Is this the way the future’s meant to feel? The NHS Long Term Plan and the future of health and social care in England

David Rowland | January 15, 2019 | Blog, Featured

The NHS Long Term Plan published last week could not have come at a less opportune moment.

Planning for the next 10 years in the midst of the political chaos caused by Brexit is a futile endeavour. With the Department of Health currently considering the stockpiling of essential medicines and trying to ensure that the supply of healthcare professionals from Europe doesn’t dry up 10 years from now feels like a life time away.

In fact, the document is so lacking in the basics of a “plan” that the Advertising Standards Authority might want to have a quiet word with the authors.

For example, what type of long term plan for a health service makes no reference to the number of hospitals and other care facilities which will be built over the coming period?

According to the plan, decisions on capital funding will be left to the forthcoming Spending Review on a date which has yet to be announced.

And we already know that the Chancellor has already blown a £3 billion hole in the original Department of Health capital spending programme by “abolishing” PFI without putting any alternative in place.

In the current circumstances it is difficult to see where the Department is going to find £10 billion of investment in healthcare facilities which the Naylor review identified – without it, planning the future becomes impossible.

And it should be noted there is no workforce plan contained within the Long Term Plan.

Nor, is there any account of how the underfunding of social care will be addressed.

Nor, is there an account of how public health services will be funded.

All of these critical decisions about how the NHS will function in the next decade are dependent on a Spending Review which is in turn dependent on the outcome of Brexit.

So let’s be clear. This is not a plan for the next 10 years – it is merely Simon Stevens submitting his homework to the Prime Minister in exchange for receiving an extra 3.4% a year of cash for the NHS.

But the “plan” does tell us more about the Stevens vision for the NHS and so it is worth engaging with.

At the heart of the document is a restructure of the service which Stevens and others in NHS England have been working on for some time.

It is a structure which has no foundations of any kind in public or administrative law but is instead coming into existence through diktats issued from NHS England’s HQ in Leeds and with the silent consent of the Department of Health in London.

So afraid are the government of another Parliamentary bust up about health service reform that they are granting Stevens unprecedented powers to restructure and reconfigure the NHS without the approval of Parliament and without being subject to any form of scrutiny.

So what does the Stevens’ vision look like? In headline terms it is an outright rejection of the “purchaser-provider” split whereby care for smallish local populations is commissioned by GPs (CCGs) from a range of healthcare providers be they public or private.

The plan explicitly ditches the idea of “patient choice and competition” and in doing so sets the NHS on a path which is directly contrary to objectives of the primary legislation (The Health and Social Care Act 2012) which governs how it is legally required to operate.

In its place, NHS England is in the process of creating a series of Integrated Care Systems (ICS) which involves those commissioning the service (eg CCGs) and those providing the service (Primary Care, GPs,NHS Trusts, Private Providers and Local Authorities) coming together to arrange healthcare on the basis of what they consider to be the needs of a geographic population.

This formal structure has many similarities of the old regional health authority structure which put population based planning ahead of choice and competition and has been advocated by many public health professionals for some time. But, it is problematic for a number of reasons.

First, by creating these ICS without any legislative underpinnings a huge accountability gap emerges.

Whereas health authorities were directly accountable to the Department of Health and the Secretary of State who was in turn answerable to Parliament, ICS have an accountability line which runs directly to NHS England with no elected representatives having any direct oversight.

Moreover, the previous health authority structure was subject to challenge and scrutiny at local level by statutory Community Health Councils which enabled the local population to have an input into decisions about their healthcare which affected them. No such local accountability arrangements exist for the ICS.

Second, there is nothing in law to prescribe the activities of the new organisations, nor anything which imposes on them any specific statutory duties. In fact, it is astonishing that there is no definition of an Integrated Care Service anywhere in the NHS Long Term plan.

The unfettered power of these new organisations is what was at the heart of the recent judicial review taken by health campaigners – if these new ICS organisations do not have a firm basis in law and no clear accountability arrangements, there is nothing to stop them handing over large swathes of NHS care to private providers and nothing to stop them contracting with US health insurance companies to make “risk profiled” decisions about the healthcare needs of their populations.

Questioning whether this is a likely outcome is beside the point – a flimsy administrative framework is always at risk of abuse which is why new legislation setting out the powers of ICS is badly needed.

Admittedly, this is something which the “plan” does acknowledge and a number of legislative reforms are proposed. But as an indication of its “ultra vires ” approach to policy-making NHS England does not see the lack of a clear legislative base for these far reaching reforms as an impediment.

The radical changes to the NHS will move forward regardless.

Finally, the public need to be able to understand how major structural changes such as these impact on the availability and quality of their healthcare services. Thus a basic test of the transparency and accountability of any healthcare system is whether it can answer this simple question: “Who determines what healthcare I can get?” Ploughing through the technocratic verbiage of the NHS Long Term plan which sets out this new structure is unlikely to leave the average citizen any wiser.

At best, the NHS Long Term plan is a valiant attempt to say something about what the NHS will look like in 2028 in the midst of a planning blight which will continue until Brexit is resolved. At worst, it provides political cover for a set of radical reforms which have yet to be discussed by Parliament and which have no firm basis in law.

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David Rowland

David Rowland is CHPI's Director. He joined the organisation in 2019 after over a decade of working in senior policy positions within the healthcare regulatory sector. For David's full bio see our People pageSee all posts by David Rowland