The major conditions strategy ‘case for change’ and strategic framework: what you need to know
Key points
The interim report of the major conditions strategy sets out the ‘case for change’ and strategic framework of the major conditions strategy. The final report is expected to be published early next year.
The strategy aims to alleviate pressure on the NHS, increase healthy life expectancy and reduce labour market inactivity related to ill health by taking a multimorbidity lens. It is intended to be a strategy for the next five years.
To respond to population changes, the strategic framework represents an evolution from a single-disease approach to health services planning to a multimorbidity approach. This will better reflect how patients interact with the NHS.
Before this interim report, the NHS Confederation held engagements between healthcare leaders and the Department of Health and Social Care major conditions strategy team. Healthcare leaders identified levers the strategy could use to maximise its impact and achieve its aims. These were published in Prevention, Integration and Implementation: Healthcare Leaders’ Views on the Major Conditions Strategy.
The nine recommendations of healthcare leaders fell under three categories: create a healthy society; make the most of existing infrastructure and policy; and implementation.
This briefing sets out the extent to which the interim report of the major conditions strategy aligns with the recommendations of healthcare leaders. As the interim report sets out the case for change and strategic framework of the major conditions strategy and does not make policy commitments, this analysis is limited to how its approach aligns or contrasts with what healthcare leaders recommended.
Overall, while the case for change and strategic framework does recognise the role of existing structures and policy such as integrated care systems and CORE20+5, it does not go far enough to ‘create a healthy society’ beyond the role of the NHS. To achieve its aims, the final strategy must make use of regulation and cross-government commitments to improve population health and reduce inequalities.
Overview
The interim report sets out the case for change and strategic framework for the major conditions strategy. While reference is made to funded programmes throughout the strategy, the funding and programmes are all existing commitments. Any new policy commitments will be in the strategy’s final report, which is anticipated to be published early next year.
The strategy sets out its approach and highlights three cross-cutting enablers: digital technologies and innovation; research; and leadership.
It also outlines five areas that the final report will focus on:
- Rebalancing the health and care system, over time, towards a personalised approach to prevention through the management of risk factors.
- Embedding early diagnosis and treatment delivery in the community.
- Managing multiple conditions effectively - including embedding generalist and specialist skills within teams, organisations and individual clinicians.
- Seeking much closer alignment and integration between physical and mental health services
- shaping services and support around the lives of people, giving them greater control where they need and want it and real clarity about their choices and next steps in their care.
Does the major conditions strategy’s interim report align with the recommendations of healthcare leaders?
The NHS Confederation held engagements between the major conditions strategy teams from the Department of Health and Social Care (DHSC) and the Office for Health Improvement and Disparities (OHID) during February and June 2023 for local health and care leaders from across the system to voice their views on the potential of the strategy and inform its reports.
We published their recommendations in Prevention, Integration and Implementation: Healthcare Leaders’ Views on the Major Conditions Strategy, and published two opinion pieces in the BMJ – first, Can the New Major Conditions Strategy Deliver On Its Aims?; and second, The Major Conditions Strategy – Just Another NHS Plan?.
The following analysis considers the extent to which the recommendations of healthcare leaders from the NHS Confederation’s report (recommendations 1-9) are reflected in the strategy’s case for change and strategic framework.
Theme 1: Create a healthy society
1. Prevention through regulation
The interim report recognises the importance and benefits of primary prevention in addressing the drivers of the conditions, including tobacco and obesity.
The interim report hails the UK’s “strong regulation [and] world leading anti-smoking marketing campaigns” despite the fact that the Khan Review: Making Smoking Obsolete calculated that we will miss the government’s target to be smokefree by 2030 by “at least seven years, and the poorest areas in society will not meet it until 2044”. It does not commit to implementing the Khan review’s recommendations.
However, the door is not closed to government action, and we will continue to encourage the government to implement the recommendations of recent independent reviews in this space, such as the Khan Review and the National Food Strategy part two.
2. Address structural factors such as racism, poverty and gender inequality which drive inequalities in the conditions
Healthcare leaders will welcome that the interim report confirmed that the major conditions strategy will consider inequalities in health outcomes by ethnicity, deprivation, gender and the wider determinants of health.
