A renewed vision for the NHS

Introduction

The NHS Long Term Plan (LTP) was published in 2019. It set out the priorities for the health service in England over a ten-year period and how £20.5 billion of additional funding for the NHS to 2023/24 would be spent. The LTP, and its associated funding, was broadly welcomed by health leaders in 2019, in particular the focus on expanding community, primary care and mental health services.

Since the publication of the plan, however, the NHS has faced the most significant pressures in its history resulting from COVID-19. As research from the Health Foundation has found, no part of the LTP has been unaffected by the pandemic. Despite the heroic efforts of clinicians, managers, administrative and support staff, the overall picture is one of significantly increased demands on services, delays in access and increased inequalities in population health outcomes – though some LTP commitments have been accelerated by the COVID-19 response. These include improving access to remote consultations in primary care and outpatients, and increasing access to mental health support in schools.

Given the unprecedented events of recent years and the very different operating environment the NHS now faces compared to 2019, the Department of Health and Social Care (DHSC) has engaged on plans for the future. To inform this, the NHS Confederation was invited to contribute ideas on why and how a long-term strategy should be different. Engagement with our members has revealed that health leaders broadly believe that any review of a longer-term approach must achieve three key objectives.

This report outlines our members' views on what national bodies and the government should consider when planning for the future, including how LTP priorities may need to be adjusted post COVID-19.

We believe that doing so should move beyond an exercise of tweaking individual targets: the opportunity must be seized to be transformational and rethink the approach. While a long-term strategy must be realistic about current pressures, it should set out a positive vision for how systems can be supported to achieve population health improvements and reduce inequalities.

Methodology

This report has been informed by direct engagement with our members – healthcare leaders across integrated care systems, provider trusts and primary care – as well as external stakeholders from local government, the voluntary, community and social enterprise (VCSE) sector and patient groups.

From May to July 2022, we hosted four roundtable events to invite views from across health and care on what a long-term strategy should prioritise. Two roundtables were hosted in partnership with NHS England (focused on prevention and system working) and two were hosted independently (focused on overall ambition and children and young people’s services).

These roundtables have been supplemented with intelligence from individual conversations with members across all parts of the NHS.

Throughout this report, recommendations are supported with quotes from members gathered through the engagement outlined above. However, in keeping with ‘Chatham House rules’, all quotes used have been anonymised.

Objective 1: A realistic, less centralised approach to reflect a different health and care landscape

We believe that discussions about the long-term strategy for the NHS must reflect the partnership approach that is now integral to integrated care systems, place- based partnerships and neighbourhood teams. A key focus must be on local flexibility and empowerment, with less reliance on top- down targets.

Recommendation 1: Fewer, more focused targets

Why?

The LTP was right to address both short-term public priorities, like reducing pressure on emergency services, and long-term strategic ambitions, such as reducing health inequalities. However, discussions about a longer-term strategy must resist simply imposing yet more targets, which is neither realistic given funding constraints (see recommendation 8) and workforce shortages, nor conducive to collaboration.

Healthcare leaders have warned that long and prescriptive lists of central targets, set across multiple strategy and policy documents, take time and resource away from local priorities:

"We are facing 200, 300 KPIs ...There is still a scatter-gun approach [and] what looks like hundreds of pots of varying amounts of money. [They] all come with a project, a reporting requirement, other requirements…which is a massive distraction from what you want ICSs to focus on.

 

“We need the freedom and flexibility to decide our priorities locally, based on what our population is telling us. Some KPIs are helpful but they always trump local priorities and are enormously reporting-intensive.”

ICS chief financial officer

The COVID-19 pandemic has drastically changed the environment within which the health service has operated. Revised targets must reflect current realities.

How?

Our position is that targets should be used sparingly and only in areas where we know national intervention has been beneficial. Healthcare leaders welcome the LTP’s strong ambitions on the five clinical target areas laid out in the CORE20PLUS5 approach (maternity, severe mental illness, chronic respiratory disease, cancer and hypertension). National focus on these areas has helped to reduce variations in care and ensure public accountability.

Now that ICSs have gained statutory footing, however, it is no longer necessary nor appropriate for the centre to draw up exhaustive lists of targets for healthcare systems and providers. To reflect the new service model of delivering through systems, there should be a reduction in the overall number of targets.

