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Reaction to the NHS long-term plan

BMA chair Dr Chaand Nagpaul:

Given the substantial and growing pressures on the NHS, the announcement of the long-term plan represents an ambitious set of aims for the health service, but this must be underpinned by a strong set of deliverable actions. 

Fundamental to the expansion of cutting-edge treatments and digital consultations is to first get the basics right, such as the workforce. There is no use in opening the digital front door to the health service if we don’t have the healthcare staff behind it.

While the Government has highlighted plans to expand capacity and grow the workforce, very little has been offered in the way of detail. Given that there are 100,000 staff vacancies within the NHS, the long-term sustainability of the health service requires a robust workforce plan that addresses the reality of the staffing crisis across primary, secondary and community care. This will require additional resources for training, funding for which has not been mentioned in the long-term plan.

There is also a pressing need to address immediate and short-term pressures given that doctors and NHS staff are routinely struggling to cope with rising demand and, as a result, are subject to low morale, stress and burnout. As well as the toll on wellbeing, this has a detrimental impact on recruitment and retention and, unless this is addressed, we risk a workforce plan without the doctors in the future to deliver it.

The technological advancements announced by NHS England have the potential to benefit many patients in areas such as cancer, cardiovascular and stroke care but the aspirational targets must be matched by operational realities. It is welcome too that the Government is recognising that patient mental health conditions deserve to have the same access and quality standards as those with physical health problems, which the BMA has long called for.

The BMA supports increased investment in general practice and community care. This is imperative for effective future planning given the ageing population and the fact that doctors are treating patients with more complex needs, though we await further detail on how this will be delivered.

With patients experiencing unacceptable waits in A&E, and waiting lists for surgery and appointments growing, we also need immediate, practical solutions and the necessary investment for hospitals to deliver both in the long and short-term. 

A renewed focus on prevention is welcome but the reality of the situation is that we are seeing a significant increase in obesity and related diseases along with worsening health inequalities exacerbated by years of cuts to public health budgets. The Government must go further than what is outlined in the long-term plan and commit to population-wide measures, such as a minimum unit price for alcohol, restricting sugar levels in food, and greater restrictions on junk food marketing, if we are to achieve the necessary improvements to the health of the public. 

Narrowing inequalities cannot occur without adequate provision of social care which is not covered in the long-term plan. The BMA eagerly awaits the publication of the green paper on social care this year which must fully align with the long-term plan for the NHS.

Ultimately, there is a need for honesty about how far the £20.5 billion over five years will stretch. This is well below the 4% uplift that independent experts have calculated is required, and below historic spending levels since inception of the NHS. World class care requires world class funding and the investment in the long-term plan will still leave the UK falling behind comparative nations like France and Germany.

If we are to truly transform the care we give to patients, and create a sustainable, world-class health service, this long-term plan must deliver beyond grand ambition and address the realities faced by doctors, NHS staff and patients today. 

Dr Michelle Drage, chief executive, Londonwide LMCs:

The Government’s decision to prioritise investment in general practice is an important step to easing the pressures created by decades of under-funding. If the NHS is to be sustainable it needs GPs and practice teams to be properly resourced to do what they do best: keeping people healthy in their communities, so fewer of them need hospital care.

London’s GPs must now see investment going directly into frontline care, rather than having it split up into different funds with bureaucratic application processes, as has too often been the case in the past.

Sarah Wilkinson, chief executive at NHS Digital:

This plan offers a hugely exciting vision for the future of the NHS. We are particularly pleased that the plan recognises the extent to which new and improved technology and digital services can enable many of the goals set-out, all of which we whole-heartedly support.

Over the coming years we in NHS Digital, working closely with our partners across the system, will work to make digital access to health and care services as pervasive as it is now across other sectors. The sophistication of commodity technology services, the plethora of advances in health technology, the track-record of reliable delivery which we have quietly laid down over recent years, and the passion and commitment of this secretary of state to transforming these capabilities combine to make this a time of enormous opportunity and potential.

A key focus of the technology and digital agenda, as with the plan overall, is allowing patients to better manage their own health and care. A broad spectrum of digital services will support individuals to take a much more proactive and responsible approach to monitoring their own health and well-being, enabling them to recognise their individual health risks and symptoms as early as possible, and manage their personal response to these risks. This, in turn, reduces the demand for health and care services.

We know how challenging it can be for organisations, particularly those under constant pressure to deliver critical services, to adopt new technology and digital systems. We are completely committed to supporting NHS organisations on all aspects of this journey from technical education, to integrating new technology into services and care pathways to the design of highly usable and accessible patient-facing solutions.

Richard Murray, chief executive at The King’s Fund:

This is an ambitious plan that includes a number of commitments which – if delivered – will improve the lives of many people. NHS leaders should be applauded for focusing on improving services outside hospitals and moving towards more joined-up, preventative and personalised care for patients.

