The NHS long term plan.

This week, national NHS bodies published their long term strategy for the NHS in England1—a response to the prime minister’s promise of £20.5bn (€23bn; $26bn) extra funding for the NHS (3.4% real terms growth a year for NHS England to 2023-242).

The plan arrives at a gloomy time for the NHS. More people are waiting longer for treatment. Performance targets are being missed all year round. And the system is short of 100 000 doctors, nurses, and other staff.3 Against this backdrop, the plan plots a pragmatic path for the NHS over the next decade, following that set by the Five Year Forward View in 2014.4

The new plan focuses on what the NHS can deliver, and how. In terms of what, the aim is to shift the NHS model of care further upstream: more preventive care, closer integration of services in the community for people with chronic conditions, better coordination of urgent care to reduce demand on emergency departments, and outpatient visits reduced by a third. Improvements are promised in priority services, including mental health, maternity, and cancer. And there is a welcome emphasis on the NHS’s role in tackling health inequalities. Gaps in life expectancy in England are wide, growing, and unjust.5

Much of this shift in care is to rest on technology—for example, on data sharing to coordinate services and target proactive interventions, apps and artificial intelligence to support “digital first” primary care, and telehealth and telecare to support people with frailty.

The plan also depends on familiar ambitions to join up services outside hospitals. General practitioners are asked to work with district nurses, social workers, and others in primary care networks, covering 30 000-50 000 patients. Networks are expected to make “social prescriptions” and provide enhanced support in care homes. In exchange, the share of funding for primary and community services is—we are told—to increase.

But the critical question is how the NHS can deliver it. Here, the plan is less clear.

Resource uncertainty

Although the extra £20.5bn for the NHS is large relative to funding of other parts of the public sector, without big gains in productivity—on which the plan is thin—it is barely enough to keep pace with growing demand.6 Trade-offs, therefore, are inevitable. Emergency departments have missed performance targets since 2015. Targets for elective care are not being met either. Yet the plan is silent on when the NHS will get back on track to meet them. And there’s a hint that expectations may soon change: revised performance standards will be announced in spring 2019, with “new ways to look after patients with the most serious illness and injury.”1

The plan relies on an adequately staffed NHS, yet current staff shortages are chronic and could reach 250 000 or more by 2030.3 A raft of initiatives to tackle this are proposed, but the NHS’s recent record on workforce planning is weak. The budget for education and training—crucial to expanding the NHS workforce—is yet to be decided by government. And its new migration white paper7 risks making the task of attracting health workers even harder.

Ensuring progress

The plan proposes a mix of policy prods and nudges to encourage progress: a revised quality and outcomes framework, new contracts for primary care networks, local quality improvement support, targets for reducing inequalities, and more. But their likely impact based on past evidence is less obvious—as are arrangements for their evaluation.

Accountability for care improvements is also murky. Sustainability and transformation partnerships (STPs) and integrated care systems (ICSs)—partnerships of NHS organisations and local government—are expected to lead local changes. But STPs and ICSs have no formal authority. Although the plan suggests legislative changes to help local partnerships function, time for new legislation is scarce. Meantime, STPs and ICSs must now write five year plans to show how they will deliver the government’s priorities. Déjà vu? The same process happened only three years ago, with mixed results.8 How national NHS bodies will assess and manage performance in a new world of partnerships and systems is also unclear.

While new technologies bring opportunities for improving care, they also bring hard questions. For example, how will digital innovations be evaluated, regulated, and—if they work—spread? And how will they be used to address the NHS’s biggest challenges, such as multimorbidity? Answering these questions must now be a priority for policy makers.

Delivering the plan depends on political choices outside the control of the NHS—particularly on Brexit, social care, and wider social policy. A no-deal Brexit could stall investment in the NHS9 and worsen staffing shortages.3 Ducking decisions on social care funding will pile even more pressure on the NHS. And continued cuts to public health and social services will undermine the plan’s ambitions to improve health and reduce inequalities.

Those looking for an ideological underpinning in the plan won’t find it—it is unflinchingly pragmatic and technocratic. The real question is whether the blend of approaches on offer will be enough in the face of growing pressures on services and major political uncertainty.