To achieve this, some existing targets should be retired:

• In mental health some targets have been met early, including a target to provide 24/7 telephone access to mental health crisis support across the country. These targets can be retired.
• Since the LTP set out its chapter on the new service model, the country’s healthcare system has been reorganised. Primary care networks (PCNs) have been established and successfully carried out the COVID-19 vaccine rollout with GP federations and community services; the Health and Care Act 2022 was passed; and integrated care systems (ICSs) are in place across the country. Associated targets in the LTP can therefore be retired.
• The COVID-19 pandemic necessitated rapid progress on the LTP’s ambition for digitally-enabled primary and outpatient care to go mainstream across the NHS. We should celebrate the significant progress that has been made on these ambitions.

Research shows, for example, that remote outpatient appointments increased drastically during the pandemic, with around 4 per cent of outpatient appointments delivered remotely in 2019 and pre-pandemic 2020 compared to a high of 36 per cent in April 2020, levelling off to around 25 per cent in the latter months of 2020. Digital targets that have been met should be retired and digital- specific targets, where necessary in certain areas (for example in hypertension case finding), should be embedded rather than being stand alone (see recommendation 7).

Aside from those targets that can be retired, we must recognise that others are now significantly off course as a result of the pressures seen through the pandemic. These should be adjusted. We therefore want to see some existing targets revised:

• Retained targets must be adjusted to reflect the progress made since 2019 and the pressures caused by the COVID-19 pandemic – characterised by increased demand for services, concurrent with a reduced workforce and reduced bed capacity, due to infection prevention and control measures.
• Our engagement with NHS leaders focused on two example areas where NHSE should consider revised targets: mental health and children and young people’s health. Detail on both is set out below.

Children and young people

*Based on analysis of the NHS England data on children and young people with an eating disorder waiting times. 

We are opposed to new targets. Fewer, more focused targets should, as far as possible, be protected from being usurped or contradicted by other targets generated by politicians and officials over the coming years.

However, if NHSE does proceed with any new targets it must be made clear how funding and resources will be made available to deliver them.

Recommendation 2: National action on dentistry

Why?

Though we wish to see fewer and more focused targets, this is not to say that there should not be new areas of focus. An example of an area where we should avoid new targets but must set out national action is in dentistry.

The LTP failed to include a single paragraph on geographical variation, access or outcomes in dentistry. This is no longer an acceptable omission. There is a crisis in access to dental services, with a recent investigation finding that 9 out of 10 NHS dental practices are unable to offer appointments to new adult patients.

There is a looming deadline facing ICSs regarding dentistry commissioning. While some have already taken on commissioning functions, all systems are due to assume formal responsibility for dental services by April 2023. This is of high concern to our members across the country. ICSs are set to inherit a broken system with perverse payment incentives and an overall lack of funding to meet growing demand.

Action at national level is needed urgently. Crucially, it is needed before all ICSs take on dental commissioning. The fundamental challenges facing dentistry cannot be tackled at a local level.

While the new health and social care secretary recently set out some limited action on dentistry in her Plan for Patients, the measures outlined were insufficient to meet the scale of the problem.

How?

We therefore believe that a long-term strategy should, as a minimum, commit to supporting the recovery of dental services in the following ways:

Recommendation 3: Supporting a new operating model that lets local leaders lead

Why? 

Our ask for fewer national targets is based on an expectation that recent reforms will precipitate a shift away from top-down national diktats and towards bottom-up locally aligned priorities through neighbourhoods and places.

Our members across the NHS have been united behind recent reforms to the health and care landscape. Under the Health and Care Act 2022 and supporting guidance, local priorities are set to be identified by integrated care partnerships (ICPs) through cross-sectoral community engagement and outlined in integrated care strategies. These will build upon the local priorities that are already set out in the joint strategic needs assessments (JSNAs) produced by health and wellbeing boards (HWBs). The local priorities identified by the ICP and national NHS priorities, such as those set out in a longer-term strategy, will then need to be brought together in the joint forward plans agreed by integrated care boards (ICBs). 

To be effective and locally responsive, ICBs and ICPs will need to be granted a high degree of autonomy and not hamstrung by a ‘tick box’ exercise of national commitments. We believe an updated approach to longer-term planning is a litmus test of the extent to which NHSE and DHSC’s positive rhetoric about local flexibility will be matched with a lighter touch, enabling an ‘adult to adult’ relationship between the centre and systems. What such a relationship would look like in practice was explored by Professor Sir Chris Ham in an NHS Confederation report published earlier this year.  