While NHS leaders have done what was asked of them within the constraints of the funding settlement provided by the government, some significant pieces of the jigsaw are still missing. A number of decisions – notably on hospital waiting times – have been postponed, indicating that trade-offs and difficult choices lie ahead.

Whether the plan can be delivered relies critically on tackling workforce shortages. While the plan recognises this, commitments to increase international recruitment depend on decisions about immigration policy and we will need to wait for solutions until a new workforce plan is published later this year.

The NHS and social care are two sides of the same coin, yet publication of the social care green paper has been delayed yet again. And while commitments for the NHS to do more promote public health are welcome, cuts to local government funding for public health services underline the need for a more consistent approach across government to the population’s health.

We strongly support the ambition to establish integrated care systems in every part of the country by 2021. The plan sends a welcome signal that NHS organisations need to work with local authorities and other partners to deliver improvements in the health of local populations.

In short, while today’s plan is a significant step forward, a number of questions remain unanswered. There should be no illusions about the scale of the challenge ahead.

Nuffield Trust Chief Executive Nigel Edwards:

The goals of this plan look right – carrying on with joining up care and improving services for older people, while pushing vital issues like heart attack survival and children’s health up the agenda. These are the most important issues for patients, and the level of ambition is good. What worries me is how difficult it will be to roll out such wide ranging changes. There are several big pitfalls ahead.

The extra funding will actually be below the historic average and what experts thought was needed (1). It’s enough to move forwards, but with little room for manoeuvre. If we face a no deal Brexit, the extra costs and tasks required would eat up the first instalments, stopping progress dead in its tracks (2). And if social care and public health continue to be starved of funding, a stretched NHS will have even less to spare.

In the NHS it is always difficult to take changes from the whiteboard to the ward. Success depends on extra effort and initiative from staff. But relations are frayed by shortages and increasing burnout, so some real leadership will be needed. Some ideas in this plan seem to assume one size fits all. But it often does not in the NHS because the distribution of people and services varies so much across England.

The biggest obstacle of all is the lack of key staff. Our calculations with The King’s Fund and Health Foundation show a shortfall of 250,000 by 2030, which would make delivering even current services near impossible (3). However, the biggest levers to resolve the workforce crisis are out of NHS England’s hands. Only bold policies on training, immigration and Brexit can deliver enough nurses, GPs and therapists for the next few years. The system of workforce planning has failed us, and needs deep reform.

Niall Dickson, chief executive of the NHS Confederation:

This plan heralds an end of austerity for the NHS and as such marks the dawn of a new era – one in which we will need to transform the way services are delivered to patients and the public.

The plan looks set to promise a host of improvements, including in areas such as maternity care, children’s services, cancer care, mental health and heart disease. It will also signal significantly more investment in community care, much greater use of digital technology and more emphasis on prevention. 

We very much welcome the increased funding for the NHS and the vision to strengthen and improve services. But the plan cannot escape the harsh reality that the NHS will still face tough decisions on what it can and cannot do. Our plea is that politicians be honest about the trade offs that will be required and that we are realistic about what can be achieved given the ever increasing demands of an ageing population. 

The next few years will be about balancing the need to keep the NHS going, overcoming the large deficits in many hospitals and other NHS organisations, delivering some improvements, and preparing for new ways of delivering care that will make the NHS sustainable. This is not about miracles – money will be tight and staffing will remain a headache for years to come. Getting a long term strategy for the NHS workforce is crucial.

The ambitions in the plan will also in part be determined by factors beyond the NHS’ control. The Government must find a solution to the social care crisis that has seen thousands of people no longer receiving the care and support they need. It must also follow through on its commitment to improve the health of the nation through better prevention by overturning the significant cuts we have seen to public health budgets. Failure to address these issues will continue to place significant extra pressure on front-line NHS services.  

We now need to see the detail of the plan. Plans are fine but the challenge is how they are implemented and we will be watching closely to see whether this plan meets three key tests of it set by our members who are leading front-line services: is it deliverable and affordable; does it enable care to shift out of hospitals and closer to people’s homes; and does it give local leaders the freedom they need to shape and develop the health services required in their area?

Vice president of the Royal College of Emergency Medicine, Dr Chris Moulton:

On face value, the NHS long-term plan is ambitious, optimistic and considered. Within it there are many fine aims which, if delivered, will improve care for some patients.

However, we fear that there are incompatibilities with expectation and reality; particularly when considering the gap between what is being promised and what is being provided.

As others have rightly pointed out, the viability of this plan will not only be conditional on tackling workforce shortages – and ensuring that those staff that we have do not leave the NHS – but also on adequate funding for both public health and social care.

The plan leans towards prevention rather than treatment, yet there has been no halt to the cuts in public health funding and this settlement does not include any increase.

Embedding social care teams in the emergency department may well be a good idea, but social care has been in a dire state for a long time and the green paper on it has been delayed for many years.

