COVID-19 is the biggest challenge the NHS has faced in its 72-year history. The impacts of the pandemic on people’s health and the health service are likely to be felt for many years to come. In this context, it is no surprise that the NHS’s previous plan for improvement and reform has been significantly blown off course. Our assessment of progress against the headline ambitions of the NHS Long Term Plan illustrates how no part of the NHS has been unaffected by the pandemic.

The impacts of COVID-19 are not all negative: some progress has been accelerated, most notably in digital access to services – though these changes come with risks and may have unintended consequences. Fledgling PCNs have played a vital role in delivering vaccinations on a massive scale. And the principle of collaboration underpinning the recent direction of NHS policy was activated on a large scale as the health and care system rapidly reorganised services.

But in many other areas, the overall picture is one of major delay, disruption and increased demands on services. There have been delays to new community rapid response services, developing new waiting time standards, and developing new services within PCNs. There has also been serious disruption to elective care and screening, and a major backlog of people waiting for routine treatment is compounded every day by limitations on services while the virus remains in circulation. The need to make progress on existing priorities has also been amplified – including the need for stronger action to address the heath inequalities exacerbated by COVID-19.

What does this all mean for the future direction of the NHS? How should priorities be refocused? In this section, we draw out the implications from our assessment of progress against the long term plan for NHS policy and priorities as it plans its recovery from the pandemic.

Waiting times

There are insufficient resources to address the growing backlog and lengthening waits

The health service’s response to the acute phase of the pandemic has been widely praised. But it has come at heavy cost. Some routine services were deprioritised or suspended entirely at the height of the pandemic. Where non-COVID-19 services continued, they were redesigned to support infection control, which reduced the number of patients that could be seen. The crisis erupted into a hospital sector that was already struggling to reduce waiting times. As services started to recover from mid-2020, the numbers of patients newly referred onto waiting lists were added to the numbers of patients whose treatment was postponed because of the pandemic.

The result is a large and growing backlog: the number of people waiting for routine hospital care in England has now reached 5.45 million. There is limited evidence available about the experience of patients waiting. Insights from patients collected by National Voices suggest that many people on waiting lists are anxious and concerned about their conditions getting worse. Other research suggests that delays to surgery are likely to have serious consequences: higher mortality in cancers, and worse outcomes for patients needing joint replacements, to take just two examples.

The long term plan devoted limited attention to the challenge of reducing waiting lists, based on a calculation that the additional funding for NHS services would enable a year-on-year improvement. It instead offered a vision of progress in outcomes against major diseases, such as cancer and stroke. But the pandemic is likely to have had a major impact on many of these goals.

Take cancer as an example. Cancer charities are concerned that the disruption caused by COVID-19 may stall or even reverse improvements in cancer survival across the UK. Achieving the long term plan commitment to increase early diagnosis of cancer may take much longer than expected, given the cumulative impact of delays to urgent referrals, suspension of screening services, increases in emergency presentations, and the backlog of over 62-day waits. A cancer recovery plan has been launched by NHS England, but cancer charities argue that government needs to do more than just return cancer services to pre-pandemic levels. Delivering earlier diagnosis, getting clinical trials up and running again and building personalised support for cancer patients will need sustained action. This includes investment to address the shortages in workforce and diagnostic capacity already apparent before COVID-19. For example, Cancer Research UK has estimated that an additional 41,000 clinical staff will be needed by 2029, over and above existing planned increases, in order to deliver improvements to services.

New pressures from COVID-19

For mental health services, COVID-19 will have directly generated additional demand beyond that envisaged in the long term plan. Estimates vary, from 10 million people needing new or additional mental health support to 1.8 million people with new, recurring or worsening mental health problems over the next 3 years. Mental health charities report a surge in demand for help, driven by the impact of the pandemic, including bereavement and loss of employment. The Royal College of Psychiatrists has warned that progress on some wider national policy goals has stalled, including reducing out of area placements, reducing waiting times for eating disorders and expanding physical health checks for people with severe mental illness. As with cancer services, workforce shortfalls are hampering progress, with 71 new consultant psychiatrist posts expected be recruited on current trends, against a target of 470 by 2023/24, and 257 mental health nurses by the same date against a target of 7,000.

COVID-19 has also created novel sources of pressure on NHS capacity. The national vaccination programme is an unexpected additional demand on resources, which will likely need to be maintained in some form for the foreseeable future. This will have implications for general practice and PCNs, which have been central to the success of the programme thus far. At the same time as running a large proportion of the vaccination programme, demand for general practice had rebounded in excess of pre-pandemic levels, leading to warnings of burnout from the profession. A well-functioning general practice sector is central to many of the long term plan goals, including early cancer diagnosis and health care for those with learning disabilities, and people in care homes.

