The Long Term Plan – what does it mean for integration?

Following the announcement of NHS England's Long Term Plan earlier this month, the RCP has engaged in a week-long discussion covering the plan's most important themes. Today RCP clinical vice president David Oliver, supported by Jayne Black, RCP joint head of policy and campaigns, examines what the report means for integration. 

The NHS Long Term Plan was published on 7 January, with a detailed set of ambitions, priorities and actions to accompany the additional £20.5 billion by 2023/4 going into the NHS. The devil is in the detail.

One key, recurring theme in the NHS plan is that of integration. Integrated care for individual patients is also a key RCP policy theme and we have published a number of related resources. The RCP is equally interested in integrated care systems for the health of local populations, to improve health outcomes and value and reduce variations.

[Integration] will mean care for patients and their families is delivered holistically and in a more person-centred, co-ordinated way, to deliver outcomes and services that meet their priorities

Professor David Oliver, RCP clinical vice president

Integration involves joining up primary, secondary and social care, taking into account both physical and mental health. Crucially, this will mean care for patients and their families is delivered holistically and in a more person-centred, co-ordinated way, to deliver outcomes and services that meet their priorities. At population level, it should make the best use of available expertise and resource within the system, maximise value, minimise unwarranted variation, and reduce duplication and waste. 

So what is in the detail?

Based on the premise that if we started from scratch we would do things quite differently, the Long Term Plan looks at removing the traditional separation that exists between primary, secondary and social care. Aiming to treat and manage conditions largely in the community, providing a more personalised approach for patients, proactively addressing issues as they arise, reducing the need for extended hospital stays and freeing up capacity within secondary care. 

Work has already started locally through sustainability and transformation partnerships (STPs) and integrated care systems (ICS). It will be expanded to the whole of the UK following a recent consultation by NHS England. Each ICS will be required to publish its own plan, though those plans are in turn expected to contain a number of key priorities from the national plan. 

To help deliver more services closer to home, whether proactive and preventative or in response to crisis, there is a planned additional £4.5 billion going into expansion primary and community care services. That includes community multidisciplinary teams and multidisciplinary clinical assessment service being embedded in NHS 111 to reduce emergency pressure.

The RCP is also aligned with the greater focus on multidisciplinary clinical teams in healthcare and welcomes the overdue focus announced in the plan on structured support for the millions of unpaid carers who play such vital and unseen roles

Professor David Oliver, RCP clinical vice president

This will provide greater support to older people with frailty and multimorbidity, requiring rapid crisis responses (within hours) or reablement (within 2 days), closer joint working with ambulance services and wider provision of urgent care centres. 

There is also a plan to expand the use of same day discharge from emergency care. Such ambulatory approaches and acute care models tailored to older people have been promoted by the Society of Acute Medicine and feature in the RCP Acute Care Toolkit and Future Hospital Programme. The RCP is also aligned with the greater focus on multidisciplinary clinical teams in healthcare and welcomes the overdue focus announced in the plan on structured support for the millions of unpaid carers who play such vital and unseen roles. 

How will this be more person centred?

Helping people to self-manage, catching deterioration early and having more support before conditions escalate. We know from the 2017 National Voices report that, although there are some excellent pockets of more person centred care and a groundswell or movement to improve it, its implementation is still patchy, especially for those living with multiple long term conditions, frailty or dementia, or with co-existing physical and mental health problems.

Helping to join up care and changing ways of working, such as patient activated appointments as outlined in our outpatients report, will make a big difference to the experience of care. And the Long Term Plan specifically references our work in its desire to redesign outpatient services for this century, not last. 

Sounds good – what is the catch?

Implementation is going to be key – it needs to work locally and have clinical and patient leadership to make progress. Crucially, it hinges on the workforce. Ambitious plans cannot be achieved without a viable workforce strategy underpinning it. We need clinical practitioners in sufficient numbers with the right skills in the right part of the system and the ability to work more flexibly with better logistical support.

True integration and a focus on prevention and reducing inequalities cannot rely on NHS services alone

Professor David Oliver, RCP clinical vice president

With all the talk of integration and a shift towards prevention, we still await even a Green Paper on social care, and both local government funding and public health services have been repeatedly cut. True integration and a focus on prevention and reducing inequalities cannot rely on NHS services alone.

Finally, it is not clear yet whether an approach based on local plans developed by ICS, but with local flexibility limited by national priorities, can deliver.

On an optimistic note – there will be opportunities for you as members and fellows of this college to contribute in your local area, first to the one year plans in 2019/20. Then, after the government’s spending review, a longer plan will be developed locally and jointly, including clinical leadership and patients. As the plan is bound to affect your own service and role within it, the more you can find out and engage the better. 

Meanwhile, we would love to hear from you how the plan is taking place in your own patch.

Professor David Oliver is clinical vice president of the RCP, working in the Care Quality Improvement Department (CQID). You can follow him on Twitter at @mancunianmedic

This blog is part of a week-long series of discussions focusing on the NHS Long Term Plan. If you have any questions or feedback about the topics covered in these posts please contact policy@rcplondon.ac.uk