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Tuesday 21 May 2019
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The long term plan: primary care can and should lead the way

After the digesting the 136-page document, practice manger Daniel Vincent shares his thought on the long term plan and what it means for the NHS, for primary care and for general practice

After the digesting the 136-page document, practice manger Daniel Vincent shares his thought on the long term plan and what it means for the NHS, and for general practice
 
The much anticipated long term plan for the NHS was finally published the other week. We only had to wait until the fifth paragraph of the 136-page document to see the, for primary care, highly anticipated promise in black and white.
 
The promise that with a funding boost of at least £4.5bn a year by 2023/24 ‘investment in primary medical and community services will grow faster than the overall NHS budget’.
 
I have to say that it was a refreshing change not to see the usual focus on secondary care investment, to the detriment of primary care. I was also delighted to see that patients will be able to access 24-hour mental health crisis care via NHS 111.
 
I have long believed that providing better specialist mental health support for patients will have a significant impact on appointment availability in general practice.
 
Fitting a plan for the whole of the NHS into 136 pages is, to be honest, quite an achievement. I have read some criticism about lack of detail, but my hope is that this will give local areas the flexibility they require to truly meet the needs of their population.
 
Overall, I felt there were few surprises in the long term plan and that it aligns closely with the evolution we have led in our locality over the past three years.
 
We see a clear primary care commissioning intention in the plan. It is, for example,  mentioned that ‘GP practices – typically covering 30-50,000 people – will be funded to work together to deal with pressures in primary care and extend the range of convenient local services, creating genuinely integrated teams of GPs, community health and social care staff’.
 
Some have taken this to mean the end of the independent contractor model. I just don't see this. The wording is ‘funded to work together,’ which indicates that there must be multiple practices supporting these 30,000-50,000 patients.
 
These primary care networks (PCNs) will be offered a new 'shared savings' scheme so that they can benefit from actions to reduce upstream activity. The term ‘actions’ suggest to me that this will be activity rather than outcomes-based.
 
The long-term plan also contains a shift when it comes to the focus on prevention, including programmes centred on combating smoking, obesity and type 2 diabetes.
 
If primary care is to survive, we are going to have to move our focus from helping people live longer lives, to helping people live healthier longer lives. This starts before people get sick but very little of the GMS contract currently incentivises this.
 
The plan also comprises an overview of the 3.4% five-year funding settlement for the NHS and it’s stated that while the long-term plan does outline an increased investment in primary and community care, it is not assumed that this funding will automatically reduce the demand for hospital beds.
 
Instead, the long term plan says that hospital funding has been provided for as if trends from the past three years will continue. Any benefits derived from the changes suggested in the plan and from seeing ‘local areas implement the long term plan effectively’ will be treated as ‘a dividend’.
 
We can see that, going forward, the model of choice will be integrated care systems (ICSs). These will be in place by April 2021 and will bring together ‘primary and specialist care, physical and mental health services and health with social care’ in an approach labelled ‘triple integration’.
 
This integration can be delivered through ‘collaborative arrangements between different providers,’ or by giving one core provider overall responsibility for service integration within a particular area.
 
A new integrated care provider (ICP) contract will be available from 2019, for the first time allowing for the contractual integration of primary medical services with other services. NHS England's expectation is that these contracts will be held by public statutory providers.
 
It would appear, from details in the long term plan, that the intention is for these ICP contracts to be held by new NHS integrated care trusts. This would, however, require changes to primary legislation.
 
The issues around digital-first primary care providers are also addressed in the plan, which outlines that over the next five years, it will become an option for every patient to choose an online or telephone consultation over a face-to-face one.
 
As part of this, the NHS has pledged to introduce a new framework to enable digital suppliers to offer their platforms to PCNs, and to ensure that the services offered by such providers are 'safe and create benefit to the whole NHS’.
 
Another focus of the long term plan is mental health. This includes a commitment to a single point of access for patients with mental health problems through NHS 111, and a pledge to reform mental health services for children and young people so they work collaboratively, incorporating services for children, young people and adults.
 
Crucially, the long term plan contains a recognition that, in order to be sustinable, ‘the NHS will need more staff, working in rewarding jobs and a more supportive culture’, with measures outlined to tackle this  – such as the introduction of a new online nursing degree.
 
These were some of the points that resonated for me within the plan. It is fair to say that I’m one of those who feels greatly optimistic about the NHS and I think primary care can and should lead the way.
 
We are, after all, the only unit in the organisation that looks after the whole population.