The much-anticipated NHS Long Term Plan has finally been revealed, promising a wholesale transformation of the health service in England. Nursing Times has unpacked the 136-page document, which sets out how a £20.5bn annual budget increase will be spent, to find out what it means for nurses both current and future.
The plan promises record investment in primary and community services. There is also a new focus on mental health and ambitions to improve outcomes for major diseases like cancer and dementia, as well as neonatal and maternity care. Meanwhile, the document also vows to kick the “digital revolution” of the NHS into full throttle.
While the aspirations have been widely applauded, commentators have already warned that without action to address to current nursing crisis, even the best-laid plans are likely to fail. Sara Gorton, head of health at Unison, said finding more NHS staff and holding on those already in the system was “key to the success” of the plan.
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Likewise, Dame Donna Kinnair, acting chief executive and general secretary of the Royal College of Nursing, warned that current shortages could scupper it. “Translating good intentions into better treatment and care for patients relies on having the right number of nurses with the right skills across our NHS,” she said.
The plan’s authors themselves admit current shortages are “unsustainable” and there are not enough nurses in training to meet demand. The plan’s workforce chapter pledges to reduce the nurse vacancy rate to 5% by 2028 through measure to increase student nurse places and improve retention.
However, the full details of how this vision will be made a reality have not yet been revealed. We must wait for this detail in a separate “workforce implementation plan” later this year.
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Controversially, the plan claims “well-qualified candidates” are being turned away from nursing courses. The plan puts this down to a number of universities having entry tariffs “well above the levels set by other higher education institutions”, though this has been disputed by the Council of Deans. The plan added that in other cases, the “rationalising factor” for rejecting students had been that Health Education England had not been able to guarantee the clinical placements needed.
To boost student recruitment, the plan reveals that the NHS will fund an extra 5,000 clinical placements in 2019-20 for undergraduate student nurses. And from the following financial year, clinical placements will be funded for as many nurse students as universities can recruit, up to a 50% increase. Furthermore, every nurse or midwife graduating will be offered a five-year NHS job guarantee within the region where they qualify.
The document also outlines ambitious plans to establish a new online nursing degree that could be launched as early as next year in a bid to “widen participation” in nurse education. The online offer will be “substantially less” than the £9,250-a-year cost to current students and will come linked with “guaranteed” clinical placements at NHS trusts and primary care practices.
NHS bosses hope this new, cheaper route will help to stem the 40% decline in applications from mature student nurses seen since the removal of the bursary in 2016.
However, the RCN’s Dame Donna said she was concerned the online option had been presented as a “magic bullet to solve the workforce crisis”. “Nursing degrees demand both academic and practical skills which student nurses learn from contact with professionals and peers, a model not easily replicated online, even with clinical placements,” she added.
A new “earn and learn” support premium will also be introduced in a bid to increase the number of mature students studying learning disabilities and mental health nursing. Brian Webster-Henderson, chair of the Council of Deans of Health, said it was “great” to see leaders working to address shortages in these areas but feared it would be at the “behest” of the other fields of nursing.
In addition, the plan vows to continue to invest in the growth of nursing apprenticeships. But as a short-term resolution to staffing challenges, leaders also announced a “step change” in the recruitment of overseas nurses, stating: “We expect that over the next five years this will increase nurse supplies by several thousand each year.”
In a move commended by nursing chiefs, the plan also suggests that the funding tap for continuing professional development (CPD) will be turned back on, with increased investment “each year”. The expected rises will go some way to restoring the CPD budget that was cut by 60% between 2015 and 2017.
Meanwhile, ambitions to shifts care out of hospitals and closer to people’s homes are to be ramped up. In a landmark move, investment in primary medical and community health services will grow faster than the overall NHS budget for the first time in the health service’s 70-year history.
A new five-year contract for general practice means surgery bosses will be able to give their staff, including nurses, a pay uplift. In addition, newly qualified nurses will be offered a two-year fellowship to start a career in general practice in a bid to encourage more nurses to consider primary care as a “first destination role”. Extra cash will also support the creation of new “expanded community multidisciplinary teams” aligned with practices grouped in “primary care networks”.
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The neighbourhood teams will provide care for a population of around 30-50,000 and will comprise a range of staff including district nurses. They will be joined up with those in the social care and voluntary sectors to create what the plan describes as “fully integrated community-based health care” for the first time ever.
This work will also be supported by the development of new urgent response teams who will visit people in crisis in their own homes in a bid to reduce unnecessary hospital admissions. The new teams will be expected to respond to a patient within two hours of a referral.
Dr Peter Swinyard, national chair of the Family Doctor Association, welcomed the re-formation of the primary care team, which he said would mean GPs and practice nurses could reconnect with community workers such as health visitors and district nurses to co-ordinate patient care.
“In recent years, the loss of this communication, along with the reduction in numbers of fully trained district nurses, has severely impacted on the co-ordination and efficiency of patient care,” he added.
Meanwhile, the plan suggested that commissioning of key public health services, such as health visiting, school nursing and sexual health, could revert back from local authorities to the NHS. The Health and Social Care Act 2012 transferred responsibility for commissioning these services to councils – a move nursing leaders claimed was simply “not working”, with numbers of school nurses and health visitors taking a nosedive in recent years.
