What was promised in the plan?


The long term plan built on existing goals from the NHS’s previous national plan – the Five year forward view (published in 2014) – and existing national strategies for cancer and mental health. It was structured around the following six themes.

1. ‘A new service model for the 21st century’

The plan promised that outpatient services would be redesigned to reduce the volume of attendances by a third. Local general practices would come together to form primary care networks (PCNs) (each covering between 30,000 and 50,000 patients) and be funded to employ additional staff, intended to achieve a set of targets ranging from earlier cancer diagnosis to action on reducing health inequalities. Community services would receive additional funding to deliver quicker rehabilitation and crisis services. For acute hospitals, action would be taken to improve urgent care, shorten emergency stays, update waiting time targets (via a review of clinical standards) and improve hospital discharge in collaboration with local government.

2. ‘More NHS action on prevention and health inequalities’

The plan committed new funding to expand NHS prevention programmes, including obesity, smoking cessation and to reduce alcohol-related hospital admissions. On inequalities, more accurate allocation of funding to local areas according to unmet need and inequalities was promised. Local ‘systems’ (now called integrated care systems (ICSs)) would be required to draw up plans to reduce inequalities in return for their funding allocations. There would be some national priorities for local systems to include in these plans, such as reducing inequalities experienced by people with learning disabilities, homeless people and those with severe mental illnesses.

3. ‘Further progress on care quality, access and outcomes’

The plan set out actions to improve outcomes for specific diseases and provide better services for particular age groups. On diseases and conditions, the plan promised earlier diagnosis of cancers, expansion of mental health services underpinned by ringfenced increases in funding, and better treatment for cardiovascular and respiratory diseases. Pregnant women, children and people with learning disabilities were promised improved care and better outcomes, while action on behalf of everyone who need planned hospital treatment would reduce long waiting times.

4. ‘NHS staff will get the backing they need’

A multi-year plan to increase the number of staff and boost access to training and development was promised, but not set out. The plan would be finalised once Health Education England had received its funding allocation from government for the following 5 years, and would be consolidated into a comprehensive People Plan. Meantime, the long term plan committed funding for increasing clinical placements until 2021/22 and an international recruitment campaign. There would also be work to improve conditions for existing staff, ranging from increased access to continuing professional development to improvements in the culture within organisations.

5. ‘Digitally-enabled care will go mainstream across the NHS’

The plan promised investment that would bring, over the next 10 years, widespread access to digital services for patients and more patients and clinicians being able to access and manage records online. Better data and analytic tools would be available to individual clinicians and those planning services within ICSs.

6. ‘Taxpayers’ investment will be used to maximum effect’

All the improvements and reforms set out in the long term plan were costed by national NHS agencies and estimated to be within the additional funding allocated to the NHS by government in 2018. Nevertheless, national NHS leaders assumed that productivity improvements of at least 1.1% a year would continue, administrative costs would be reduced and that all NHS organisations would return to financial balance.

Implementation timetable and key events (2019–2021)

The NHS Long Term Plan expected 2019/20 to be a ‘transitional year’. Progress would be made on some commitments and the groundwork laid for the shift towards ‘system’ working, in which many of the existing sustainability and transformation partnerships (STPs) – geographically based groups of NHS providers, commissioners, and local government, responsible for leading local service changes – would begin their transition to ICSs (see section on Integrated care systems). Later in January 2019, local systems received their financial allocations for the 5-year period (2019/20 to 2023/24). In return, they were asked to develop local plans for delivering the long term plan commitments.

NHS England offered to help ICSs with this process, including ‘intensive support for the most challenged systems’. The long term plan emphasised the need for organisations to collaborate to improve care and manage resources, not pursuing objectives to benefit their own organisations at the expense of others. The plan also described the need for legislative change to support progress on delivering its objectives, and set out a series of proposals (including rolling back NHS competition rules and establishing a firmer legal basis for local partnership working), which were put out for wider engagement the following month.

In June 2019, NHS England published an implementation framework, containing detailed guidance for local areas about to draw up their 5-year plans. STPs and ICSs were instructed to complete these by November 2019, and the plans were to be incorporated into a national implementation plan by the ‘end of the year’. This was intended to allow the national plans to ‘…properly take account of the government Spending Review decisions on workforce education and training budgets, social care, councils’ public health service and NHS capital investment.’

NHS England continued to draft proposals for the legal underpinning it argued was needed to deliver the long term plan. In September 2019, NHS England published recommendations to government for an NHS bill, based on the findings of an engagement process that had begun in February 2019. NHS England reported strong support for repealing legislation relating to NHS competition and procurement, and recommended statutory guidance for the creation of joint committees running ICSs.

At the end of January 2020, a year after the publication of the long term plan, the NHS Operational Planning Guidance was published. The guidance noted that 2020/21 was going to be a ‘critical year’ in creating new ways for the NHS to work as a system. The guidance set out a revised timetable for local plans, which had not been published at the end of 2019 as promised. These were now due by April 2020. A people plan was due ‘in the coming months’, after which a national implementation plan would follow.

The arrival of COVID-19

Less than 2 months later, COVID-19 had plunged the NHS into an unimaginably different world. By mid-March 2020, although confirmed COVID-19 cases were still under 1,000 in the UK, modelling was predicting a huge surge of illness and deaths: if no action was taken, health services would be overwhelmed. Even with a combination of suppression measures, such as population-wide social distancing, pressures on hospitals were expected to be severe.