“Features of success [of working through systems] include…the importance of parameters over prescription. An agreed set of national outcomes that demonstrates what good looks like and has a strong line of democratic accountability from central government, but where there is a significant degree of freedom to figure out how one gets there at a local level.”  
ICB chief transformation and delivery officer

How?

To accompany a reduction in the overall number of national targets, there should be acknowledgement and reiteration of the significance of locally determined priorities in areas that fall outside of the five national clinical areas of focus (maternity, severe mental illness, respiratory disease, early cancer diagnosis and hypertension). Health leaders welcomed the commitment to local outcomes frameworks set out in the integration white paper, which will help to facilitate and shift focus away from activity and towards outcomes. 

Rather than nationally mandated targets or approaches, ICSs should be tasked with developing bespoke strategies for addressing complex health and public health issues where local factors (particularly around the wider determinants of health) are important contributors. These include issues such as obesity and suicide prevention. Similarly, while NHSE should be clear about available national support, a long-term plan should acknowledge the importance of system-level plans in non-clinical areas, such as workforce retention and capital.  

In keeping with a ‘letting local leaders lead’ approach, where possible it should also be made clear that the ambitions set out in a long-term strategy for the NHS will not be delivered across England at the same pace. What one system prioritises in its early years will be different to another, though all systems should seek to have delivered progress in all areas of the updated plan by 2029.

The new NHSE operating model will be a key development in clarifying the relationship between the centre and system leaders and therefore the degree of autonomy they will have. Any review of the current approach to planning should reference and be aligned with the operating model.

Recommendation 4: Acknowledge the key role of non-NHS partners in delivering ambitions and set out where cross-sector action will be required 

Why? 

Defining just the NHS’s role is increasingly difficult (and unhelpful) in a world that is now driven by system working across multiple partners. In the context of system and place working, there must be recognition of the crucial role of local authorities, the VCSE sector and government departments other than the Department for Health and Social Care in influencing the wider determinants 
of health.

When we spoke to leaders at our roundtable on system working, they were clear that any plan for the NHS has to acknowledge the key role played by partners from outside of the health service and apply lessons learnt during the COVID-19 pandemic, especially during the vaccine rollout:

“This is an NHS plan, but we are increasingly reliant on our voluntary sector partners so we must include support for them. There is currently no sustainable plan on how we engage with them.” 
Foundation trust chief executive

Centrally, the Department for Health and Social Care must also acknowledge the need to partner with other government departments to deliver the ambitions of a long-term plan for the NHS. To take the example of obesity, the NHS has made good progress on initiatives such as the Diabetes Prevention Programme. However, tackling obesity will require not only NHS action, but also central, cross-departmental action and the plan should address this. Government delays on a new obesity strategy, for example, have been detrimental to LTP ambitions.

Similarly, coordinated cross-government action will be essential to addressing the cost-of-living crisis and subsequently the demand this places on health services. 

“The NHS needs to be a partner with others to address the determinants of ill health… The prize of system working is to address those important gaps and leverage everyone's resources for a common prize.” 
ICS health inequalities director

How?

While an updated approach will set out what the NHS is aiming to deliver over this decade, it should acknowledge the key role of non-NHS partners in delivering its ambitions (particularly around reducing health inequalities and improving population health outcomes) and set out principles for meaningful engagement with partners. This will help to ensure the plan has relevance beyond the NHS and can be used as part of NHS organisations’ engagement with partners. 

Objective 2: Clarity on how systems can act as bridges to a bolder and more optimistic future

We believe that any review of the long-term strategy for the NHS must reflect a ‘realistic optimism’ about what the NHS could achieve by the end of the decade, but it must be clear in its narrative about how to get there – specifically how systems will be supported to deliver improvements in population health. 

Recommendation 5: A comprehensive and funded workforce strategy that addresses the profound challenges in social care as well as health

Why? 

With 130,000 vacancies in the health service at the time of writing, and a further 150,000 in social care, workforce is the key challenge facing the health and social care sector. The Health Foundation has projected that by 2030/31, the NHS in England will need around 314,00 more full-time equivalent staff (relative to 2021/22), over and above existing vacancies, to deliver 2018/19 rates of care. 

