Time to rethink the NHS Long Term Plan

When it published three years ago, the NHS Long Term Plan (LTP) was broadly welcomed by the NHS and national bodies alike. Coming hot on the heels of additional £20.5 billion pounds investment, health service leaders recognised the need to demonstrate to politicians and the taxpayer how the extra money would make a difference.

NHS leaders now argue that the time is ripe to re-examine and refresh the plan. The question is how

There was enthusiasm for its emphasis on prevention, on the expansion of out-of-hospital services and on tackling health inequalities. There was also wide support for more specific commitments in areas such as cancer, maternity care and mental health. However, the big implementation gap concerned staffing, and with an estimated 105,000 workforce shortfall, little has changed.  Given the pandemic and as the NHS takes stock and reassesses following the last two years, NHS leaders now argue that the time is ripe to re-examine and refresh the plan. The question is how.

One option is simply to review the long list of targets in the existing LTP and update them where there is good reason to do so, if, for example, they have already been achieved or conversely, if they are highly unlikely to be met.

Take mental health as an example. While some LTP targets have been met early, the surge in demand for services as a result of the pandemic has rendered achieving other targets within current timeframes unrealistic. The 2019 target that within a decade 100 per cent of children and young people who need specialist care would be able to access it, will be largely missed. Since the pandemic, there has been a 77 per cent increase in referrals to children and young people’s mental health services and this has significantly affected access. Mental health leaders tell us that on the current trajectory, a 70 per cent access target would be more realistic by 2029/30, though even this depends on both demand hitting a plateau and significant additional resources.

Any restated or new targets must focus on areas where national direction and investment can make a useful difference. Getting people with learning disabilities and autism out of long-stay hospital, for example, continues to be a priority for our members. A renewed commitment to reduce the numbers of those with learning disabilities and autism in inpatient units by 2029/30 would be welcomed.

…it is vital the LTP brings clarity and coherence rather than simply adding to the noise

Aside from clinical targets, many of the structural reforms originally set out in the LTP have now been implemented. Both primary care networks (PCNs) and integrated care systems (ICSs) are now in place and the vision for what both will deliver in the coming years will need an update.

Given the plethora of other central plans for the NHS, including a slew of promised white papers, it is vital the LTP brings clarity and coherence rather than simply adding to the noise. In the case of primary care, it should reinforce the ambition set out in the Fuller Review for integrated neighbourhood ‘teams of teams’ to evolve from PCNs.

However, there is room to be bolder. This starts with an acknowledgement that the NHS is facing a perfect storm.

…there is growing public dissatisfaction with their experience of the health system - something which is seen as a political opportunity by those who have always been sceptical of the NHS’s core egalitarian principles

On the one hand, we are only at the beginning of recovering from COVID-19, a process which involves not just elective recovery but dealing with unprecedented demand in almost all parts of the service. On the other, there is growing public dissatisfaction with their experience of the health system - something which is seen as a political opportunity by those who have always been sceptical of the NHS’s core egalitarian principles.

Any LTP refresh is an opportunity to articulate a stronger narrative, one which combines realism about the challenge of recovery with optimism for the medium and long term. Using concrete examples and evidence, the LTP should reprise the core argument of the 2002 Wanless review, namely that with the right sustained investment and the right policies of prevention, collaboration and innovation we can start to flatten the demand curve and achieving a step change in outcomes and productivity.

But the NHS is only a part of what shapes the nation’s health. The more the LTP can look across sectors and recognise the crucial roles of other partners such as local authorities and government departments, the better.  A concerted approach to the social determinants of health is also vital for credible plan to tackle inequalities. 

The plan needs to empower systems, places and localities to develop social contracts with their populations, defining the mutual responsibilities of the NHS, local government, the voluntary and community sectors and the general public

The plan must acknowledge the new governance of the health and care system including a renewed commitment to the local flexibility and partnership working that is at the centre of the Health and Care Act.  The plan needs to empower systems, places and localities to develop social contracts with their populations, defining the mutual responsibilities of the NHS, local government, the voluntary and community sectors and the general public.

Fewer, more realistic and better focused targets; adding coherence to other policies; addressing the wider social determinants of health; making the case for investment of the right kind; acknowledging and supporting system working; and most of all, articulating a powerful narrative of realistic optimism; this is the valuable work the next Long Term Plan should seek to accomplish. 

This article was first published in Healthcare Leader on 16 June 2022.

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