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- David Oliver, consultant in geriatrics and acute general medicine
- davidoliver372{at}googlemail.com
Follow David on Twitter @mancunianmedic
The government’s 10 year plan for England’s NHS, Fit for the Future, was published on 3 July.1 But can it deliver the goal set in its title? Is it an actual plan or more a set of ambitions, and what is it missing? The document runs to 148 densely referenced pages setting out numerous requirements for the direction of local services, despite telling us that “the system has become dependent on and obsessed with instruction from the centre.”
There are to be around 200 neighbourhood health centres by 2035, covering the whole of England and employing a variety of medical, nursing, allied health professional, pharmacy, and care navigation staff, as well as health visitors and social care staff. There will also be advisers on debt or employment and on obesity and smoking cessation, while community outreach workers will carry out health checks in people’s homes. All of this aims to shift much of the traditional secondary care outpatient activity away from hospitals and improve availability throughout the week. The neighbourhood health service model aims to simplify access and care coordination, in what can feel like a fragmented service.
Two new forms of GP contracts will “encourage and allow GPs to work across larger geographies and lead new neighbourhood providers,” which sounds a long way from the traditional partnership model. Current problems with access to NHS dentistry will be tackled through more use of dental therapists and a requirement for UK dental graduates to do NHS work for a minimum period after qualification.
On mental health, the plan reiterates the commitment to 85 mental health emergency departments for people in crisis, backed by £120m a year, which won’t go very far.2 The plan makes vague, detail-free statements about transforming wider services into “community mental health models” and expanding coverage of “assertive outreach care.”
The plan is similarly light on urgent and emergency care, beyond the use of a “My NHS GP” app to help patients find alternatives to emergency department attendance; increased use of paramedic practitioners to assess and support people at home; and greater direct access for first responders to specialist advice to help patients avoid going to hospital.
Missing details
Indeed, the plan is shot through with blind faith in the use of NHS apps for patients to navigate their own care. It also focuses strongly on the use of artificial intelligence, greater adoption of digital technology, and remote digital access to help patients seek advice or have consultations, to “transform” outpatient care. There are also big assumptions about the scale of benefits from all this technology, based on flimsy evidence.
As for the capital expenditure needed to enable all of this, or to upgrade NHS facilities and equipment, the details are vague at best and seem to enable more partnership with the for-profit sector.
On prevention and health inequalities, there’s a lot about regulation; about advertising and labelling of tobacco, vapes, and food and drink; and about a “nudge” approach to enabling healthier lifestyle choices. The plan lacks anything of substance about local government services, restoring public health funding, or tackling the wider socioeconomic determinants of ill health and inequalities. And, of course, it completely ducks the issue of social care reform—now kicked into the long grass again until Louise Casey’s commission reports back, scheduled for 2028.3
There are other serious omissions, not least the lack of a chapter on delivery. To my mind, this makes it more a set of ambitions written by committee than a “plan” per se. It’s missing all the timelines, the earmarked funding, and the actions, logistics, and risk and impact assessments that might make it worthy of that name.
The details on workforce planning are threadbare, beyond some general ambitions around focusing on staff wellbeing, support, and retention. And where’s the risk assessment or planning around moving staff from existing services to new models of care? There’s a modest commitment to increase training posts “in specialties with the greatest need,” but this is a sticking plaster for the huge bottlenecks in postgraduate training and the plummeting morale among resident doctors.
Pressing priorities
Being “fit for the future” also rests on heroic assumptions about productivity and efficiency gains, with no additional resource above that currently promised. Bear in mind that the Nuffield Trust has recently estimated that the additional 2.8% real terms uplift for the NHS over three years will be swallowed up maintaining existing commitments.4
What’s more, the plan promises a transformative shift of resources away from hospitals and into primary and community care by 2035, without telling us how this shift in financial flows will happen—often the sticking point in previous NHS plans. Crucially, the value of core GP contracts surely needs a major uplift if we’re to strengthen the role of primary care, but such a commitment is lacking here, despite a welcome pledge to change the funding formula to favour more deprived and underserved areas. Training more GPs won’t help if, as now, they’re unable to find employment because of underfunding or if experienced GPs continue to burn out, leaving the role or cutting their hours.
This plan also tacitly assumes that shifting more care away from acute hospitals will save money, but the evidence for this assumption is weak. It ignores the reality that we already have the fewest hospital beds per 1000 people in OECD nations, so losing even more general and acute or mental health beds could perpetuate our current problems.5
Finally, while the plan focuses on the medium term, it does little to tackle the pressing “right now” priorities of waiting lists, GP access, workforce retention, patient flow through hospital beds, or the community services needed to help people leave them.
Fit for the Future has a lot of bold ideas, some of them sensible and worthy. But, like other long term NHS plans before it, I doubt that it can deliver half of what it promises by 2035—by which time there’s no guarantee that the Labour Party will still be in power to see it through.
