Guest blog from Dave Buck, Senior Fellow at The King's Fund and member of the Expert Advisory Group to the Taskforce on Multiple Conditions.
It has taken a while for everybody to digest the NHS long-term plan, a meaty document of over 130 pages and by some counts around 500 commitments. As if that weren’t enough, it has also been followed by a plethora of further detail.
Before the plan, my number 1 ask of it was, ‘Get out of your disease and condition silos. We know that multimorbidity strikes 10–15 years earlier in disadvantaged populations. This should shock and shame us. Tackling this inequality needs to be a priority across the plan.’ To the Richmond Group’s credit, this also lies behind the thinking of the work it is pursuing through its Taskforce on Multiple Conditions, in partnership with Guy’s and St Thomas’ Charity and the Royal College of General Practitioners.
I have gained and learned a lot through the privilege of being on the advisory group for this work, particularly about the excruciatingly heavy load that our services place on people with multi-morbidities in navigating them. In fact, it can be a full-time job. So much so that it pushes many people out of work itself, which has further financial and health implications. In the light of this, and having tried to digest the plan quickly, I was disappointed, and astonished, to see that multi-morbidity hardly featured in the long-term plan. Rather, it is a collection of many commitments, on specific clinical issues and areas from cancer to learning disabilities, and a ‘back-end’ about rolling out integrated care systems. There is nothing wrong with this per se, but where is the person with multiple long term conditions (of which there are 15 million or so in England)? And where is the focus on inequalities in health as a core rational and goal for the roll-out of integrated care systems (if you check the 2012 legislation, this is what integration is for, alongside quality improvement)?
The plan, as published, disappointed on both these fronts. Since then, you’ll be glad to know, I have changed my mind, to some degree, following what has come in the wake of the plan’s initial publication. In particular, the focus on universal personalised care and the introduction of primary care networks presents an opportunity to refocus on delivering and supporting the care of people with multi-morbidity. The former includes a specific section on multi-morbidity and inequalities in health, and the underlying ‘operating model’ includes a step-up in supported self-management and personal health budgets as ways of helping to personalise care. The devil, though, will be in the detail, especially on how primary care networks develop in practice. In principle they could address three core problems that to help alleviate the burden that the system places on people with multi-morbidities. The first is bringing in a wider workforce into primary care, particularly physiotherapy; the second, making it easier to integrate primary care with the rest of the NHS; and the third, as a mechanism for the NHS to do more on population health.
The first two should – with clear and strong leadership – make people’s lives easier when dealing with the health and care system, as well as hopefully improving care directly. The last, though, is perhaps the biggest challenge of all, and this is the area where there is much less clarity. Only when the NHS really starts to think ‘outside itself’ will it maximise the contribution it can make to population health and inequality reduction, especially for the millions with, or at risk of, multi-morbidities. That means a focus on connections between the NHS and the wider determinants of health, such as housing and transport; playing a bigger role in behaviour change (there is welcome support for smokers and on alcohol through some acute settings in the long-term plan, but the offer beyond the acute setting is noticeable by its absence); and in working with and supporting communities much more than it does now.
This way of thinking is still noticeable by exception in the long-term plan and is less clearly worked up in what has followed, including primary care networks to date. The NHS must do more in this respect, playing its full role in population health through its partnerships with others, as we have recently set out in The King’s Fund’s vision for population health and in which we are helping, and learning from, leaders from within and beyond the NHS.
In my view then, the NHS long-term plan missed the sweet spot for multi-morbidities and population health, but there is room for optimism and the publication of the plan itself was not a one-shot game. What has followed has the potential to be really helpful but, as ever, there is more to do in ensuring the NHS plays its full role in population health and in both preventing, and supporting people living with multiple conditions.