Long-term plan: system reset
Integrated care systems (ICSs) will be the driving force behind this. They will become the basic unit of financial planning and service prioritisation, with commissioners and providers working together to make joint decisions. The plan says ICSs will cover the country by April 2021, potentially precipitating more clinical commissioning group mergers – typically, there will be one CCG per ICS, the plan says. The plan acknowledges that systems will be at different levels of maturity and national support will be provided to help developing ICSs.
ICSs will be charged with delivering what the plan calls a new service model for the 21st century – boosting out-of-hospital care and ensuring there are no barriers between primary and community services. Out-of-hospital services will receive at least £4.5bn more by 2023/24.
ICSs will be responsible for reducing unwarranted variation locally and they will be expected to bring together clinicians and managers to introduce appropriate evidence-based care pathways.
Crucially, ICSs will be supported by a raft of operational and financial policy changes designed to ensure they succeed. The provider financial framework will be reset to encourage system working. Control totals are being rebased for 2019/20 and central ‘grip’ is due to be relaxed – financial oversight via control totals will be dismantled from 2020/21 as and when individual providers return to financial balance.
ICSs and sustainability and transformation partnerships (STPs) will be given greater freedom to change the control totals of individual organisations within their systems to improve operational and financial performance. However, this must be financially neutral, with the system control total remaining unchanged.
Collaboration will deliver system affordability, with trusts and commissioners agreeing the services to be provided and the reasonable costs that will be incurred to do so.
As ICSs develop, they will be allowed to take on more responsibilities for wider objectives in relation to the use of NHS resources and population health. As they will be working in partnership to ensure the local system lives within its means, no organisation will take actions that will adversely affect the system financial position, even if it improves their institutional position. Regional oversight will ensure that this does not happen.
Financial recovery plans
ICSs and STPs will be central in the formation of financial recovery plans. ICSs are due to cover the whole of England by April 2021, at which time most providers and commissioners are expected to be back in financial balance. The plan is clear that ICSs must be built on ‘strong and effective providers and commissioners, underpinned by clear accountabilities’.
Reforms of funding flows and contracts will support ICS development in 2019 and beyond. Local alliance contracts or arrangements giving a lead provider responsibility for integrating services for a population could be used to support the move towards ICSs.
A new integrated care provider contract is also due to be introduced in 2019 following consultation. This will allow, for the first time, the contractual integration of primary medical services with other services, leading to greater integration. The overall degree of integration will be measured with a new index, which will provide the views of patients, carers and the voluntary sector on how well an ICS is providing joined-up, personalised and anticipatory care.
ICSs will have the prospect of earned autonomy. They will agree and implement system-wide objectives with their regional NHS England/NHS Improvement team. The objectives will include integration, improvements in financial and operational performance and priorities for care quality and outcomes. They will have the opportunity to earn greater freedoms as they meet – and improve on – their objectives.
One of the key means of delivering greater integration in the forward view – the better care fund (BCF) – is being reviewed. This follows concerns that the mechanism is overly complex and complaints that funding was replacing core council spending.
There is no hint in the long-term plan that the BCF will be scrapped – instead, it says that the review will be completed early this year and in 2019/20 the revised BCF will continue to require reductions in delayed transfers and the improvement in care packages for patients ready to leave hospital.
- Most of the changes to promote integration have been achieved so far without legislation and the plan says no further legislation is needed to achieve the integrated system it outlines. But, in response to a request from the Commons Health and Social Care Committee and the prime minister, the plan outlines a number of legislative changes that could speed up integration. Some of the legal changes would repeal measures in the Health and Social Care Act 2012. Legislative changes in the long-term plan include: Giving CCGs and providers a statutory duty to promote the triple aim of better health, better care and sustainability
- Removing barriers to place-based commissioning and public health collaboration
- Supporting the effective running of ICSs by allowing trusts and CCGs to make decisions jointly without needing to create additional bureaucracy
- Allowing greater flexibility when creating integrated care trusts to reduce administration costs and aid clinical sustainability
- Eliminating the counterproductive effects of competition rules on integration, including the Competition and Markets Authority duty to intervene in proposed NHS provider mergers, and its powers on NHS pricing and provider licence condition decisions
- Cutting delays and costs associated with commissioners automatically having to go through procurement processes
- Increasing flexibility in NHS prices to support the move away from activity-based tariffs, facilitate better integration of care and make it easier to commission some public health services as part of a bundle of care.
