The NHS Long Term Plan pledges at least a £4.5bn boost in funding for primary and community care over the next 5 years, meaning that for the first time, investment in primary medical and community services will grow faster than the overall NHS budget.
However, additional investment is tied to the establishment of new ‘network contracts’ and a major overhaul of how these services are co-ordinated.
The document, published earlier this month, reveals: 'The £4.5bn of new investment will fund expanded community multidisciplinary teams aligned with new primary care networks based on neighbouring GP practices that work together typically covering 30-50,000 people.’
NHS England says it has now learned enough from 'vanguard' areas trialling new models of care through the primary and acute care systems (PACS) and multispecialty community provider (MCP) schemes 'to commit to a series of community service redesigns everywhere'.
Expanded neighbourhood teams will comprise a range of staff such as pharmacists, district nurses, community geriatricians, dementia workers and AHPs such as physiotherapists and podiatrists/ chiropodists, joined by social care and the voluntary sector.
Teams will be supported through the ongoing training and development of multidisciplinary teams in primary and community hubs.
There will be extensive changes to QOF. The least effective indicators will be retired, and the revised QOF will also support more personalised care and include a new quality improvement element that is being developed jointly by the RCGP, NICE and the Health Foundation.
This year will see a fundamental review of GP vaccinations and immunisation standards, funding, and procurement. The goal is to improve immunisation coverage, by targeting variation and focusing on groups and areas with low vaccine uptake.
The plan also aims to reduce unwarranted A&E attendance, hospital admissions and delayed hospital discharge. A ‘shared savings’ scheme will reward networks that achieve these objectives.
The networks will also have to tackle health inequalities. From 2020, primary care networks will assess local populations for risk of unwarranted health outcomes, and take a more proactive approached to earlier detection and intervention got conditions such as frailty and heart failure.
The Long Term Plan funds specific evidence-based NHS prevention programmes, to cut smoking, reduce obesity, double enrolment in the Type 2 NHS Diabetes Prevention Programme, and to limit alcohol-related A&E admissions.
By 2023, an extra 110,000 patients will be offered annual physical health checks. The uptake of annual health checks for people with a learning disability will be increased to 75%.
The Plan states: ‘The performance of any healthcare system ultimately depends on its people. Our staff are feeling the strain due, in part, to the number of vacancies across many roles. The current number [of vacancies] is unsustainable, with the biggest shortfall in nursing.
‘To make this Long Term Plan a reality, the NHS will need more staff, working in rewarding jobs. As we invest in our workforce we need to ensure the NHS has primary care and generalist skill to complement what has been a major move to more specialised hospital-based care in recent decades. To date, workforce planning has been too disjointed.’
The funding available for additional investment in the workforce for training, education and CPD has yet to be set, and a workforce implementation plan won’t be published until later in the year, but a new national workforce group is to be set up to ensure that any agreed workforce actions are delivered quickly.
The Plan acknowledges that ‘we are not yet training sufficient nurses to meet demand’ and the workforce group will agree action to improve supply. Since the bursary system was abolished the total number of applications for nurse training has fallen, but the Government claims there were still ‘nearly two applicants for each place,’ and 22,200 applicants were accepted onto English nursing courses in 2018, a higher number than in seven of the last ten years. However, a further 14,000 applicants were not accepted – partly because some higher education institutions have higher entry standards than others or above the levels set out by the NMC.
From this year, the number of funded clinical placements will increase by 25% – an extra 5,000 placements, and from 2020, funding will be provided for clinical placements for ‘as many places as universities fill, up to a 50% increase.’ Every nurse who graduates will be offered a five-year job guarantee in the region where they qualify. A new online nursing degree will also be launched, linked to placements at NHS trusts and in primary care, at a ‘substantially’ lower cost than the £9,250-a-year cost to current students. More flexible undergraduate degree options will be explored to attract mature students to mental health or learning disability nursing.
To increase the number of doctors, the number of medical school places will be expanded from 6,000 to 7,500 and options such as more part-time study and accelerated, 4-year degree programmes will be explored.
Newly qualified doctors and nurses entering general practice will be offered a two-year fellowship, ‘offering a secure contract of employment alongside a portfolio role tailored – where possible – to the aims of the individual and the needs of the local primary care system. This will enable newly qualified nurses to consider primary care as a first destination role.’
However, the plan also stresses retention of staff as an important part of it workforce strategy. Among nurses, the leaver rate was 8% in 2017, up from 6.8% in 2013. Training lead times mean new investment will not deliver additional nurses for at least three years. Improving staff retention by at least 2% by 2025 would deliver the equivalent of 12,400 additional nurses.
One of the top reasons for people leaving is that they do not receive the development and career progression that they need. Further investment in CPD could offer career progression that motivates nurses to stay in the NHS and equip them with skills to work in more advanced roles (See Advanced Practice, page 28). HEE has committed to increasing the proportion of its budget spent on workforce development, particularly in primary care and community settings but the amount it will have to spend will depend on the outcome of this year’s Government spending review.
In recent years, patient satisfaction with access to primary care has declined, particularly among 16-25 year olds.
Over the next 5 years, every patient in England will have the right to choose ‘digital-first’ access to primary care, either from their own practice or from one of the new digital GP providers. This will also mean a review of current out-of-area arrangements, and adjustment to the GP pay formula to ‘ensure fair funding without favouring one style of GP provider over another’.
From this year, NHS 111 will start direct booking into GP practices across the country and next year, the NHS App will be launched, to provide simple triage and direct patients to an appropriate service. Other condition-specific apps will also be developed or endorsed. Patients will be able to add information themselves to their personal health record, and all NHS staff will have access to the patient’s care.
Beccy Baird, senior fellow at The King’s Fund:
‘The NHS long-term plan places general practice at the heart of improvements to the health service. If that ambition is to be met, then general practice should be provided with support and training in leadership, management and organisational development, and it will need to be central to integrated system plans.’
BMA council chair, Dr Chaand Nagpaul:
‘Given the substantial and growing pressures on the NHS, the announcement of the long-term NHS plan represents an ambitious set of aims 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 NHS 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.
‘Ultimately, there is a need for honesty about how far the [total NHS funding pledge of] £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.’
Dame Donna Kinnair, Acting RCN Chief Executive:
‘…translating good intentions into better treatment and care for patients relies on having the right number of nurses with the right skills across our NHS. It is equally concerning that online courses are presented as a magic bullet to solve the workforce crisis.
‘Nursing degrees demand both academic and practical skills which student nurses learn from contact with professionals and peers, a model not easily replicated online, even with clinical placements. Nursing is career like no other, and it takes the right values and ambition to succeed. Entry standards are rigorous because they have to be - it is what safe patient care demands.’
NMC Interim Chief Executive and Registrar, Sue Killen:
‘Increased investment in the NHS is much needed and the long term plan, setting out how that extra money will be spent, is a step in the right direction.
‘Nurses and midwives are the cornerstone of the NHS and the plan rightly recognises the need for greater investment in people – both in terms of attracting more and retaining those we have. But more detail is needed on how this will be achieved, particularly in relation to ensuring nurses and midwives get the ongoing support, training and development opportunities they need throughout their careers. We know this is key to retaining staff and improving the quality of care.’