The NHS Long Term Plan (LTP) outlines what the NHS in England intends to deliver over the next ten years.
It gives cause for both optimism and opportunity, but it also raises concerns and could represent a missed opportunity for the social care sector.
Both the structural changes to the system and the workforce issues detailed in the LTP will affect the sector. Its genesis recognises concerns around funding, staffing, increasing inequalities and pressures from a growing and ageing population. All these factors herald a need to accelerate redesign across the whole health and care system so that it is properly joined-up and care is given at the right time and place.
While it’s important to note that the Department of Health and Social Care (DHSC) does not own the plan, its publication represents a great opportunity for DHSC to act as the driver of integrated health and social care.
The LTP contains statements of genuine intention to integrate the sectors. GPs will be funded to collaborate with community health and social care staff – to deal with pressures in primary care and extend the range of local services – and NHS and social care budgets will be blended ‘where councils and CCGs agree this makes sense’.
It also promises to ‘boost “out-of-hospital care” and finally dissolve the historic divide between primary and community health services,’ which could be interpreted to include the care sector, but might not. It must be said that some of the statements in the LTP, such as this one, give the feeling that the NHS will take the upper hand with the care sector rather than truly collaborate with it.
The rising acuity of care is recognised, with the LTP stating, ‘Sicker patients are being successfully looked after without hospitalisation by GPs, community health and social care services, none of which have seen their expenditure grow at the same rate as acute services.’ The recognition that acute care can be given in the community effectively and efficiently is positive, but there needs to be greater recognition that acute and complex care is already being given in the community, at home and in care homes with nursing, and this recognition must include the need for this care to be funded.
Integrated Care Systems
Given this context of complexity and a desire to give care closer to home, the system of planning and commissioning needs to change. This will be the remit of Integrated Care Systems (ICSs), which will be created across all of England by April 2021.
ICSs will plan and optimise care and provide more person-centred support by bringing together ‘local organisations in a pragmatic and practical way to deliver the “triple integration” of primary and specialist care, physical and mental health services, and health with social care.’ ICSs will have partnership boards, but it is not clear from the LTP if these will include members from social care.
ICSs should be able to routinely identify gaps in care pathways and commission services to fill those gaps. Greater transparency of health and social care data will also be enabled. This could be an important and useful development for integration, bringing about a flow of data for mutual benefit, but it will be reliant on IT and the right attitudes.
Commitments to the care sector?
There are some commitments in the LTP which affect the care sector directly, but they read as though they are NHS solutions rather than being co-produced.
The LTP recognises that, ‘One in seven people aged 85 or over permanently live in a care home. People resident in care homes account for 185,000 emergency admissions each year and 1.46 million emergency bed days, with 35-40% of emergency admissions potentially avoidable. Evidence suggests that many people living in care homes are not having their needs assessed and addressed as well as they could be, often resulting in unnecessary, unplanned and avoidable admissions to hospital and sub-optimal medication regimes.’
It also states that 70% of people in care homes have dementia or severe memory issues. It goes on to suggest that enhanced community multidisciplinary teams and the application of the NHS Comprehensive Model of Personal Care might help to reduce the number of people living in care homes, by providing more frequent assessments and making them more available to those in the community.
This investment in needs assessment in the sector would be welcome; it is a complex and time-consuming area and needs extra resources if it is to be conducted effectively.
A Clinical Assessment Service (CAS) is also proposed, which will support the public to navigate the best care pathway for them. The CAS will also support care home staff (amongst others) to make the best decisions about supporting patients closer to home and avoiding unnecessary trips to A&E. This service should include professionals familiar with the care sector to ensure its success.
The LTP also confirms a laudable aim to continue to improve performance in terms of delayed transfers of care. NHS England’s Enhanced Health in Care Homes Vanguards have shown that collaboration can reduce A&E attendances and admissions and the hope is that these will continue and be replicated. There is also the promise of ‘extra recovery, reablement and rehabilitation support to wrap around care services and support people with the highest need’, which intends to prevent unnecessary admissions to hospital and residential care. Hopefully, this will be a co-ordinated enterprise with input from both sides of the sector.
Significantly, there will be ‘guaranteed NHS support to people living in care homes’ which needs an ‘upgrade’. This implies NHS support to care home residents is not currently guaranteed or of the necessary standard. Improvement is welcome, although it is not stated how this will be achieved or measured.
Another promise is that of an NHS Assembly, which will be established early in 2019 and will bring together organisations and individuals to advise the NHS as part of the ‘guiding coalition’ to implement the LTP. This is an opportunity for the care sector to be represented, by organisations like Care England, the National Care Forum and Skills for Care.
Workforce issues are acknowledged in the LTP as being of profound concern. There are major worries about the supply of nurses, some allied health professionals and doctors.
Health Education England (HEE) has a strong role to play in the LTP’s workforce ambitions, and it recognises that workforce planning has been too disjointed, stating that HEE will become more accountable to both health and social care employers.
The LTP also admits that NHS workforce growth has not kept up with need and makes the frank admission that staff are feeling the strain. This is undoubtedly true, and some of that strain is because health and social care are still far from integrated. Care staff are also under strain, but the LTP fails to mention the 42,000 registered nurses in the social care sector.
Nursing is bigger than the NHS, and this must be recognised in any actions to remedy nursing shortages. A national recruitment campaign is proposed and it would be short-sighted for this to be solely for the NHS. Having one campaign for the NHS and one for social care really underlines that, despite the rhetoric, integration is not a reality.
Positively, the LTP does confirm that international recruitment of nurses will continue and steps will be taken to ensure the post-Brexit migration system provides the necessary certainty for health and social care employers.
Workforce planning is complex and the LTP commits to its workforce efforts being ‘attentive to both the detail and the wider context’. And there is reason to be optimistic that this will consider social care. There will be a new cross-sector National Workforce Group to include the new Chief Nursing Officer (CNO) for England, and a national workforce plan will be published in 2019.
I am confident the CNO recognises that nursing is bigger than the NHS and that her leadership remit is for the whole profession across all sectors.
To enable the education of more nurses, DHSC is planning a 25% increase in nurse undergraduate places, and an extra 5,000 clinical placements will be funded from 2019/20. The Teaching Care Homes initiative has demonstrated that the sector is an excellent learning environment, and a proportion of these placements must be in social care.
Also detailed in the LTP is a new post-qualification employment guarantee which seems only to apply to the NHS. However, it’s important that, as clinical placements are expanded, the employment guarantee should keep the clinician within their profession regardless of sector.
There is an additional intention to make training more accessible and build on the success of nursing apprenticeships. An online nursing degree for the NHS will be established.
Although this has not received universal support from the profession, if it does gain approval, it should be a source of registered nurses for all sectors and parts of the country.
As a policy document, the LTP is clear about what needs to change but not how it will be done. To explain this, a national five-year implementation programme will be published by Autumn 2019. Local implementation plans are due in April 2019, and the LTP offers assurances that Government is committed to adult social care being funded so as not to impose additional pressure on the NHS.
There are some clear positives and opportunities to take away from the LTP, but without proper consideration of how health and social care can be brought together, some of the promises made may be doomed to fail.
Dr David Foster OBE is Chairman of the Foundation of Nursing Studies. Twitter: @DrDavidFoster
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