Relatively small increases in NHS funding in recent years have contributed to the workforce pressures facing the health service today. Extra funding promised as part of the NHS long-term plan - and the insight into how it will be invested - are therefore welcome.
The New NHS Alliance also recognises that the plan has some good, evidence-based ideas. However, overall we are very concerned that people and community-centred approaches to improving health are absent.
The key points we welcome include:
- The renewed NHS focus on health inequalities, issues that matter to so many of our communities. The plan asserts that it will produce (with PHE, VCSE & Local Authority partners) a ‘menu’ of evidence-based interventions to tackle health inequalities. We call upon NHS England to include the New NHS Alliance’s resident-informed Health Creation framework and the invaluable work from Professor Sir Michael Marmot.
- The emphasis on personalisation. We consider this a positive step forward; an individual and their health and wellbeing needs must be at the heart of any decisions we make about supporting them.
- The revived interest in tackling learning difficulties, homelessness and mental health, key contributors to health inequalities.
- The boost to primary care with a long overdue commitment to more community nurses and health visitors, critical partners in the cross-sector collaborations needed to address health inequalities.
- The boost to health tech. There is no question that this can empower citizens all sectors of society and make care safer and more efficient.
- The promise that adult social care funding 'not impose any additional pressure on the NHS over the coming five years’. Although, sadly this suggests that the coming green paper on social care will not reverse the impact austerity has had. This is a critical barrier to effectively addressing health inequalities.
- Finally, New NHS Alliance welcomes the fact that the plan does not assume that interventions at a local level will reduce hospital demand.
While we welcome these aspects of the plan, we have some significant reservations. There is no workforce plan at this stage - although that is promised later. And, as the National Audit Office trenchantly points out, the funding - welcome as it is - is insufficient for the ambitions of the plan.
However, community deficit is our greatest concern. The plan fails to recognise that harnessing the ‘renewable energy’ of people and communities is perhaps the most sustainable form of prevention there is.
We know that community and people-centred approaches protect health, promote wellness, help to tackle health inequalities and help make statutory services more responsive.
It is now widely accepted that, to stay well, people need sufficient levels of contact with other people that is enjoyable, meaningful and purposeful; control over the circumstances of their lives and the things that affect them; confidence to see themselves as an asset able to have a positive impact on their own and others’ lives. These 3Cs - contact, control and confidence - are the basis of 'health creation'.
Health creation comes about when local people and professionals work together as equal partners and focus on what matters to people and their communities. Health creation enables practitioners to harness the power of people and communities, as described in the Five Year Forward View.
This theme has vanished from the plan, despite a strong evidence base that is supported by Public Health England. This is a missed opportunity that will leave communities and people worse off than they would otherwise be. We shall be working with other organisations and the NHS's Personalisation Group to see this changed.
Many partners outside the NHS are adopting health creating practices to help to tackle some of the more entrenched inequalities that conventional methods (such as smoking cessation programmes) typically don't reach.
For the NHS, all non-NHS front-line providers sectors should be seen as valuable partners. This includes housing organisations, a sector often overlooked by primary care. They often work directly with many of the most disadvantaged communities, increasing numbers of whom have complex needs. The best have developed excellent practice in addressing health inequalities that could be shared more widely with NHS partners.
We recognise that the relationship with local authorities can be difficult. However, taking public health and other local authority health responsibilities back into the NHS is the wrong solution. Fund them more generously instead, giving them the resources to collaborate more fully.
Core NHS organisations also have partnership roles to play, including primary care, mental health, community trust and acute trusts. We see them playing their part in multi-disciplinary teams that tackle health inequalities.
The plan gives no sense that these partnerships are valuable and doesn't encourage NHS organisations to participate in them. This is a missed opportunity, and its absence undermines the prevention ethos of the plan.
We call on the government to require NHS organisations, such as integrated care systems and CCGs, to form partnerships with non-NHS sectors to reduce health inequalities. We also call on the government to support the widespread adoption of health creation among all front-line practitioners.
The roll-out of ICSs, although a vehicle for cross-sector integration, poses risks. One is the risk of privatisation which would result in the private sector planning huge health economies. Another risk is the breakneck speed at which they will be created and set to work, making it impossible to include public involvement. This will continue their so-far undemocratic emergence that has led to much criticism. It will make change more difficult and decisions more inappropriate.
However, we offer a solution. New NHS Alliance is ready to work with local areas to help them find their own ways to tackle health inequalities through health creation, engaging directly with disadvantaged people and communities. This includes the development of a 'wellness workforce' at the frontline of all sectors.
Let’s bring back community. Let’s work with primary care to make health creation a reality. Let’s not let primary care lose sight of the power and benefit people and community-centred approaches can bring.