One of the biggest limitations of the LTP was that it was not supported with any strategy on the numbers and types of roles required for its delivery. We heard this repeatedly from system leaders:

“Despite chapter 4 focusing on workforce and giving staff the support they need, it is clear that this has only become significantly worse as a result of COVID-19. Therefore, we need clarity on what the workforce plan is and how we get there.” 
Foundation trust chief executive

The NHS has benefited from some increased staff numbers due to the expansion of medical and nursing school numbers and a renewed recruitment drive. The successful element of this has been growing international recruitment of nurses. However, the progress towards the 50,000 nurses programme relies disproportionately on international recruitment and has not addressed the deep risks in nursing numbers in mental health, learning disability and community services. 

Without action, problems are set to intensify. A renewed commitment to the vision of the LTP is needed, with new commitments to meet emerging challenges.

How?

NHSE and Health Education England are expected to submit a workforce strategy in autumn 2022. As we understand, this will not constitute the fully funded and long-term plan to address workforce gaps that health leaders have called for, with independently verified estimates on numbers required. However, an updated plan for the NHS should be fully aligned with the NHSE/HEE strategy, with reference to how it will help to support achieving LTP ambitions over the course of this decade. 

We accept that responsibility for a funded workforce plan, as outlined above, sits with government rather than NHS England. However, given the importance of robust long-term workforce planning for delivering the LTP’s ambitions, we felt it right to include.  

Other recommendations to address workforce challenges:

• The additional funding for education and training allocated in 2019-2021 should be sustained beyond 2024. This would help fund additional training capacity, cover for staff release and continuing professional development.  
• The People Promise gives a positive framework for staff experience in the NHS. Further implementation of the promise should support LTP delivery. This requires a realistic assessment of pressures on staff and what can be achieved in relation to health and wellbeing.
• Discussion of workforce challenges rightly focuses on the issues facing its 1.4 million employees. However, to meet the challenges of the future, an updated approach to planning should highlight the need to: draw more effectively on the capacity and skills of volunteers; work more closely with carers; and find ways to expand the workforce to respond quickly to future pandemics.

Recommendation 6: Alignment with the government’s existing reform agenda but commitment to co-production on future reform

Why? 

We have heard clearly from health leaders that they are struggling to keep up with an ever-growing number of policy initiatives and reviews. In addition to the Health and Care Act 2022, we have seen a raft of white papers, strategies, consultations and guidance documents. The degree to which the direction of travel remains the same under the new government’s health and social care secretary remains to be seen and there is exasperation about the prospect of further structural upheaval. 

To provide some certainty and stability for the coming years, and to be considered a comprehensive plan, an updated approach should do more than list targets. It should commit the NHS to the reforms that have been set out since 2019, many of which have had support across our membership. 

“The LTP must be complementary to various planning documents as opposed to it being historically separate.” 
ICB chief transformation and delivery officer

Bringing together different strands of policy in recent years should feed into a clear narrative for how the NHS should look different by the end of the decade. As has been highlighted by some of our members, this was lacking in the original LTP.

“The Five Year Forward View was clear on narrative but not on detail. The LTP was the reverse – clear on detail, but not on a clear overall narrative.” 
ICB chair

Health and care leaders have welcomed the opportunities that both NHSE and DHSC have offered for input into national policy, including the Health and Care Act 2022. However, there is appetite for this to go further and for co-production to become a defining feature of central policy-making. This would help to ensure that key policy decisions are being informed and directed by those closest to the realities ‘on the ground’. There is recent precedent for this. In her review of primary care, for instance, Dr Claire Fuller ensured that her recommendations had the backing of all 42 ICB CEOs (at the time CEO-designates). NHS Confederation chief executive Matthew Taylor has since referred to this idea – that major policy recommendations should be backed by the leadership of all ICSs – as the ‘Fuller Principle’. 

How?

A long-term strategy for the NHS should include a ten-year moratorium on any further imposed structural reform of ICSs. In doing so it should commit to supporting ICSs until the end of this decade to reflect the international evidence that integration reforms take time to improve population health outcomes. 

The strategy should be clear about how existing and forthcoming policy documents – including the urgent and emergency care strategy, integration white paper and Fuller stocktake – tie into achieving the ambitions of the LTP.  