NHS England chief executive Simon Stevens says three truths were evident as the NHS celebrated its 70th anniversary last year. First, there was concern about funding, staffing, increasing inequalities and pressures from a growing and ageing population. However, second, there was legitimate cause for optimism – about the potential for continuing advances in medicine and outcomes for patients. And, third, there was pride in the service.
‘In looking ahead to the health service’s 80th birthday, this NHS long-term plan acts on all three of these realities. It keeps all that’s good about our health service and its place in our national life. It tackles head-on the pressures our staff face. And it sets a practical, costed, phased route map for the NHS’s priorities for care quality and outcomes improvement for the decade ahead,’ he adds.
King’s Fund chief executive Richard Murray backs the development of ICSs. ‘We strongly support the ambition to establish integrated care systems in every part of the country by 2021,’ he says. ‘The plan sends a welcome signal that NHS organisations need to work with local authorities and other partners to deliver improvements in the health of local populations.’Primary and community focus
As previously highlighted, the plan includes a commitment that primary medical and community budgets will grow faster than the rest of the NHS, with a ringfenced fund of at least an extra £4.5bn a year in real terms by 2023/24.
The focus on community and primary care is welcomed by Matthew Winn, chair of the NHS Confederation community network. General practice, community and social services will work together in expanded community multidisciplinary teams, with primary care networks across GP practices taking on enhanced service activities.
‘It is extremely positive that community services, working in partnership with primary care, will play a central role in supporting a sustainable NHS for the long-term future,’ he says. ‘A shift in focus towards prevention and community care will help ensure people can live healthier, longer lives, and receive care in or close to their homes, reducing admissions and demand on already over-stretched hospitals.’
Under the new service model, there will be a move to reduce face-to-face appointments in a bid to avoid the NHS spending an extra £1bn a year. Currently, there are around 400 million of these appointments a year and under the scheme every patient will have a right to an online consultation with a GP, while redesigned support will avoid up to a third of hospital outpatient appointments (around 30 million each year).Mental health
Mental health will also have ringfenced funding, with a new local investment fund worth at least £2.3bn a year by 2023/24. The funding will target service expansion and faster access to community and crisis mental health services for adults and, in particular, children and young people.
Centre for Mental Health chief executive Sarah Hughes says the plan is right to extend mental health services and improve response times. She adds: ‘If they are properly funded and resolutely implemented with a robust workforce development plan, they will make a big difference. However, this plan on its own falls short of offering a comprehensive shift towards equality for mental health within the NHS.
‘It says little about the role of primary care in mental health, despite the growing gap in services for people with a range of needs that fall between existing services. And there is scant focus on seeking to address longstanding inequalities in mental health despite the clear evidence about differences in access, experience and outcomes for many of the most disadvantaged and marginalised groups in society.’
New urgent care services, which will be rolled out across all acute hospitals, will relieve pressure on emergency departments and inpatient beds. Longer-term action will also be taken to stem demand with a focus on ill-health prevention. The plan insists this is complementary to – not instead of – individuals, communities, government and companies taking responsibility for shaping the nation’s health.
Evidence-based prevention programmes will be funded. For example, as trailed in Healthcare Finance (December 2018, Stubbing it out), there will be a new hospital-based smoking cessation service. Other programmes aim to tackle obesity, alcohol-related A&E admissions and air pollution.
