The Integrator: Target inequalities, invest in general practice

We’re about two months from the due date of the NHS long term plan, and national directors and outsiders lucky enough to find themselves tied to a workstream are hurriedly engaging, drafting and revising, the next deadline being second drafts at the end of this month.

Twenty-odd workstreams have been named, issued, revised, renamed, reissued; provider chiefs have been allotted; and other luminaries’ names dropped in and dropped out. A consultation document of a sort has been issued. The next decade is being plotted in hours, days and weeks.

The experience of important policy documents in recent years is that the really important bits are worked up in a few days, by a small group of people, and shaped by the individual in charge. Famously in the case of the Five Year Forward View, it was not even seen by the then health secretary until way too late in the process for him to influence it - similarly Next Steps.

Of course circumstances now are different to 2014 – for one thing this is a plan not a view – so perhaps things could be different.

In interesting comments to MPs the other week, new NHS England chair Lord David Prior said: “This cannot be seen to be Simon’s plan. If it is Simon’s plan, it will not work, not least because he may not be here in 10 years. At some point, he will leave, so it is no good having his plan if he is no longer there.”

One feature of this mid phase of the long term plan’s short gestation is a focus on specific conditions and groups. This can help connect with people, lends itself to political announcements, and focuses minds on addressing some real and serious shortcomings. Cancer, mental health and diabetes remain to the fore, cardiovascular and respiratory are back in the mix, and so are learning difficulty and autism.

There is a scramble too for specific eye catching and costed ideas, as part of the jostle for funding.

The big strategic and cross cutting decisions take a lower profile – work on financial system reform, efficiency, legislation, and “system architecture” are left off the literature – and are probably more subject to that last minute decision making and maneuvering.

Thinking about integration, two cross cutting ideas for the long term plan - not radically novel ones - stand out to me as sensible, mutually supporting, and as so far not getting much air time.

One is the suggestion - highlighted by David Buck of the King’s Fund – of an overarching goal for reducing health inequalities, which will be appropriately performance managed, linked to tackling the early onset of multiple long term conditions (or multimorbidity) in particular areas and groups.

It makes sense as a unifying objective for prevention, transformation and integration. Cutting health inequalities can potentially be rewarded through payment systems, something touched on in discussions with vanguards.

The second, related, good bet – and one not consistent with multiple competing bids on central pots of money – would be trusting, investing in, and developing general practice in the places which need it most. Nigel Edwards’ advice on where to start with the NHS’s new funding was to invest in primary and community staff, infrastructure and technology, with a focus on “case finding and proactive models of primary care”.

More radically targeting primary care funding at places with the most severe premature illness and death has long been discussed, both nationally and within areas, but not pursued. As per current plans primary care teams working across larger populations can be grown and developed, providing and coordinating better primary, secondary and tertiary prevention.