General practice will also be the first point of contact for those with chronic side effects from COVID-19. NHS England has allocated £100m for ‘long COVID’ care, including £30m for general practice. The National Institute for Health and Clinical Excellence has published guidance on the range of staff who might be needed for these services, including specialists from respiratory medicine, physiotherapy, occupational therapy, psychiatry and rehabilitation medicine. All these services will need to be provided in addition to existing long term plan priorities, and as the virus continues to circulate, the numbers of patients will undoubtedly increase.

The government has recognised these challenges and has increased funding, but considerable uncertainty remains about the extent to which COVID-19 will continue to disrupt services. In March 2021, the government announced a cross-government recovery plan for mental health and wellbeing. This included details of an additional £500m to be spent in ‘recognition of the pressures mental health services are likely to face in the coming years’. At the same time it also released £1bn for the first half of 2021/22 to reduce the elective care backlog. The experience of the 2000s shows that the NHS and its staff can reduce long waiting times, given sufficient time and resources to do so.

In September 2021, the government announced additional funding for the NHS to clear the backlog, amounting to an extra £2bn a year from 2023/24 to 2024/25. Projections by the REAL Centre suggest that, to put the NHS on course to clear the backlog by 2024/25, NHS England's budget needs to increase by a minimum of £7.1bn in 2022/23. This would cover increases in underlying pressures, the costs of implementing existing long term plan commitments and meeting increased demand for mental health services – but does not include the immediate costs of dealing with COVID-19 or, crucially, any ongoing impact of the virus on the NHS’s ability to deliver care.

Prevention and inequalities

Stronger NHS action and broader measures are needed to tackle inequalities

Addressing the major backlog in elective care is likely to be a highly visible and political priority for the NHS as it recovers from the pandemic. The Prime Minister has said that his government will do ‘whatever it takes’ to ‘beat the backlog’. But there is a risk that wider objectives – particularly those that lack clear goals and measures of progress – receive less attention.

Before the pandemic, the long term plan made ambitious statements about increasing the NHS’s role in tackling health inequalities and preventing ill health. But the plan was lacking detail about how this would be done beyond specific goals on smoking, alcohol and obesity. Local 5-year plans – backed by the allocation of funding according to unmet need and the development of a new set of inequalities measures – were intended to be the primary vehicle for NHS action on inequalities. But the ICS planning process had already been delayed prior to its suspension at the outset of the pandemic, and the new measures have still not been published. Previous versions of these 5-year plans focused primarily on individual level approaches to disease prevention and few included interventions addressing the wider determinants of health.

COVID-19 has exposed and amplified existing health inequalities in England, with the most socioeconomically deprived communities facing the greatest risks to health. National NHS leaders have responded by setting what actions local areas should be taking to reduce health inequalities as part of the COVID-19 recovery, such as restoring NHS services inclusively and strengthening leadership and accountability. But detail on how these actions should be delivered is limited and it is unclear how much progress has been made. A more detailed framework of priorities, interventions, and measures for NHS agencies on tackling inequalities will be needed to ensure that greater awareness of inequalities is translated into tangible action to reduce them.

NHS services for smoking, alcohol and obesity are resuming post-pandemic, but comprehensive action to address these risk factors is also dependent on wider central government policy, which has been affected by the pandemic. The publication of next steps for delivering on the government’s ambition for a smoke-free society, for example, was delayed by the pandemic and was expected as part of the new Tobacco Control Plan for England due in summer 2021. The 2021 Budget announced over £70m for weight management services, with investment to be focused on parts of the country most affected by COVID-19.

The NHS cannot prevent disease and reduce inequalities on its own. Greater action on prevention and inequalities within the health care system must be supported by a much broader range of public policy interventions designed to give more people the opportunity to live a healthy life. The government has announced a white paper on ‘levelling up’ for later in 2021, but it is not clear whether it will cover health. Government currently has no national strategy for reducing health inequalities in England. And, after the allocation of the public health grant of £3.3bn for 2021/22, local government faces a real terms per capita reduction of 24% compared with 2015/2016.


Service changes made during COVID-19 need evaluation to prevent widening inequalities

As part of the COVID-19 response, a number of long term plan commitments were accelerated – notably, improving access to online consultations in primary care and reducing the number of face-to-face outpatient appointments. The almost overnight switch to online and mainly telephone-based services in the NHS was hailed in July 2020 by Matt Hancock as one of the successful and irreversible changes brought about by the pandemic: ‘From now on, all consultations should be teleconsultations unless there’s a compelling clinical reason not to.’

However, it would be premature to ‘lock in’ the current volume of remote appointments in primary and secondary care until more is known about their impact on both patients and staff. Public polling suggests that people with experience of technology-enabled care during the pandemic were generally positive that their care had been able to happen, but most believed it was no better than face-to-face care and some thought it was worse. A similar mixed picture has emerged from research with patients. A survey of patients using mental health services conducted by Mind during 2020 found that 49% of patients who took up the offer of mental health support on the phone or online said it was easy to use, but 35% reported finding it difficult, often because of unreliable technology. An exploration of the experiences of patients known to be ‘digitally excluded’ because of poor access to technology found that remote access to general practice brought benefits for some, for example carers or patients with mobility problems, while others struggled to navigate remote booking systems and failed to access care.

