Last reviewed 26 February 2019
In this feature, Thoreya Swage, healthcare consultant, highlights the key points affecting primary care in the NHS Long-term Plan.
In the first week of January this year NHS England published the NHS Long-term Plan. This was produced by a bottom-up process in response to the £20 billion agreed by the Government to recognise the 70th anniversary of the founding of the NHS in July 2018.
There was an expectation that the plan would be simple in its ambitions such that the tasks identified were deliverable and continued on a course of integration.
The plan also highlights that primary and community services will receive a greater share of the total NHS funding over five years from 2019/20 to 2023/24 reaching £4.5 billion by the end of this period.
What does the plan cover?
The plan was produced following consultations involving professional bodies, patient groups and NHS leaders at the frontline in over 200 events, over 2500 individual responses, from views offered by 85,000 members of the public and organisations representing over 3.5 million people.
The plan covers the following:
new service models
NHS focus on prevention and health inequalities
priorities for improving the quality of care and health outcomes
investment in technology and IT
getting the NHS back onto a sustainable financial path.
The plan sets out a strategy for the NHS for the next 10 years and this feature describes the key areas that affect primary and community care.
New service models
Enhancing out-of-hospital care
For the first time since its inception the NHS will develop fully integrated healthcare based in the community setting supported by training and development of multidisciplinary teams in primary and community care hubs. These teams will also include local community hospitals.
Patients will be booked directly into GP practices and to community pharmacies by NHS 111 for self-care, self-management and urgent care that could be treated in the community from 2019. Pharmacy connection schemes will be established by clinical commissioning groups (CCGs) for patients who do not require primary medical services.
Changes to the Quality and Outcomes Framework
In addition to retiring the least effective indicators and revised indicators supporting more personalised care, the changes include a new quality improvement element.
There will be a review of GP vaccinations and immunisation standards, and procurement and funding with a view to increasing immunisation uptake.
“Shared savings” scheme
This will be offered to primary care networks in response to their actions to reduce avoidable A&E attendances, admissions and delayed discharges as well as reducing avoidable outpatient visits by streamlining pathways and pharmacy reviews of over-medication.
Supporting older people
This will be through:
enhanced NHS support to care homes comprising of a consistent team of healthcare professionals as well as a named general practice; this is following the successful implementation of Enhanced Health in Care Homes Vanguards
ensuring that older people in care homes have good oral health, remain well-hydrated and well-nourished, have access to good rehabilitation care and have medicine reviews by pharmacists
emergency services and primary care networks providing emergency support, including out-of-hours advice
the sharing of information made easier between care homes and NHS staff through the former having access to NHS mail
Primary Care Networks assessing their local population by risk and identify earlier those at risk of undiagnosed conditions, such as heart failure, and offer support for health needs including musculoskeletal conditions, cardiovascular disease and dementia from 2020/21; there will be an emphasis on prevention, eg falls prevention schemes
increasing the use of wearable, home-based monitoring equipment to manage people at home better
identifying unpaid carers who are increasingly getting older and have complex conditions and provide support in accordance with their needs
supporting people with dementia through the use of the NHS Comprehensive Model of Personal Care and working with the Alzheimer’s Society to extend the use of the Dementia Connect programme which supports people who have been newly diagnosed with dementia.
Reducing pressure on A&E services
The pressure on emergency and urgent care continues to increase and the 4-hour constitutional standard is being missed by more emergency departments across England. To reduce pressure, acute trusts are required to increase their same day emergency care provision so that people are seen, treated and are discharged the same day. This is to be embedded in acute settings by 2019/20. This also reduces the need to admit patients and consequent delays in discharges, some of which are reliant on social care provision.
Urgent care outside the hospital setting will be integrated into a single multidisciplinary Clinical Assessment Service (CAS) combining NHS 111, ambulance and GP out-of-hours beginning 2019/20. This will include specialist advice from a wide range of healthcare professionals, have links with secondary care through collaboration plans and better access to medical records.
Care delivered at home by paramedics and healthcare professionals supporting staff at care homes and providing care outside hospital and other community-based professionals will enhance care in the community and reduce the need for attendances at A&E. The single access model is designed to streamline this response from community services.
The Urgent Treatment Centres (UTCs) model will be enhanced such that this is provided in all localities by 2020 with an opportunity to book appointments through NHS 111 or online. UTCs will be working with other services including GP services, community pharmacists, ambulances and other community-based care to offer an alternative to A&E for patients who do not need this.
Better management of patients during their hospital stay
The challenge of reducing delayed transfers of care (DTOC) continues with greater input of therapy and social work teams earlier in their admission (within 14 hours of admission), such that there is a clear date of discharge, a more efficient patient flow system and multidisciplinary team reviews on a daily basis. This, of course, is dependent on the capacity of social care to respond to this need.
