The long term plan has a wash of warm words about working with the voluntary and community sector but no definite intent to direct commissioning pounds that way, notes Don Redding
There are so many plans within the Plan that it feels like a supermarket sweep of initiatives, but there is one set of changes here that could potentially be profound for the people who make most use of healthcare – the rollout of a new comprehensive model for person centred (“personalised”) care.
Embedded as part of the “new service model” described in Chapter 1, personalisation should be seen as the central mechanism in the tilt towards primary and community care, that aims to equip, support and empower people to manage their health and health conditions successfully enough to stay away from inappropriate urgent and emergency care.
Systematic reviews told us a decade ago that people with continuing conditions can be supported to learn how to manage these; to participate in decisions about their health and care; and thereby both to achieve the most appropriate courses of treatment and management, and to make the best use of healthcare resources.
Approaches and interventions
There is a range of approaches and interventions that can help, including education for self management, shared decision making, peer support, health coaching, and “small steps” behaviour change. And there is a clear business case for many of these, most recently explored in the Realising the Value programme.
More recently, personal health budgets and social prescribing have become increasingly established as “real world” attempts to increase people’s control, and create access to the non-clinical as well as clinical support that is fundamentally important to people’s emotional, social and physical health.
National Voices’ 140 member charities have been calling for this “new deal” since 2011, only to see NHS plans reference it and then fail to deliver: for instance, the original Mandate to NHS England required it to achieve a “radical” increase in people’s ability to self manage.
More recently, personal health budgets and social prescribing have become increasingly established as “real world” attempts to increase people’s control, and create access to the non-clinical as well as clinical support that is fundamentally important to people’s emotional, social and physical health
What has been lacking is a way to embed this as the “normal” care that people with long term conditions should experience. The “comprehensive model” is serious, backed by a detailed action plan (forthcoming) and will be the most significant attempt yet to move towards a health service that supports people’s own management of their health.
Now the “ifs” and “buts”! First, this new model will only progress if there is a strong drive from very senior levels to position it, not just as one of a thousand “things to do”, but as the new way of doing mainstream care.
Second, the concept of “supported self management” should be seen not as single intervention but as the framing that ties together what, in the Plan document, appear as disconnected workstreams.
The new commitment to tackle health inequalities, for instance, should mean targeting personalised approaches to those with the highest burden of ill health and lowest “activation”, who have most to gain.
The “prevention” initiatives won’t work with people with low health literacy and poor decision making, unless there is coaching and support for small steps towards behaviour change and greater control.
The examples of self management education mentioned in the Plan – specifically for people with diabetes or COPD, for example – should not be silo-ed. Many people with these conditions have multiple conditions, and self management education should be available and properly commissioned for all.
Similarly, the pledge to provide proper personalised care planning at the end of life is welcome, but should be a natural extension of a care planning approach that is the “gateway” to personalised care for everyone who needs it, along the life course.
The long-term plan is overwhelmingly centred on STPs/ICSs, but these are too remote for the coalface work of quality improvement, culture change and the retraining of staff which personalisation requires
The care planning consultation is where people define what matters most to them; work with a partner to identify the menu of treatment, care and support to achieve their goals; and are signposted onwards (through clinical pathways, commissioned interventions like health coaching, or community support).
While NHS England ultimately wants millions of people to have personalised care planning, it remains confused about how.
Some local areas, such as Newcastle and Gateshead where the majority of general practices now offer care planning for people with long term conditions, have shown this is possible in mainstream primary care.
NHS England has yet to back that general practice as the setting for this. Or to say whether it prefers people to have a clinical or “community” partner. And the draft new Standard Contract appears to require every NHS provider to do care planning – a recipe for confused patients to have multiple plans.
The long-term plan is overwhelmingly centred on STPs/ICSs, but these are too remote for the coalface work of quality improvement, culture change and the retraining of staff which personalisation requires.
Primary care networks might be the more appropriate layer for care redesign of this kind; and should be properly funded and supported as the engines of population health, personalisation, prevention and equity.
Finally, like the Five Year Forward View, the Plan has a wash of warm words about working with the voluntary and community sector but no definite intent to direct commissioning pounds that way.
You can’t have community engagement in governance, codesign of new models, support to tackle health inequalities, delivery of self management support, and provision of social prescribing, all for free.
If the NHS again fails to make genuine, equal, respectful and co-productive partnerships with other sectors, nothing in this Plan will succeed.