While the ‘Fuller Principle’ would not be realistic nor pragmatic in all cases, the updated plan should commit to co-production with system leaders on national policy direction. 

Recommendation 7: Health inequalities and digital should be central golden threads  

Why? 

During a roundtable event we held with NHSE on prevention, we heard about some of the limitations of the LTP when it came to addressing health inequalities. 

While there was a specific chapter on the issue, it concentrated mainly on individual behavioural factors contributing to health inequalities, such as smoking, obesity and alcohol. A long-term strategy requires a more nuanced narrative which applies a system-wide approach to prevention. One which, for example, distinguishes between primary and secondary prevention and which takes a ‘life course’ multimorbidity approach. 

There was also concern that the targets in the LTP failed to provide a coherent central narrative or follow the existing research base and central policy on prevention (such as CORE20PLUS5): 

“What is lacking is the harnessing together, rather than ten dozen strategies pulling in different directions which mean NHS leaders get caught up with reporting on different things.

 

“If the refresh corrals the learning we already have, reinforces CORE20PLUS5, proportionate universalism and parity of esteem, and reinforces the mechanisms that research has shown us work in long and short term, this will allow the LTP to not be a revolution but an evolution. [It should] ask the question, ‘what are the ways we can start nudging towards prevention and turn this tanker around?’” 
ICS health inequalities director

On digital technology and virtual care, which should be considered a tool for addressing health inequalities, there has been speculation that an adjusted long-term plan will not include a specific digital focus. Our members have indicated that they are relaxed about this. For too long digital has been considered its own entity, when in fact it should be an integral aspect of all areas of care.

How?

Health inequalities should be a focus throughout each aspect of a long-term plan for the NHS. For example, elective recovery should not simply focus on targets to bring down waiting lists, but on ways to address the elective backlog which prioritise tackling inequity in access to elective services. 

Similarly, now that digitally enabled care has ‘gone mainstream’ across the NHS, focus must shift to ensuring that this benefit is felt equally. Ambitions to close the digital gap will have a protective effect on the health of the country’s worst-off communities.

Digital should join health inequalities as a golden thread throughout. Again, to use elective recovery as an example, the use of digital solutions such as expanding access to home treatments using virtual and digital care has supported meeting key waiting time targets. 

The government has published a suite of digital and data strategies and roadmaps in recent months. Discussions about the long-term strategy for the NHS should continue to build upon original commitments made in 2019 to lower carbon emissions and air pollution by embracing the use of digitised care. Digitally enabled care models and increased use of virtual care will contribute to net zero targets by significantly reducing the number of journeys patients make to physical NHS locations.
  

Objective 3: Honesty about expectations and acknowledgement that public engagement is required to navigate capacity challenges

We believe that a long-term plan for the NHS must address the public’s understandable concern about access, but it must be realistic about what can be achieved without further funding.

We also believe that, while this strategy should set out a plan for the NHS, it must also be clear on the more active role that the public themselves will need to play as the health service evolves over the coming years. 

Recommendation 8: Address funding considerations and be realistic about what ambitions will require greater investment 

Why? 

The LTP offered some degree of certainty on how the NHS would be resourced to achieve the ambitions of the plan. It was backed by new funding of £20.5 billion across five years, with a broadly stable national economic outlook. 

We are now in a very different position. The scrapping of the health and social care levy will make a difficult financial situation worse. Even prior to the new government scrapping the levy, NHS Confederation analysis had shown that the health service was facing a real-terms cut in funding of between £4 billion and £9.4 billion this year. This is due in large part to the damaging impact of inflation.

Therefore, while health leaders understand the need for national targets to be ambitious about improving quality and outcomes, there is concern that a long-term strategy must be clear about what the NHS can deliver within the existing funding settlement and the havoc that inflation may continue to wreak on NHS finances over the coming years. 

We believe that the government should seek to be more ambitious on health and care funding to end a reoccurring ‘feast or famine’ approach. We have called for a long-term commitment to a 4 per cent annual increase in the NHS budget. Two decades on from the Wanless Review, there is a need to demonstrate how the NHS could reduce demand and improve productivity in the longer term. But honesty is needed that this can only be achieved with increased, targeted investment over the short and medium term.          

How?

