhaul of the ‘overly bureaucratic contracting processes, supported by reforms to the payment system’. This has been a long time coming and will take concerted central and local action. And a throw-away line about automating all core transactional services, including processing invoices, sounds like we can expect some major progress on e-invoicing and perhaps even a different approach to dealing with low-value invoices (Traffic control, Healthcare Finance, December 2018).

The long-term plan was a necessary summary of where the NHS needs to be heading – adding some new promises and pulling together existing initiatives and aims into a single document. That has been helpful. But there can be no doubt that the real work starts now. There needs to be clear recognition of the scale of the task facing local health economies.

But success will also rely on the government putting the right funding in place for the wider NHS budget and social care budgets and delivering much needed detail on how the plan can move forward.