There is also limited understanding of the impact on staff of using remote methods to consult with patients. Researchers who modelled the impact of digital-first consultations in general practice found it had the potential to increase workload by up to a third.

Robust evaluation of the complex service changes introduced during the pandemic will be needed to understand what worked, for whom, and in what contexts. There are real risks that inequalities in access to care could be widened, because not all people have access to technology, have enough digital skills, or live in homes where private consultations cannot take place.

Delivering improvements

Creating new structures will not be enough to deliver improvements

The long term plan was based on the idea that greater collaboration would improve care and manage resources more efficiently. NHS leaders have made progress in establishing the new structures designed to deliver this: PCNs and ICSs. 1,200 PCNs were established in 2019, and NHS England announced that 42 ICSs had been created by April 2021. New legislation is likely to put ICSs on a statutory footing from 2022.

But these new structures are still early in their development and there is a risk that the expectations being placed on them are unrealistic. Past evidence from ‘large scale’ general practice suggests that implementation will take several years and – even then – clinical or financial benefits are not a given. Evidence is also limited that closer collaboration between organisations and services improves health outcomes. Both PCNs and ICSs will require time and resources to operate effectively. Establishing new agencies is something that the NHS is good at, but making collaboration work in practice depends on culture, management, resources, and other factors. Organisational change in the NHS risks disruption. It is still unclear how ICSs will operate and what role PCNs will play in the new NHS structure.

PCNs have played a central role in delivering COVID-19 vaccines, but the implementation of other planned services has been delayed and expectations for PCNs will need to be reset. The role that ICSs have played since the long term plan is more challenging to assess. Lack of transparency was a key concern in the early development of STPs. An STP ‘dashboard’ was produced – once – in 2017, but the metrics to assess performance were skewed towards hospital care and the overall ratings produced were contentious. If ICSs are to become statutory bodies, clarity on their objectives and how they will be assessed and publicly reported is essential. NHS England has produced a framework on how ICSs will be assessed and managed, using more than 70 performance metrics, but it is not yet clear whether these will be published.

More broadly, data on progress against the objectives in the long term plan were difficult to find and the available metrics often fail to align with the original commitments. Metrics on alcohol care teams, for example, are based on the number of hospital sites with services, rather than the number of trusts with comprehensive services. Data on participation in the Diabetes Prevention Programme is based on offers of participation rather than acceptance of support. Plans for a metric on SDEC utilisation have not yet led to published data – and progress reported by NHS England is at odds with reports from the Royal College of Emergency Medicine, Society of Acute Medicine, and others. There are some exceptions, such as the Mental Health Dashboard, which contains some data at ICS and CCG level, and shows progress against national targets. The National Cancer Registration and Analysis Services also publishes a wealth of data, much of it available at sub-national levels. Future national plans for the NHS should have clear measures of progress that are transparently tracked and reported.

Wider spending and reform

Progress depends on wider government spending and reform

The long term plan made clear that progress in achieving the NHS’s objectives could only go so far without additional policy action and investment from central government. Improving NHS services depended on government investment in education and training budgets and decisions on NHS capital spending. And improving people’s health depended on adequate investment in social care and public health services, and wider policy action to improve social and economic factors that shape health. Yet government action on these issues has been limited and largely short term.

For the NHS, the most glaring gap in government support is the continued omission of a fully funded, long-term plan for expanding and supporting the NHS workforce. The addition of manifesto commitments on workforce, such as the promise of 50,000 additional nurses, is not a substitute for this. Increasing the nursing workforce will need to take account of varying patterns of regional workforce demand and respond to demographic shifts in the nursing workforce (such as the implications of an ageing community nursing workforce).

Praise for NHS staff has yet to be translated into a comprehensive programme of reward and support. The pandemic has seen many NHS staff working under enormous pressure for an extended period, leading to growing concerns about retention and health and wellbeing. The government’s response to the pay review body report has not resolved broader questions about the value the government attaches to the work of all NHS staff, particularly nurses and other non-physician roles. While COVID-19 has raised interest in NHS careers, recruitment will continue to be constrained by the time taken to train new recruits and limited funding for expanding training places. Relying on international recruitment to plug the gap is complicated by COVID-19, as well as the post-Brexit immigration system.

Although a 5-year Health infrastructure plan has been published for the NHS, without a long-term funding commitment this remains incomplete and largely aspirational. There is no long-term certainty over funding for local government public health services, while other broader national strategies for improving health have been delayed during the pandemic. Government plans for levelling up the country after the pandemic have been largely silent on health.

Successive prime ministers have made commitments to ‘fix’ adult social care, but plans have only now partially emerged. After repeated delays, plans for a cap on social care costs were announced in September 2021. While a bold and positive step forward that will start protecting people from incurring catastrophic costs, this falls well short of what is needed to stabilise the current system and deliver the comprehensive reform needed to increase access and improve the quality of care.

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