On 17 March, the NHS took widespread action to free up staff and beds in anticipation of the coming surge. NHS England asked hospitals to postpone non-urgent operations for 3 months from mid-April at the latest and to urgently discharge all patients deemed ‘medically fit’ to leave. Community services were given responsibility for leading the care of discharged patients and funding was promised for any social care that might be needed. Hospitals were told to continue emergency admissions, urgent cancer care and other types of clinically urgent services. General practices were also asked to switch as much care as possible to remote forms, with face-to-face consultations only if absolutely necessary. Long term plan deadlines for ICS plans, the clinical standards review and the national implementation plan were dropped.

On 29 April, NHS England paid tribute to the ‘fastest and most far-reaching repurposing of NHS services, staffing and capacity in our 72-year history’, which had allowed the NHS to care for over 19,000 inpatients per day with COVID-19, and continue to deliver other essential services. The letter also noted that there had been steep falls in non-COVID-19 emergency admissions (as well as the expected drop in non-urgent activity) and called for local areas to ‘step up’ non-COVID-19 emergency care and start planning to restart routine elective care, while maintaining capacity in case of a COVID-19 resurgence.

Over the summer of 2020, cases, hospitalisations and deaths from COVID-19 continued to fall. On 19 June, the UK’s COVID-19 alert level was dropped from 4 to 3, meaning that the virus was in general circulation but no longer rising or increasing exponentially. At the end of July, NHS England declared that a ‘third phase’ of NHS pandemic response should begin, with the aim of returning non-COVID-19 services to normal levels as soon as possible, while planning for winter pressures, including a possible COVID-19 resurgence. Some of the long term plan priorities were to be resumed for PCNs, community and mental health services, and services for people with learning disabilities.

During the summer lull in infections, the government announced a major reorganisation of Public Health England, which had led the response to COVID-19 and is also responsible for prevention and screening. On 18 August , the former Secretary of State for Health and Social Care announced the abolition of Public Health England and the creation of a new UK-wide organisation, the National Institute for Health Protection (subsequently renamed The Health Security Agency), to improve the response to COVID-19 and future threats to public health. The secretary of state promised to ‘consult widely’ on the future of Public Health England’s ‘incredibly important’ role in health improvement and prevention.

The second wave hits

There was to be no ‘fourth phase’ letter. Instead, on 4 November, NHS England announced a return to an incident ‘level 4’ (the highest level) in the face of rising cases and hospitalisations. Shortly before Christmas, NHS trusts were advised by NHS England to mobilise all their available surge capacity, prioritise ‘timely and safe’ discharge, and make full use of the independent sector and other available capacity to continue to treat as many elective cases as possible, while maintaining urgent non-COVID-19 services. General practice was urged to maintain pre-pandemic appointment levels, at the same time as assisting with vaccinations, described as the ‘highest priority task’ for PCNs for the foreseeable future.

On 4 January, the chief medical officers of the UK warned that there was a ‘material risk’ of the NHS being overwhelmed within 21 days if no action was taken. The same day, the Prime Minister announced a third lockdown for England.

In its board meeting on 28 January, NHS England’s performance update captured the enormity of the second wave of COVID-19: 33,000 patients with COVID-19 in hospital beds in England, and over 250,000 cared for since the pandemic began. Even though NHS organisations had tried to keep as many non-COVID services open during this peak as possible, the January board papers reported that 200,000 patients had waited more than a year for routine hospital treatment (this was over 330,000 by May 2021).

By early March 2021, cases and hospitalisations had begun to fall again. Government committed to a gradual relaxation of lockdown restrictions, extending the duration of emergency economic support to millions of employees and businesses. On 3 March, the Chancellor unveiled a Budget that added a further £65bn to support the economy over the next 2 years on top of the £270bn already committed. 2 weeks later, the Secretary of State for Health and Social Care announced that the NHS would be receiving an additional £6.6bn for the first half of 2021 to meet COVID-19-related costs. But there was less generosity towards other sectors crucial to delivering the long term plan. The public health grant for local authorities (announced on 16 March) of £3.3bn for 2021/22 represented only a small (£45m) increase on the previous year, and a real-terms per capita reduction of 24% compared with 2015/16.

After analysing the public spending commitments in the Budget for departments not protected by previous funding arrangements (defence, the NHS and schools), the Institute for Fiscal Studies concluded that unprotected budgets faced real-terms cuts of around 3% between 2021/22 and 2022/23. This includes local government, a key partner in many of the long term plan pledges on prevention and reducing health inequalities. The promise to reform adult social care was repeated in the Queen’s Speech on 11 May, but was not linked to a potential bill.

Rising expectations

On 16 March 2021, the government announced its expectations for the health service for the next year, via the 2021/22 ‘mandate’ to NHS England. This included delivering the commitments made in the Conservative party’s 2019 election manifesto, such as 50,000 more nurses, alongside continuing the response to COVID-19 and resuming work to implement the long term plan. Together with a new annex of ‘headline commitments’, the updated mandate added substantially to what the NHS was expected to deliver – with additional priorities effectively set through the inclusion of new metrics to assess progress. The accompanying planning guidance, published on 25 March 2021, specified that local systems work together to support staff recovery, address inequalities, maintain the response to and recovery from COVID-19, and accelerate delivery against the commitments in the long term plan. Despite lingering uncertainty about the future course of the pandemic, ICSs were tasked with developing plans for the year ahead by 3 June 2021.

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