The flurry of news reports in response to last week’s release of the NHS Long-Term Plan has all but died down. As we sift through the text of a wide-ranging strategy, we’ve been considering the direction of travel for an organisation older than most of us and about to enter a new digital future.
Some of the implications of the plan are not yet clear. Some initiatives described in it are already well underway in some areas. But with a few exceptions, we believe it presents a positive ten year vision.
Let me highlight the issues from a mental health perspective that we think signal the biggest positive changes.
The Role of the NHS
First, it’s interesting to see policy-makers reminding us that the NHS cannot solve the country’s biggest health issues on its own. It is a “complement to – not a substitute for – the important role of individuals, communities, government and business in shaping the health of the nation.”
This positioning statement is the spine running through the whole paper. It paves the way for a focus on preventative measures aimed at reducing demand. It also lends itself to the strong integration theme in the plan, which sees closer joined-up services and greater co-ordination of care.
And while some may see this ‘shared responsibility for health’ as a way of absolving responsibility and as a precursor to increasing privatisation, an approach based on early intervention and prevention is a sensible one.
If the NHS plan was to include the role of Public Health – an area which needs further investment, and is crucial to realising these ambitions – the cynics amongst us would be, well, less cynical.
A Digital Dawn
The report signals big change in other ways. One of the most obvious is the huge role for digital in supporting the NHS. This is a significant shift and one which commentators have been predicting for some time – and with greater certainty since the appointment of Matt Hancock as Secretary of State for Health and Social Care, an MP known for his pro digital stance.
We welcome this move. Digital has massive potential to integrate and expand our health service and for supporting those working so hard in it, often with antiquated technology.
But it’s not just about ditching fax machines and installing new IT systems.
It’s the capacity of digital systems to join-up services across the NHS while reducing wait times and supporting wide-ranging efficiencies. This potential is already well recognised by NHS England.
In essence, digital can enable an integrated, personalised, more effective and efficient service.
It can also tackle major workforce issues. New models of care create new models of working and with some professionals keen to work flexible hours, they in turn can offer more flexible out-of-hours services, such as online GP appointments.
We have argued for a long time that digital has a big role in scaling up mental health services, enabling early intervention, making children and young person-friendly online services available how and when it suits them. Giving children the skills to manage their mental health and emotional wellbeing is a significant part of the Long-Term Plan’s preventative agenda.
But this is just the tip of the digital iceberg. We welcome the ‘digital first’ primary care option and see this having a big impact on patient satisfaction, on the workforce and for creating efficiencies across the NHS.
And change will not just be seen in primary care; by 2024 the intention is that secondary care providers in England will be digitised.
We hope that digital IAPT services for children and young people (CYP) will include a wide range of interventions, drawing on the pluralistic approach used in our own services, school-based counselling and YIACs. Children and young people need choice.
And in a positive signal to those focused on tech and innovation within healthcare, we were especially pleased to see that APIs will be open and free for developers.
The digital flag-waving and the messages in the report around ‘self-management’ don’t mean we’ll all be cared for by robots and nor should it signal a distancing of the NHS. In fact, we also see digital as having the potential to create a far closer relationship between patients and their NHS. With access to patient records, the promise of greater personalisation and the prospect of more online services being available to complement and support face-to-face services, digital – although it can’t and shouldn’t do everything – has an opportunity to realise positive change.
The plan describes how Integrated Care Systems (ICSs) will bring together primary and specialist care, physical and mental health services and health and social care. This is essential and a move we would welcome in promoting joined-up care in the community and as a basis for moving forward.
Children and Young People from 0 to 25
For us, this was great news. Like many mental health professionals, we have been advocating extending mental health services for young people to the age of 25 for many years; the recognition that transition services needed changing is extremely positive news.
The extension will remove the terrible barriers experienced by many young people leaving CAMHS and moving to AMHS. We do not want to wait until 2023 for this however, and would push for it to be considered a far greater priority. It is key to prevention and offering accessible early help.
We hope to see backing for digital services here too that enable young people to access services on their own terms, anonymously and out of hours. We know that anonymity in particular is valued by young people, including hard-to-reach communities, and a key driver for them getting early, often preventative, help.
It is why we recommended, in response to last year’s Green Paper, that mental health support should also be offered outside schools, in community settings and online. While we support moves to support young people at school or college, not everyone will want help in school hours or will want to incorporate counselling into their school day.
The ambition to open a mental health help-line for adults and young people is a laudable one, needing careful planning and local integration. As a digital and face-to-face provider, we have experience of how difficult this can be. NHS England would need to plan this carefully and roll it out via a pilot programme.
We look forward to hearing more about the new Children and Young People’s Transformation Programme to deliver on the plan.
For adults with severe mental health problems, the plan promises “a new community-based offer… [which] will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use.”
This is particularly positive news and can only be achieved via the ICS model.
We were pleased to see the term ‘trauma-informed care’ as so many adults with longer term mental health needs or/and with medically unexplained symptoms, have experienced childhood trauma.
If we want to support these populations effectively, services will need to deliver more than six sessions of CBT. Digital services working alongside primary and secondary care could deliver flexible therapeutic support working out of hours with access to a multidisciplinary team.
We were pleased to see the promised expansion in the IAPT programme, particularly for people with long-term physical conditions, and look forward to taking part in discussions around how these services could be shaped and developed.
The plan also reflects concerns related to health inequalities, especially noting the known link between income and mental health. This issue was made clear in the recent NHS Mental Health in Children and Young People Prevalence Survey which showed clear evidence of health inequalities for children and young people in lower income households.
What about funding? Unlike some previous plans where funding has not been ring-fenced or has been pledged over time or has not been clearly stated, the plan makes a commitment that “for the first time in the history of the NHS…real terms funding for primary and community health services is guaranteed to grow faster than the rising NHS budget overall”.
Particularly pleasing in view of the preventative agenda is the news that funding for children and young people’s mental health will rise faster than the average for the NHS and more than for mental health services for adults. But, as stated, concerns remain over the role of and resources behind Public Health.
A major weakness of the plan, and a source of much frustration and criticism, is the lack of workforce to support it. There are, however, measures described in it which would help attract more people to the health profession and dissuade others from leaving.
Programmes to increase access to training and a greater use of apprenticeship schemes seems a good start, but progress seems likely to take some time.e
Overall, although the plan lacks detail in some places and in part is dependent on the long-awaited Adult Social Care Green Paper, it paints a bright future.
Similar plans before this one have struck the right note in signalling change and have somehow disappointed. Our hope is that with the future of the NHS at stake, politicians and all NHS stakeholders push for the change the plan promises and help us move towards an integrated, digitised, personalised service – free at the point of need – which we can all be proud of.
Elaine Bousfield, founder, XenZone