The report confirmed that data is an enabler to understanding and tackling health inequalities. Healthcare leaders are calling for the final report of the strategy to take the opportunity to establish central consensus on ethnicity coding in health and care.
3. Health in all policies
The chapter on primary prevention recognises the impact that the wider determinants have on our health. However, it emphasises the NHS’s role here without fully recognising the key role to be played outside of the NHS. Healthcare leaders want to see the health impacts of all policies being considered, across government sectors at a central and local level.
The major conditions strategy needs to be more than just an NHS plan and can do this by embedding a cross-government approach in the implementation and delivery of the strategy. Healthcare leaders want to see physical and mental health equity impact assessments of new government policy and programmes, assessed by a cross-government health committee to ensure equity of outcomes for all is considered.
The strategy does cite some policies as examples of cross-government working to promote population health, such as the cycling and walking strategy; the Green Infrastructure Framework, and the Renters (Reform) Bill. These, however, are examples of health in some policies, not health in all policies. The major conditions strategy is an opportunity to change this piecemeal approach into business as usual.
4. Take a life-course approach
The interim report confirmed that the strategy will take a life-course approach. Healthcare leaders know that this is especially crucial in mental health, and the strategy confirms the government’s existing commitment for mental health support teams (MHSTs) in schools to cover half of all pupils in England by 2024/25. Healthcare leaders are calling for the funding to be expanded to cover all pupils.
Theme 2: Make the most of existing infrastructure and policy
5. The role of integrated care systems (ICSs)
The interim report recognises and celebrates the key role that ICSs will play to deliver a patient-centred service for a multimorbid, ageing population. It aligns itself with the recommendations of the Hewitt Review into accountability and autonomy of ICSs, by acknowledging the need to reduce the number of central targets on systems and by aligning with the planning cycle of ICSs – the strategy’s five-year timeframe ‘aligns with the planning cycle for our new ICSs’. While we welcome the sentiment of alignment, systems have already set joint forward plans (JFPs) for the next five years, which is the whole timeframe of the major conditions strategy. The major conditions strategy will need, therefore, to consider the direction of travel that systems have already set locally.
6. The role of primary care networks
While the strategy’s foreword notes the ‘network of primary care that reaches into every community’, the role of primary care networks (PCNs) specifically is not mentioned in the strategy. Stability is required for primary care, and this needs to be committed to through funding for PCNs beyond 2024. This will enable PCNs to play their role in integrated neighbourhood working.
7. Build on existing policy in this space
The interim report is a helpful repository of existing policy and confirms its support for initiatives including Core20PLUS5.
Theme 3: Implementation
8. Outcomes focused
The interim report aligns with our recommendation to focus on outcomes rather than procedure. This is very welcome, and we are working with the DHSC on the shared outcomes toolkit it mentions.
“We recognise that central government has an important role to play, including by reducing the number of central targets on systems. In the next phase of the major conditions strategy we will focus on understanding how central government, working in partnership with NHSE, can better enable systems to improve the health of local populations and support the delivery of local approaches and innovation. Our shared outcomes toolkit will support this local approach by supporting local areas to develop their own robust shared outcomes.”
9. Move to a workforce working in a more integrated way
The interim report agrees with the need to support a transition to a more integrated workforce:
“Delivery [of a person-centred service by an integrated workforce] will require concerted effort from the UK government and the NHS working in tandem, alongside social care, patient representatives, industry and partners across the health and care system.”
“By 2036/37 the mental health workforce will grow by 73 per cent through having ...physical health support across mental health pathways, and more mental health support across physical health pathways.”
Healthcare leaders have also called for the final report of the strategy to include creating a long-term workforce plan for social care. This will support the transition to a more integrated workforce, coordinated nationally across health and social care.
The interim report also does not mention the challenge posed to integrating the workforce by current pay policy not accounting for the full breadth of staff on Agenda for Change pay scales, such as those working in the community.
Next steps
The interim report sets out the case for change and strategic framework for the major conditions strategy. The NHS Confederation will continue to engage the major conditions strategy teams from the DHSC and OHID in the lead up to the publication of the final strategy.