Aiming to relieve pressure on hospitals by shifting towards care in the community is commendable, and patients naturally want to be treated as close to home as possible. But if this change is to work, then this care must be available, like emergency care, 24/7. This will need serious commitment on the part of other specialities and agencies.

While the College welcomes moves to relieve pressure on emergency departments, it is disappointing to find that despite the proposed measures to do this, it has still not resulted in a firm commitment to restoring hospital four-hour performance to 95% – a sensible target that is very much achievable given the right resourcing and desire to do so.

We also fear that the Clinical Standards Review that the document alludes to but provides scant details of, may not be driven by patient interests alone. Targets ensure patient safety, drive improvement and provide a level of transparency around system performance that is essential for good decision making.

While experience shows that diversion strategies do not work as desired, most of the aims within the plan are laudable, if perhaps too readily promised. Unfortunately, it appears to be the case that while many patients will benefit, this may be to the detriment of others – those attending A&E will continue to suffer from delays and overcrowding.

Labour shadow health secretary Jonathan Ashworth:

The fact NHS bosses are now proposing significant changes to the Health and Social Care Act confirms what a wasteful, bureaucratic disaster it was in the first place. 

Labour have long called for this Act to be binned and will study legislative proposals carefully. The Tories must apologise for wasting billions of taxpayers’ money on the privatisation, constant tendering of contracts, top down reorganisation and demoralisation of staff this Tory Act ushered in.

The Tories have spent nine years running down the NHS, imposing the biggest cash squeeze in its history, with swingeing cuts to public health services and the slashing of social care services. They have failed to recruit and train the staff desperately needed, leaving our NHS struggling with shortages of over 100,000 staff.

What’s more, it’s a damning indictment of the impact of Tory austerity, cuts to public services and rising poverty that the NHS today admitted that socioeconomic inequality causes £4.8bn a year in greater numbers of hospitalisations.

While the aspirations for improving patient care NHS England has outlined today are welcome, the reality is the NHS will continue to be held back by cuts and chronic staff shortages. Labour will give the NHS the funding it needs to provide quality care and recruit the staff for the future.

Unite national officer for health Colenzo Jarrett-Thorpe:

This new cash is, in reality, putting in the funding that the government removed a decade ago. ‘Smoke and mirrors’ is the name of the game.

The money that is now coming on stream is not enough to meet the ambitious targets to save the almost 500,000 lives outlined in the long term plan.

The NHS is like a Rolls-Royce that needs constant care and attention – the Tories, since 2010, have neglected its annual maintenance. The NHS requires an immediate cash injection to meet increasing demand. That’s the grim reality.

We know that even the projected boost of government funding to the NHS over the next four years does not meet the historic average increase in NHS funding over the last 70 years, which has run at about 3.9 per cent compared to the three per cent minsters are proposing.

From 2010 up till now, increases in the NHS budget have been barely one per cent.

For example, because of the massively flawed Health and Social Care Act, many of our public health services have been transferred to local authorities since 2013 and funding in public health has fallen by eight per cent since 2013/1,4 according to the Kings Fund.

How can this long term plan be implemented if the government gives with one hand and takes away with the other?

This plan is doomed to failure if ministers do not reverse cuts to local authority budgets or give incentives to councils not to cut public health or community health budgets.

On top of all this, there are an estimated 100,000 vacancies in the NHS, which are compounding the current crisis. As a country, we also rely on the 63,000 EU citizens working in the NHS in England whose future is being blighted by the unpleasant atmosphere created by Brexit.

Jennifer Dixon, chief executive of the Health Foundation:

The Prime Minister’s promises to improve mental health and other NHS services are welcome, but making them a reality will be extremely tough given growing pressures on services, chronic staff shortages, and cuts to other parts of the health and care system.

While £20.5bn extra funding promised for NHS England by 2023/24 is generous compared with other public services, it is barely enough to keep pace with growing demand for care. This means trade-offs are inevitable, and these must be spelled out clearly so the public know what they can expect from the NHS.

The NHS’s ability to deliver the long-term plan will also depend on wider political choices. Without a solution to the growing crisis in social care, people will continue to suffer unnecessarily, and more pressure will be piled on the NHS. Yet the government’s green paper on social care funding is still yet to appear, and current funding is not enough to meet rising pressures.

Continued cuts to public health and local authority budgets will hold back the NHS’s ambitions to keep people healthy and tackle unjust differences in health between the best and worst off. Next year’s public health grant would cut spending by £240m in real terms. The core public health grant has fallen by a quarter (25%) per person since 2014/15. These funding cuts come at a time when life expectancy improvements are stalling and inequalities are widening. 

And a no-deal Brexit risks making the NHS’s workforce problems even worse. Currently there is a shortage of around 100,000 doctors, nurses and other crucial NHS staff.

Securing the future of the NHS is therefore as much about political choices by government as what NHS leaders say in their long-term plan to be published on Monday.