Key questions the ten-year plan will need to answer

On the eve of its publication, we reflect on some of the burning questions we hope the plan will answer.

1. Left shift: The ten-year health plan needs to be the catalyst for finally making the left shift happen (increasing the proportion of NHS investment and activity going into primary and community services). The plan should include a credible account of how to make progress, starting immediately to support recovery (based on examples of where this is already happening) and accelerating over the next few years to support reform. Central to this should be significant changes to financial flows – and the metrics which underpin them – to support greater delivery of activity that is preventative, delivered closer to people’s homes and therefore more cost-effective. 
2. Prevention interventions: As well as providing the financial and regulatory incentives to invest in early intervention and preventative services, the plan should empower system partners – including NHS, local government and voluntary, community and social enterprise (VCSE) organisations – to direct money towards the most effective interventions, many of which sit, for example, within children and young people’s services and mental health services, as well as the most cost-effective settings, such as primary care. An immediate priority should focus on vaccination programmes that are one of the most cost-effective ways to save lives, improve health and support long-term prosperity, but there is a risk of uptake falling amid NHS reorganisation, as happened during the 2012 Lansley reforms.
3. The wider determinants of health: We welcome steps to increase healthy food options and uptake in supermarkets. However, this needs to be part of a strong and wide-ranging approach to reducing harms which should encompass alcohol, gambling, young people and social media, as well as healthy food. It is also vital to recognise the social determinants of poor health and health inequalities in areas such as poverty, debt and housing. However far the plan goes, this needs to be part of a strengthened whole-government commitment to addressing social harms, reinforced by clarity over where responsibility for wider prevention sits locally.
4. Data sharing: To have the best chance at improving efficiency and quality of care, the NHS needs to be brought into the digital era. But to get the most from digital technologies, the ten-year health plan should focus on getting the basics right in terms of data sharing, quality and interoperability across providers. Data sharing will be essential to unlock the full potential of digital tools and data analysis that are needed to deliver the most effective population health management approaches. A specific change that would support a system-wide view of data would be to remove the sole data controller responsibility from general practice, so it becomes a shared role across primary and community providers.
5. Neighbourhood health: We need a new model of care which is community engaged, enabling, personalised and holistic. This must be delivered at neighbourhood level and must focus on those most at risk of mental and physical ill health. Neighbourhood health is not a new concept and is being invested in by integrated care boards (ICBs) in areas such as Dorset and Derbyshire. But for neighbourhood health to thrive, the ten-year health plan must go further than setting up multi-disciplinary teams. Neighbourhood health requires integrated infrastructure and a shared endeavour across a range of partners and professionals, including leaders from across the full range of primary care (including general practice, community pharmacy, dentistry and optometry) as well as local government and the VCSE sector. Strong partnerships should enable aligned commissioning and contracting, shared data, digital capabilities, population health-informed risk stratification and leadership strategies that connect neighbourhoods to system priorities. Regardless of which organisation becomes the neighbourhood health provider, building a strong primary care at scale infrastructure will be essential to supporting increasingly fragile primary care providers and achieving the left shift and neighbourhood health.
6. Strategic commissioning: We also support the renewed focus on strategic commissioning led by integrated care boards. ICBs will play a vital role in shaping the way care is delivered by investing in more preventative care closer to people's homes, improving population health and delivering best value for money. We hope the plan will include a clear description of how ICBs can harness the collective power and expertise in the system to design services for outcomes, not activity. This will need to be backed up through an effective development programme to ensure that ICBs are supported to deliver against their new objectives. 
7. Workforce: The government should be upfront about the fact that the changes under the ten-year health plan will place different expectations on the current and future NHS workforce. To ensure the workforce is equipped to deliver the three shifts, we hope the plan will include a comprehensive review of education and pave the way for multi-professional contract reform in the longer term. Health leaders accept that they must dramatically improve the experience of our people so that all parts of the workforce consistently experience an equitable, valued and flexible employment. Best practice needs to be built on and scaled. For example. Midlands Partnership University NHS Foundation Trust successfully piloted a flexible working scheme in community nursing, which is now being adopted more widely across the trust and shared across other community teams nationwide. Health leaders are also committed to ensuring that all parts of our communities can access all careers in the NHS; much work is already taking place to help ‘left behind communities’ access the careers on offer in the NHS.  We look forward to this gaining further support in the plan, not least as a key contribution of the NHS to improving the health of the nation.
8. Capital: Healthcare leaders need clarity on how they can secure the capital funding that local services need to transform services and models of care, enabling them to deliver care in more effective and productive ways. This capital funding is essential in primary and community settings to meet the government’s ambition of delivering a neighbourhood health service. But capital may remain an area of unfinished business in the ten-year plan. We know from the Spending Review that capital budgets have remained largely the same, as announced in the autumn. We have also heard senior NHS England colleagues talk about plans to introduce an off-balance-sheet capital investment model. We need to learn the lessons of the past with PFI, but there are effective investment models out there that the government could deploy to boost capital spending on buildings, equipment and other infrastructure. We look forward to working with NHS England and the government to develop these model(s).
9. Operating model: The plan should contain a clear operating model which devolves power to the most local level. The plan must place communities at the heart of these reforms and empower them with greater choice and with the tools to be active agents in their own health and wellbeing, as well as in the design of public services. To make the NHS fit for the future, the NHS’ foundations have to be rebuilt as a partnership between the government, the NHS and the public.  Local leaders also need greater autonomy over how the changes are delivered, while being held to account for a set of outcomes. 
10. Clarity on the new foundation trust regime: As the Secretary of State confirmed at NHS ConfedExpo last month, we expect the plan to usher in a revival of the foundation trust (FT) model ‘for the modern age’. Provider leaders need clarity on how this regime will operate and inclusion criteria given concerns over finances and performance across the sector. The suggestion at ConfedExpo was that FT status would be dependent on collaboration with other providers to drive vertical intervention models, focusing on outcomes, the left shift and improving population health. Learning from the history of Monitor, consideration should be given equally to finances and quality/safety as measures of high performance. Whether in the plan or in subsequent guidance, provider leaders need clarity on how they will be supported to achieve this new FT status and what the pipeline will be into becoming integrated health organisations (IHOs).
11. Resetting the relationship with the public: To recover the NHS and successfully embed a new model of care will require resetting the NHS’ relationship with the public. The expectations of both ‘parties’ will change as part of a reciprocal relationship or ‘compact’. The system will give citizens greater ownership and choice over the care they receive and equip them with knowledge to improve their health and wellbeing. In return, greater responsibility will be placed on citizens. For example, this means accepting that the greatest support will need to be given to those who need it most, such as those who need to see the same GP for continuity of care due to co-morbidities; and requiring the public to wholly embrace new initiatives such as patient-initiated follow pp, that puts the patient back in control of their health and reduces unnecessary demand on the NHS. This model should be anchored to citizens through optimising the trusted organisations and familiar expertise that are already rooted in communities – general practice, community pharmacies and local VCSE organisations. 
12. Delivering the vision: We understand that the ten-year health plan will not be accompanied by a detailed implementation plan and some details will emerge in subsequent plans, including the Long Term Workforce Plan and mental health and cancer plans. However, some detail on implementation/delivery will be essential to give local leaders enough information on how they will be supported and enabled to drive forward the envisaged changes.