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Long-term plan: moving on up

Niall Dickson, chief executive of the NHS Confederation, reflects on the NHS Long-Term Plan, and outlines the vital role the voluntary and independent sectors will play in the future of the health service.

The government’s long-term plan for the NHS in England will set out how the health service should spend the extra £20.5bn – and the rest of its budget – over the next five years.

The country we live in has a growing population which is living longer and with a range of chronic diseases, meaning their care is often complex and fragmented. This leads to worse health outcomes, but is also very wasteful. The challenge for health systems is to join up the care that people receive. So what is the answer? The NHS is embarking on an ambitious plan to create more integrated systems of care.

The driving force behind all of this is the conclusion that only by joining services up and bringing teams of professionals together will it be possible to give people the right treatment in the right place at the right time, and make the service sustainable. The new buzz words are integration and so-called ‘place-based care,’ and there is evidence both here and abroad that integrated services are at least a prerequisite for tackling the inexorable rise in demand.

The NHS has already embarked on this journey. Rather than thinking about organisations, it is being told to think about places. Rather than organisations focusing on their own interests, they are being urged to join with others to work out the best way to spend the local NHS pound.

But what will this mean in practice? Evidence from around the world suggests the key is to create a seamless supply chain, to develop new services which – as far as possible – prevent patients from becoming acutely ill and enable them and the information about them to move easily from one service to another.

That means encouraging and incentivising different physical, mental, and social services not only to work more closely together, but at times to form single teams. It means knocking down the very real barriers that exist now between GP, community, social care, and hospital services.

This is not as straightforward as it may seem. A survey of NHS Confederation members suggested that 86% felt they had made little or moderate progress in taking integration forward over the last few years. (Letting Local Systems Lead NHS Confederation, November 2018).

There is concern at too much regulation and day-to-day interference from the centre, and concern about how we make sure these services are accountable at a local level. Thus far, there has been little discussion about accountability.

There is a recognition too that other vital partners in this endeavour are not always fully involved in the new order. This is especially true of local government and the independent sector, as well as voluntary and community organisations. We need the capacity and creativity of the independent and voluntary sectors to complement and challenge statutory services.

But what should integration mean in practice? Evidence from around the world shows that the challenge of integration is about joining up services; it’s about answering the tough challenge of encouraging and incentivising different physical, mental, and social services to work closely together. It’s about making sure that moving between primary, community, and hospital care is a seamless experience for patients – taking the best of the NHS, the independent, and the voluntary sector.

In the NHS, there is a real danger that the move to integration risks jettisoning some important principles of openness, transparency and accountability. In seeming to downgrade the importance of patient choice, and increasing the importance of top-down planning, we risk heading back to the 1970s – creating not integrated care systems (ICSs), but local monopolies.

But all too often the NHS plan for integration is simply a plan for NHS organisations. Independent and voluntary providers have been excluded from local system planning, and seen contracts ignored or overridden. We know we need the capacity and creativity of the independent and voluntary sectors to both complement and challenge NHS organisations, but we are increasingly concerned they don’t have a seat at the table.

If integration simply becomes about bringing more and more services in-house in NHS organisations, then, ultimately, patients will lose out. We are calling for a vision of NHS integration that is about openness, responsiveness and accountability – challenging providers to work together to the benefit of patients, and holding them to account when they don’t.

The NHS Long-Term Plan will set a direction of travel which looks set to create ICSs across England, covering around one million people each (though with variations, for example where there are metropolitan elected mayors). They will have responsibility for allocating health – and perhaps social care – spending and for agreeing local priorities.

Thus far, there has been relatively little public debate and less public understanding of these bodies which currently have no statutory powers and are, in effect, coalitions of the willing. But that will change, and these will, or should, be the engine rooms driving new ways of delivering care in every part of the country.

One test will be that the government must make sure all providers of NHS and care services, whether they be from the statutory, independent, voluntary or community sectors, have an equal place around the table. We need the capacity and creativity of the independent, community, and voluntary sectors to complement and challenge NHS organisations.

The chair of NHS Improvement, Baroness Harding, told a recent meeting of the Independent Healthcare Network (part of the NHS Confederation) that the independent and voluntary sectors had a vital role to play in the new NHS, and that they would be actively encouraged to contribute to and shape the future pattern of services. We need to see those promises in print. 

And we must not lose sight of one of the real gains of recent years: increasing patient choice. There will always be a limit on this given the nature of healthcare services, rurality, and cost, but we should be doing everything we can to encourage more, not less, choice. Traditionally this has been around routine operations, 22% of which are now carried out by independent operators and, providing they are giving great care and value for money, that should be encouraged alongside great NHS care. But we also need to explore greater choice for people living with chronic disease, and again it should not matter who is providing that care or support; so long as it is high-quality, good value, and joined up to other services.

We need a vision of NHS integration in the plan that promotes a diverse range of providers and fosters openness, responsiveness ,and accountability – challenging everyone in the system to work together for patients, and holding them to account when they don’t. We must get this right – the plan is a once in a generation chance to shape an NHS for at least the next decade, Brexit permitting…

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