Viewpoint: A long-term plan for the NHS: now we need a vision for health, care and wellbeing

In a series of blogs over the past few weeks Christine Heron has been examining the implications of the NHS Long Term Plan (LTP). In this third and final instalment the focus is on making it happen.

The NHS long term plan (LTP) delivers what it says on the tin – a plan for the NHS. The series of measures it presents are largely focused on what is to be done to put the health system onto a sustainable footing for the future and to make improvements on important health and wellbeing issues – like cancer diagnosis, a healthier start for children and mental health.

The Adult Social Care Green Paper was supposed to be published alongside the LTP to present a joined-up approach. This didn’t happen, and the latest aim appears to be before the end of April. It is hard to imagine a less auspicious time to try and tackle an issue that could not be sorted in times of stability.

To pull these strands together, and to move beyond transactional arrangements, a national vision for transforming health, care and wellbeing is badly needed.

One thing a national vision might resolve is the mystery of the disappearing ‘place’.

Workstreams preparing for the LTP apparently explored the three levels of planning and delivery that have been emerging from STP arrangements:

System (ICS) – generally thought to be around 1,000,000 population.
Place – generally the areas covered by health and wellbeing boards/top tier councils/and one or more CCGs, around 150,000 to 500,000 population.
Neighbourhood/primary care networks – 30,000 to 50,000 population.

There were also suggestions that work was taking place to identify what types of service and support were best planned and delivered at each level.

However, in the end, the LTP says much about establishing ICSs and primary care networks across England, but very little about ‘place’ other than that ICSs will have a key role in working with local authorities at place level. It also mentions health and wellbeing boards (HWBs) only once – I previously reported that they were not mentioned at all, but a sharp-eyed person spotted the reference that ‘ICSs and HWBs will work closely together’. The other relevant factor relating to place is that CCGs, which generally work very closely with councils at place level, are to shift to ‘typically’ one CCG for each ICS area. The LTP does not specify a 1,000,000 population for an ICS, probably because some of the most advanced systems are not this size, but we should think much bigger than many current CCGs – in some areas a potentially unhelpful and destabilising move.

Whatever the reasons behind the lack of focus on place, it seems clear that a sensible integrated NHS system – or, preferably, integrated health, care and wellbeing system – can’t operate from the levels of one million population and 50,000 population without something in the middle – which leads us back to place.

So, the coming months will be crucial, as partners further develop ICSs and, for large areas, integrated care partnership arrangements. Different configurations will be needed for different areas, but hopefully they will become more meaningful and coherent for making the shift to prevention, tackling the wider determinants of health and integrated community services than some STPs.

In the absence of a national vision, local areas may find it useful to consider a partnership vision produced through the collaboration of national health and wellbeing organisations in November. Shifting the Centre of Gravity was developed by ADASS, ADPH, the LGA, NHS Clinical Commissioners, the NHS Confederation, and NHS Providers. It sets out a vision focused on people rather than systems or structures and actions for what local leaders can take. Headlines of the vision are: