Response to the long term plan for the NHS Rachel PowerChief Executive The Prime Minister enjoyed a day of positive headlines yesterday, heavily promoting the new long-term plan for the NHS in the media before it had been published. Now that the plan is available, we can assess it against the Prime Minister’s bold claims. It is clear that the plan on its own, although essentially sound, does not secure the NHS’s future as she would like us to believe. Lack of strategy The publication of a plan for the NHS in isolation highlights the Government’s complete lack of any strategic approach to stewarding the health and wellbeing of the nation. We recommended, as the plan was being developed, that the Government should ensure that its policies in all areas that relate to people’s health and wellbeing should be aligned. This includes housing, social care, public health and the benefits system (all subject to cuts and underinvestment in recent years), as failings in these areas harm people’s health, and leave the NHS to pick up the pieces. Instead, the Prime Minister has described the Government’s decision to partly close the NHS’s funding gap as leaving ‘less room for manoeuvre’ in spending on other services. Not only is it not clear that there is any bar on investing more in other services, but it is certainly not a virtue: restraining investment in other policy areas that affect people’s health is a classic false economy, and leaves the NHS having to stretch its resources even further. Things not covered by the plan: workforce and social care Two vital aspects of care that sit outside the scope of the plan remain in crisis: social care, and the health and social care workforce. There is no plan yet for addressing the massive and growing shortfall in the health and social care workforce, without which the plan cannot be successfully delivered. Training cannot fill the gap quickly enough, so the only option is to recruit from overseas - but uncertainty over Brexit and some of the proposals in the immigration white paper apparently rule that out as an option as well. Retention of experienced staff will also be essential, and a non-trivial challenge. We need effective action on workforce shortages urgently – but a plan on this is not due until an unspecified time later this year, and could be subject to the delays and slippages we have seen with the long-term plan and the social care green paper. It is disappointing that the social care green paper has not been published alongside the NHS plan. Social care is vitally important in its own right, and not merely an adjunct to the NHS. Nonetheless, its long-running crisis remains a colossal hindrance to the NHS. It seems likely that the green paper has been held back because mentioning social care funding tends to generate political blow-back by creating a fresh wave of people who find out, for the first time, that they will need to pay for it. That said, Conservative Party messaging has promised that it will set out sustainable solutions - let’s hope that it does. Inadequate funding We observed when the Prime Minister made her funding announcement that, while it is better for the NHS to have the extra money than not, it means a further five years of below-trend funding growth for the NHS, on top of the eight it has just endured. It does not include any extra money for public health, NHS infrastructure or workforce development, and neither the last Budget nor the Prime Minister’s media appearances yesterday announced any new investment in those areas. The new plan nonetheless commits to bold and much-needed transformation of services, to meet the requirements of patients today. But this leaves the NHS trying to use its new funding both to make big changes and steady the ship after the recent decline in NHS performance, even though it is not enough to do both. The NHS’s services will therefore continue to face enormous pressure, and the best we can hope for is that the rate at which they deteriorate slows somewhat. But it seems inevitable that NHS funding will be back on the political agenda again by 2022. As we said in our response to the Budget, political leaders need to be honest about the fact that high quality public services need to be paid for. The Prime Minister’s media appearances yesterday did not make a start in doing that – instead, they sold a short measure on funding as if it will solve the NHS’s problems. The plan itself The extremely difficult context in which the plan has been launched unfortunately risks obscuring its many strengths. Within the remit that was set for it, the plan goes in the right direction. NHS England has delivered what the Government asked of it. The first section of the plan sets out how services will be refocused onto the community, breaking down traditional barriers between primary care (GPs) and other community services, including by investing more rapidly in these areas than in hospitals. This recognises the need to support people to live well with one or more long term conditions, which is ever more common as a result of demographic change. It’s exactly the right priority, and potentially a really historic move. The focus on prevention is also particularly welcome, not least the inclusion of tackling antimicrobial resistance and health inequalities as priorities. Elsewhere, the NHS app and focus on digital should create a better way in to NHS services, for people who feel comfortable with using technology in that way (although those who don’t must not be left behind). While much of the plan picks up from the Five Year Forward View in a positive way, there is some continuity in the risks it holds as well. While major changes to services are essential, they need to be done with full engagement of patients and local people at every stage. There has been a very variable picture on this so far, and therefore risks remain of missteps that will be difficult and expensive to correct. The plan further signals the quiet dismantling of the NHS’s internal market, and recommends changes to legislation to create a set of NHS institutions that work together rather than compete with each other. This is surely the right move, but does create the risk of a set of NHS bodies that are unresponsive to input from patients (who come and go), and instead dominated by the interests of clinicians and professionals (who are present over the long term). We support moves to a new NHS architecture, but it must build in strong mechanisms for ensuring that all NHS organisations are accountable and responsive.