Is the 10 year plan the prescription the NHS needs?

14 January 2019

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by David Morris Public Sector Health Leader

Email +44 (0)7841 784 180

The NHS is struggling to cope - of that there can be no question. The pressure on the service is immense and, despite the efforts of an amazing workforce, the day to day is constant firefighting. Step forward the new NHS 10 year plan, a detailed blueprint for the future health of the sector.

The plan sets out some clear assertions that will resonate with all of us connected to the service - pride in the sector and in its enduring strength; concern about the pressures caused by increased demand and an abiding optimism for the future. It makes clear that it aims to be ‘ambitious but realistic’. These are all worthy statements of intent but what is important about the plan is what’s in the detail and whether the stated ambitions be met by the specific proposals.

Certainly the plan is full and, whilst only 133 pages in length, there is a richness and complexity in the planning aspirations. The following represents a broad appraisal of some of the more salient points. We will be issuing further blogs on other aspects of the plan over the coming weeks.

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Funding uplifts: The annual funding uplift to 3.4% is not insignificant. However, at the heart of the plan lies a significant gamble. The plan proposes that the development of integrated care through Integrated Care Systems (ICS), Integrated Care Providers (ICPs) and Primary Care Networks (PCNs) enabled through population budgets, coupled with new technology and action to reduce clinical variation, can bend the demand/expenditure curve down from its historic average of around 4.5% to a level lower than 3.4%. This outcome would see income exceeding expenditure as it did in the years 2000-2010. If this is the case, then the NHS can recover financial stability and have money to invest in schemes to improve the value of every pound we spend.

The risks are of course real. The cost of labour will increase as the pay freeze returns to pay awards, the price of materials including drugs and services may increase if Brexit stutters and the availability of the workforce required to deliver vital services may drive up, rather than down pay costs as we have to perpetuate bank and agency staffing at higher levels etc.

Furthermore, with an underlying provider deficit of c.£4.3bn and inflation increasing, it is critical the additional funding is put to good use. The development of an ‘accelerated turnaround process’ and a Financial Recovery Fund (FRF) is a positive step forward. Whether the additional focus should only be provided to the 30 poorest performing organisations is questionable although an improved and expanded improvement focus by NHS Improvement is necessary. Organisations will need to relentlessly continue to reduce inefficiency.  The lessons we shared in Road to Recovery, which charts financial turnaround in health institutions, are more relevant than ever.

Recognition of the need for legislative change: In our report, Redrawing the health and social care architecture, we noted the dysfunction of the current architecture governing health and social care. There have been a number of changes over the last few years that have helped to create greater alignment (NHS England & Improvement working more closely together, Department of Health and Social Care providing oversight to social care etc) but as the report notes there will need to be legislative change to help realise the significant organisation change required.

The disconnect between health and local government and the plan has some way to go in proper integration and remains of concern; albeit the ability to enable CCG and local authority combined leadership, as has been seen in Tameside and other places, is a significant step in the right direction.

The flow of money through the system: Addressing how money flows through the system is critical and there are a number of proposed changes to the architecture of funding flows that are significant. Most notably, the shift away from organisational control totals to system wide totals, which was a key recommendation in our report, Making money work, . Whilst this is absolutely welcome and necessary, the critical risk here is how to keep an eye on organisational efficiency when the regulatory focus is diluted between two organisations (NHSI/E and CQC). That said there are early signs of it already working in parts of the country, with the benefits of better alignment outweighing the risks. The move to a population based payment mechanism has been long heralded and an absolute must if we are going to focus on the patient journey and experience and encourage system integration.

Shifting left’ and the increased focus on prevention: This is critical and I imagine music to the ears of Public Health England and its lobbyists. The concern among many was not whether there would be a shift to increased prevention but whether there was going to be the necessary balance on the here and now. This hasn’t been totally answered in the plan and we’ll need to wait and see how it plays out over the coming months but, again, the direction of travel is positive.

Access and performance targets: The plan sets out a number of significant access and performance aspirations across a number of disease groups that if fully implemented would see significantly improved patients experience. What we are yet to see is whether there will continue to be a softening of the access targets stated in the NHS constitution which would allow the bend of the cost curve as stated above. This is a significant political conundrum that is played out annually and there needs to be a firm statement of intent which adequately balances out patient need with the overall availability of resources.

Technology as an enabler to change: Matt Hancock has been a true proponent of the greater use of technology in the sector. Certainly the tech sector is fully geared up to take on this challenge - we meet tech companies on a daily basis offering solutions to some of the most pressing healthcare needs. However, health and tech are not natural allies - making this partnership happen, allowing organisations to invest in future gains and taking the patient with us will all need to be considered as we roll out a digital health future. At PwC, we’re fully behind an accelerating focus on technology enablement, and have invested in new technology, for example Perfect Ward, to support this.

The 10 year plan is certainly welcome and an important tonic in the journey to recovery. The sector needs to get behind it and early signs are that they do. However, let’s use the plan in the way it was intended. Despite the proposed reductions to management costs, let’s invest in making sure the detailed plans required to truly drive change happen and continue to care for, nurture and celebrate the NHS for years to come.

At PwC we are committed to playing our part in supporting the NHS and would welcome your comments.

by David Morris Public Sector Health Leader

Email +44 (0)7841 784 180