NHS Long Term Plan: Let’s hope this vision holds action over ambition

9 Jan 19

The NHS Long Term Plan is welcome but without firm plans for social care funding many of its ambitions are unrealistic and unclear, says CIPFA’s Eleanor Roy.


After much heralding – and a few false starts – finally we have sight of the NHS Long Term Plan. On first reading it presents an inspiring vision for the next 10 years, which surely few could argue with. However after more detailed consideration, we wonder how feasible these ambitions actually are, particularly with the underlying requirements to realise them as yet unknown.

Proposals to improve the financial position of the NHS are particularly welcome. Emerging changes to the financial architecture suggest a more realistic approach than has gone before, with measures to support providers in deficit signalling an intention to divert funding to those areas in most difficulty.

Similarly, the efficiency targets are far more realistic than those in the Five Year Forward View and will likely result in a huge sigh of relief from many. Although this paints a brighter picture in the short to medium term – these proposals are unlikely to realistically improve the overall financial sustainability and resilience of the NHS in the long term.

The plan also signals a welcome move towards removing some of the financial and legislative barriers to greater integration of health and social care. This includes an intention to accelerate the development of Integrated Care Systems (ICSs), support budget sharing with local government, review the Better Care Fund (again), change funding flows and contract arrangements to support integration (with more to follow in 2019-20), to support sharing of budgets, and make improvements to the performance and accountability of ICSs. Each of these is a positive development, and supports the policy rhetoric on integration and place-based, person-centred care.

However the missing jigsaw piece is glaringly obvious: the lack of another long-awaited document, namely the social care green paper. Given that we still have no indication of how (or when) the long-term sustainable funding of social care will be addressed, never mind come to fruition, the assumption stated in the long-term plan that social care will not impose any additional pressure on the NHS over the next five years seems unrealistic, given the £3.6bn funding gap to be addressed by 2025. Without the green paper the puzzle of how integration can be achieved remains, and you can see this theme recurring throughout the plan.

A truly integrated approach would have been to ensure that the long-term plan, social care green paper – and prevention green paper if we are seeking an ideal – were jointly produced and published

Similarly, in term of prevention the long-term plan signals a move in the right direction. The plan identifies new commitments for the NHS in prevention, particularly with reference to commissioning. This in itself is unclear as it could be interpreted as the NHS taking over responsibility for local government functions. However, the plan does recognise that it cannot substitute for the role of local government. Again, this rhetoric does not appear to be supported by the fact that the public health grant has been cut by £600m in recent years. We hope the green paper on prevention – expected in the spring – will provide a more holistic view of the preventative agenda, and the respective roles of the NHS and local government.

A truly integrated approach would have been to ensure that the long-term plan, social care green paper – and prevention green paper if we are seeking an ideal – were jointly produced and published. This represents a missed opportunity by the Government to lead from the top and provide a comprehensive picture of the intended direction of travel and the means of supporting it.

Unfortunately, this theme is continued elsewhere in the long-term plan – much remains to be clarified. The ambitious vision cannot be delivered without addressing NHS staffing issues – but a workforce strategy will not appear until later this year after the Spending Review. Similarly, improvements to capital regime and investment in transformation are to be considered post-Spending Review. Bear in mind that as yet we have no date for this momentous event. Proposals for legislative changes to remove some of the barriers to integration are welcome – but will take time and are subject to the uncertainty of the legislative process.

Much remains unclear or relies on further developments. Meanwhile, the buck has been passed to NHS organisations and local health economies to produce plans by spring, using the long-term plan as a framework. Given that many aspects still lack any real definition, we can only hope these long-term plans do not turn out to be just pillars of sand. Local plans will be scaled up to national level by autumn – by which time we may have had a couple of green papers and perhaps even a Spending Review. The mists may have cleared by then.

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