A long-term strategy for the NHS should make clear from the outset the context of real-terms funding cuts for the NHS. It should be frank about where certain ambitions will require additional funding and acknowledge as part of its overall narrative that worsening inflation will have implications for delivery. 

It should set out a narrative that the NHS is an ‘investable proposition’ and that it is critical for wider economic and social development. Investment in this sector goes well beyond simply delivering health services – it plays a significant role in addressing low productivity through ensuring a healthy and productive workforce, attracting private sector investment and stimulating economic growth. The LTP was the first national NHS strategy to raise the importance of this ‘anchor’ role of the NHS. With the subsequent inclusion of the ICS purpose of ‘helping the NHS to support broader social and economic development’, a long-term strategy will play an important role in underpinning the next stage of this journey.

Recommendation 9: Commitment to close and meaningful engagement with the public on self-management and personalisation

Why? 

The NHS is rightly looking to use novel models of care to reduce pressures on services (by incentivising treatment at home) and to empower patients to take more control over their own pathway. 

These include: 

• Virtual wards. An ambition to expand virtual wards was set out in the Elective Recovery Plan and the NHSE letter on winter planning. Despite warnings about the limitations of virtual wards in some contexts, there is emerging evidence that virtual wards can reduce readmissions while allowing people to be treated at home.  
• Patient-initiated follow up (PIFU). NHSE has encouraged systems to make use of PIFU as a means of freeing up outpatient capacity, as set out in guidance from May 2022. A systematic evidence review by the Nuffield Trust states that there is some promising evidence that PIFU could result in fewer overall outpatient appointments.
• Anticipatory care. In many areas providers have come together to deliver anticipatory care for those at high risk of unwarranted health outcomes. It is also the focus of a service specification (in the Network Contract Directed Enhanced Service) which PCNs will be required to deliver. There is limited evidence of the effectiveness of anticipatory care models in England, though there is evidence from Scotland that it can effectively reduce admission to hospital. 

Despite the potential of such innovations, however, they require a shift in the type of engagement and relationships between patients, clinicians and systems through culturally competent conversations. Rather than being passive receivers of care, patients will need to be active co-producers; clarity will be required on the respective responsibilities of them and those delivering care. 

We believe that NHSE and the government should therefore be leading a national conversation about these different ways of providing care. One based on realism about the challenges ahead and genuine consultation on what role patients are willing to play in meeting them. This will make it easier for clinicians to have open and frank conversations with patients about innovations such as those above in the years ahead. 

The Welsh NHS Confederation has already made similar asks of the Welsh Government in its report Reshaping the Relationship Between the Public and the NHS. This called for a roll out and promotion of the ‘Help Us Help You’ campaign across all public sector organisations to raise awareness of the most appropriate NHS service for individuals’ needs. 

How?

We would welcome commitments to increase personalisation (through a population health management approach). This should aim to ensure individuals can be treated at home or in the community through innovations such as those outlined above. However, this should be accompanied by a commitment to co-production with the public on how such innovations are implemented.   

Viewpoint

Engagement with our members has revealed that health leaders broadly believe an updated approach to planning for the future should achieve three key objectives:

1. Set out a less centralised approach to reflect a different health and care landscape 

Power should shift away from the centre, with more autonomy for local systems and a clear focus on collaboration and partnership between the NHS, local government and other stakeholders. The NHS is already too centralised and we need to see a sustained shift towards empowering integrated care systems to focus on the things that matter most to their local communities.

2. Offer clarity on how systems can act as bridges to a bolder and more optimistic future  

A compelling vision is needed for integrated care systems over the coming years and specifically how they can achieve three key shifts: from meeting demand to meeting need; from focusing on performance activity to focusing on outcomes; and from investment in reactive services to investment in preventative out-of-hospital services. 

3. Be honest about expectations and acknowledge the public engagement required to navigate the capacity challenges of the coming years 

The public has understandable concerns about the current state of services and healthcare funding. These should be addressed, with a clear ambition for the public to have a much greater role in co-designing personalised services – particularly where we are asking individuals to play a more active role in their own care through shared decision-making.

Incorporating the recommendations in this report will help to ensure that any review of plans for the future offers a clear, realistic and effective vision for the NHS over the coming years. 

A long-term strategy should be considered an important component of providing much-needed reassurance to the public that the NHS stands ready to meet the challenges ahead. 

References

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