The long-term plan was eagerly anticipated and has been widely welcomed. Even so, there are questions over the detail of how it will be implemented – will the extra funding be enough to expand and transform services while bridging the gap in NHS finances; will workforce issues finally be addressed; and can years of competition be overcome to produce collaborative, sustainable ICSs?Workforce – key issue, main risk
The National Audit Office’s NHS financial sustainability report last month highlighted workforce as a key risk to delivering the long-term plan, writes Steve Brown. While NHS England funding has been set for the next five years, we have yet to see the all-important plans for clinical training budgets. It also warned that the NHS could find itself unable to spend the average 3.4% real-terms increase optimally because of existing staff shortages.
The NHS long-term plan – while confirming that the NHS will have to wait for a workforce implementation plan until later in the year – does at least acknowledge there is a serious issue. While it says there will always be a ‘background number of vacancies’, the current situation is ‘unsustainable’. NHS Improvement has reported that there are more than 100,000 vacancies, including 41,000 nursing and 9,300 medical posts.
Workforce planning has been too disjointed. Many would argue that the timing of the end to nursing bursaries, coupled with the massive uncertainty created by the government’s handling of Brexit, suggests this planning has been non-existent. The NHS plan highlights that more applicants were accepted onto English nursing courses last year than in seven of the past 10 years. But it acknowledges that turning away an additional 14,000 applicants at a time of staff shortage is ‘to say the least paradoxical’.
On nursing, the plan promises to increase nurse undergraduate places by 25%, aided by a 25% increase (an extra 5,000) in the number of funded clinical placements in 2019/20. From 2020/21, this will rise to up to 50%. And every graduating nurse or midwife will be offered a five-year NHS job guarantee in the region in which they qualify.
A 50% increase in the number of new nursing associates, delivered through nursing apprenticeships, should help the service to invest half of the £200m apprenticeship levy back into the NHS
next year. Apprenticeships will also be expanded more generally in clinical and non-clinical roles, with an expectation that all entry-level jobs will be offered as apprenticeships before considering other recruitment options.
It is less clear how the centre aims to meet commitments to address shortages in specific allied health professional roles – paramedics, podiatrists, radiographers and speech language therapists, for example.
Medical school places will also grow from 6,000 to 7,500 a year. However, given current vacancies and with doctors’ trade union the BMA claiming that six out of 10 consultants are intending to retire before or at the age of 60, this can only be seen as a partial response to medical shortages. The plan says that medical school places could grow further if Health Education England’s budget – due to be set in the spending review – allows it.
The plan also sets an aspiration to develop a better balance between highly specialised roles and more generalist ones – in part as doctors increasingly need to be able to manage multiple comorbidities alongside single conditions. It reiterates plans to boost the GP workforce by 5,000.
It claims that recruitment has been increasing, but this is being offset by early retirements and part-time working. There will also be a continued push to increase the multidisciplinary teams working in primary care – partly funded through new primary care networks – to relieve pressure on GPs. A step change in the recruitment of international nurses over the next five years is also promised, to increase supplies by ‘several thousand each year’.
Retention is equally important to staff expansion plans – arguably more important in early years. The plan promises more development opportunities and more flexibility in working patterns. The plan also recognises that the NHS needs to make the most of the staff it has and signals a renewed effort in getting NHS providers to deploy electronic rosters or e-job plans.
Workforce issues are key to delivering the long-term plan, but while the plan makes the right noises about expanding capacity and growing the workforce, the BMA criticises it for offering little detail. ‘Given that there are 100,000 staff vacancies within the NHS, the long-term sustainability of the NHS requires a robust workforce plan that addresses the reality of the staffing crisis across primary, secondary and community care,’ says BMA council chair Chaand Nagpaul. ‘This will require additional resources for training, funding for which has not been mentioned in the long-term plan.’
And the Royal College of Nursing is similarly concerned by the lack of detail – particularly around money for nurses to develop specialisms in areas such as cancer and mental health.An HFMA summary of the long-term plan is available at www.hfma.org.uk
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