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Cheryll Adams, executive director of the Institute of Health Visiting, said she was “absolutely delighted” that the need for change had been recognised. She maintained the health visiting profession had been caught in a damaging cycle of “feast or famine, investment and disinvestment” over the past 25 years, and it was time services were put on a sustainable footing once and for all.
Unsurprising, measures to prevent people getting ill in the first place are front and centre of the plan. Alcohol care teams will rolled out in hospitals with the highest number of alcohol-related admissions to support patients to get sober.
In addition, patients who smoke will be “helped to stop” in a new drive that will see all smokers admitted to hospital encouraged to quit, including pregnant women and their partners. The schemes sit alongside action on obesity and diabetes that form part of a “renewed focus on prevention”.
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The plan reveals that funding for mental health services will also grow faster than the overall NHS budget.
“This will enable further service expansion and faster access to community and crisis mental health services for both adults and particularly children and young people,” the plan said. There are also plans afoot to introduce waiting time targets for more mental health services.
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Sean Duggan, chief executive of the Mental Health Network, which is part of the NHS Confederation, said: “The long-term plan represents vital progress towards parity of esteem for mental health services and has come through genuine and meaningful engagement with the sector.”
Mr Duggan added that the new access standards would improve care people received when they were most vulnerable. However, he warned that there were “challenges to achieving this bright vision”, including 20,000 staff vacancies. “It is vital we have the right staff in the right places to provide care, and they need the right facilities to do so,” he added.
The plan vows to do more to tackle “health inequalities” that persist across England, including offering better support to people with learning disabilities and autism. This will include ensuring children and young people with these conditions get “timely care” and continuing with the long drawn out bid to move the majority of care into the community. Staff will be encouraged to make “reasonable adjustments” when treating patients with a learning disability or autism, while premature deaths will continue to be reviewed to identify “common themes and learning points”.
Unsurprisingly, the plan promises to bring “digital-enabled care into the mainstream”, as part of health secretary Matt Hancock’s vision to modernise the health service. For example, all staff working in the community will be expected to have access to mobile digital services over the next three years and there is recognition that “too much” of the technology within the NHS is a “burden” on staff with devices being slow to log in to, clunky to use and unreliable in moments of crisis.
Nurses and other staff will be able to “capture all health and care information digitally at the point of care” if the plan meets its aims. Such moves will allow professionals to increase the amount of time they spend with patients and the number of patients they can see, it said. By 2021, all patients will be able to choose to have a web or video GP consultation instead of a face-to-face one.
However, Jackie Williams, national officer for health at the union Unite, said the increasing the reliance on technology was an area for “concern”. “Unite believes that this is a precursor to requiring nurses to undertake far more work in the community,” she said. “Nurses will effectively become lone workers, which has its own challenges, without the support they can currently enjoy.”
In addition, the long-term plan reaffirms the commitment to cut the number of stillbirths, as well as baby and mother deaths and serious brain injuries by 50% by 2025. To help achieve this, the saving babies’ lives care bundle will be rolled out to every maternity unit in England in 2019. Furthermore, every trust in England that looks after pregnant women and newborn babies will be brought under a “safety collaborative” and will each be assigned a “maternity safety champion”.
The NHS plan also reveals ambitions to ensure “most women” are able to have contact with the same health professional throughout their pregnancy, birth and postnatal period. Extra neonatal nurses will also be brought into the workforce. The document also vows to improve access to and the quality of perinatal mental health care for mothers, their partners and children.
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Gill Walton, chief executive of the Royal College of Midwives, said there was much to celebrate about the plan, but like other unions warned that there was currently a “gap” between the ambitions for maternity services and the reality on the ground, especially in terms of staffing. She said it was “vitally important” that sufficient funding was made available to carry out the improvements and that there was enough midwives and other staff in place to deliver them.
Further details of how the plan will be implemented are expected in the spring to coincide with the government’s spending review, which will confirm the NHS capital budget, funding for education and training, as well as the local government settlement to cover public health and adult social care. Changes are then due to come into force in October 2019.
NHS Long Term Plan – What they said:
Professor Martin Green
“The challenge for the NHS, and indeed the entire system, will be a cultural one”
Professor Martin Green, chief executive of Care England
“Translating good intentions into better treatment and care for patients relies on having the right number of nurses with the right skills”
Dame Donna Kinnair, acting chief executive and general secretary of the RCN
gill walton incoming rcm ceo may 2017
“The plan is honest about the scale of the staffing challenge. But nothing will happen without more money”
Sara Gorton, head of health at Unison
“It is very encouraging to see maternity front and centre of this plan”
Gill Walton, chief executive and general secretary of the RCM
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“My main concern is its statement that thousands of highly motivated and well-qualified applicants are being turned away by universities”
Professor Brian Webster-Henderson, chair of the Council of Deans
“We welcome the acknowledgement that additional ring-fenced investment is needed in community and primary care services”
Crystal Oldman, chief executive of the Queen’s Nursing Institute