The personalised care model, in which people are supported to manage their own health, will be rolled out reaching 2.5 million people across England by 2023/24. A key initiative within this is enhancing social prescribing, opening access to a wide range of activities such as art, dance, social clubs, etc to people who would otherwise receive medication, facilitated by link workers who will develop individual plans and put people in touch with groups and other services.
The use of personal health budgets will be enhanced to provide greater autonomy to patients to manage their care, eg through the provision of bespoke wheelchairs and packages of care and domestic support delivered in the community, as well as support to improve end-of-life care outside of hospital.
Healthcare enhanced by greater use of digital technology
Some changes have already happened in the NHS using digital technology, for instance electronic referrals to outpatients and the electronic prescription service. In addition, the following are to be implemented.
National roll-out of the NHS App enabling people to have access to NHS 111 online, their medical record, be able to book appointments or register for organ donation through a computer or smartphone; through the NHS App by 2020 every patient with a long-term condition will have access to their summary care record — by 2023 this will be replaced by the personal health record held within the Local Health and Care Record.
Trialling innovative devices, eg “smart inhalers” and remote monitoring of conditions.
Developing a “digital first” model of care, enabling longer face-to-face consultations with healthcare staff when needed.
A digital version of the maternity “red book” covering the whole country by 2023/24.
Creating apps to support various conditions, eg diabetes prevention, depression and anxiety.
Patients will have a single NHS login to permit them to identify themselves to a range of services.
Personal health records will hold a care plan and information added by the patient and/or carer.
Developing Integrated Care Systems across the whole of England
Sustainability and Transformation Plans (STPs) and Partnerships were initiated as part of the NHS Five Year Forward View to enhance joined up working across health and social care. A few STPs developed further into Integrated Care Systems (ICSs) to consolidate joint working signing up to a system-wide control total and more robust governance comprising the main stakeholders in a geographical area. The NHS Long-term Plan expects that by April 2021 ICSs will cover the whole of England.
This means that planning between health and social care will be at a “place” level ensuring that decisions about the design and commissioning of services will be shared with the common aim of improving the health of local populations. It is anticipated that CCGs will merge and become strategic organisations covering an ICS area.
To support this move ICSs will be required to agree objectives that are system-wide and will be accountable for their performance against these objectives as assessed by a new ICS accountability and performance framework.
Prevention and health inequalities
Five key priorities have been identified for focus on prevention and health inequalities.
Smoking — people admitted to hospital are offered stop-smoking services.
Obesity — targeted support for people with type 2 diabetes or hypertension with a BMI of greater than 30 will be offered weight management services.
Alcohol — specialist Alcohol Care Teams (ACTs) will be established in hospital with the highest rate of alcohol-related admissions.
Air pollution — reducing air pollution from all sources including NHS business mileage.
Antimicrobial resistance — continue the actions of the Government’s five-year plan on Antimicrobial Resistance through reducing the need for prescribing antibiotics and sporting the development of new antimicrobials.
Later in 2019 a workforce implementation plan will be published although the extra funding for this has yet to be identified. Building on the work of the GP Five Year Forward View, the long-term plan continues to support the increase in the numbers of doctors in primary care as well as enhancing the skill-mix with other professionals such as pharmacists, counsellors, physiotherapists and nurse practitioners.
Primary Care Networks, in building their expanded multidisciplinary teams, will be able to fund additional staff such as clinical pharmacists, link workers, physiotherapists, physician associates and, over time, community paramedics.
Newly qualified nurses and doctors entering general practice will be offered fellowships lasting for two years as recommended by the GP Partnership Review.
There will also be a new indemnity scheme for GPs backed by the Government from April 2019 responding to concerns about rising indemnity costs and extending the scope of cover.
Issues that have not been addressed
There are two main areas which have not been addressed as part of the long-term plan for the NHS.
Social care — there is no extra funding for this sector although a long-awaited paper on care for adults and older people with social care needs has been anticipated since the autumn of 2018.
Apart from public health initiatives that the NHS can directly implement, other public health activities under the jurisdiction of local authorities are not mentioned.
System-wide working will be central to the delivery of the long-term plan. Local health systems will have 5-year indicative allocations of funding from 2019/20 to 2023/24 and will be asked to agree local plans for implementing the actions described in the long-term plan.
In parallel, NHS England and NHS Improvement will be working under a shared operating model, focusing on shared regional teams and supporting service improvement and transformation.
To enhance engagement of patients and the public an NHS Assembly will be established in early 2019. This Assembly will bring together a wide range of bodies, groups and individuals regularly to advise the boards of NHS England and NHS Improvement to help in guiding the implementation of the long-term plan.
Legislative changes were proposed by the Plan, such as sharing CCG and provider duties and the development of integrated care trusts, however this requires Parliamentary time which is currently occupied with Brexit issues.
http://www.longtermplan.nhs.uk/ January 2019, NHS England
https://www.england.nhs.uk/five-year-forward-view/ October 2014, NHS England