NHS long term plan: all patients to have access to online GP consultations by 2023-24BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l87 (Published 08 January 2019) Cite this as: BMJ 2019;364:l87
All rapid responses
The Institute of Health Promotion and Education welcomes the government’s pledges on prevention, public health, and reducing inequalities.(1-3). The new NHS long term plan is certainly ambitious and we commend certain elements.(2,4)
We are pleased that key public health topics have been highlighted, especially alcohol, diabetes, obesity and smoking. We also welcome the shift towards primary care and community services.
It is also positive that certain groups that are most in need will be supported, including vulnerable children and young people, mothers from deprived communities, people with learning disabilities and autism, carers, rough sleepers, and veterans.
However, if the new plan is to be successful there are three considerable issues that need to be urgently addressed:
1) public health funding,
2) staff shortages, and
3) social care.
Public Health professionals have accomplished much in the past and they have the potential to substantially improve the health of communities, reduce inequalities and take some of the pressure of our overloaded NHS.(5-10) The plan will not be turned into reality if the low status and under-resourcing issues are not addressed.(11-13) Cuts to budgets need to be curtailed and investments made. Staff and programme budgets need to be sufficient for the scale of our current and future public health challenges. The government’s forthcoming prevention green paper provides the chance to do this.(3)
The second critical issue is NHS staff shortages, some 100,000 doctors, nurses, and other staff are needed.(14) In some areas, with this level of staffing, dedicated professionals will just be firefighting and there will be no time for health promotion. Opportunities to tackle problems before they become more serious will be missed. For example, the lack of school nurses and mental health nurses will have implications for children’s mental health.(15) A robust workforce strategy is needed.
The impact of staff shortages on the health of staff themselves is of concern. We have heard anecdotally of many committed doctors and nurses who are working very long hours in stressful environments that are not health promoting. We really should be aiming to maintain and promote the health of doctors and nurses. As part of the NHS long term plan all hospitals should be Health Promoting Hospitals which look after patients and all staff.(16,17)
The challenges and hard choices that need to be made in relation to social care have recently been clearly and succinctly expressed.(18) Although the government’s aim is to enable more people to be cared for at home rather than be admitted to hospital or a care home, we will need to wait and see if costs incurred by the NHS will be covered properly and addressed in the long-awaited green paper on social care. If social care is not funded adequately then it will have profound implications for the future of the NHS.
Although we applaud the intention to upgrade technology, digitally enabled care and the use of appropriate technology across the NHS, we do not think the plans will be realised so easily. Video consultations for example, when clinically appropriate have been shown to have high satisfaction with patients, but they will not be suitable for all conditions, and issues such as inequalities of access and security need to be considered.(19) The significant organisational impact of changing traditional outpatient appointments will need to be addressed.(19,20)
To conclude, although we think the new plan has many elements that are positive, it has been issued at a time of conflicting policy and practice. The secretary of state for health will only be able to deliver his vision for the NHS by securing more investment in local government public health and in social care and by urgently addressing the severe NHS staffing shortages.
1) Department of Health and Social Care. “Prevention is better than cure.” London: DHSC, 2018. https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
2) NHS England. The NHS long term plan. January 7th 2019. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term...
3) Watson M C and Lloyd J, Re: Hancock pledges to invest in prevention to tackle “root causes” of ill health. British Medical Journal Rapid Response 12th November 2018. https://www.bmj.com/content/363/bmj.k4684/rr
4) Iacobucci, G. NHS long term plan: all patients to have access to online GP consultations by 2023-24. BMJ 2019;364:l87
5) CDC. Ten Public Health Achievements of the Twentieth Century - United States, 1900-1999. MMWR Weekly 1999;48(12):241–3
6) Tones K, Tilford S. Health promotion: effectiveness, efficiency and equity. Cheltenham: Nelson Thornes, 2001.
7) Gray S, Pilkington P, Pencheon D, Jewell T. Public health in the UK: success or failure? J R Soc Med 2006;99: 107-11.
8) Hemenway D. While We Were Sleeping. Success Stories in Injury and Violence, Berkeley: University of California Press, 2009.
9) Watson M C and Errington G. Preventing unintentional injuries in children: successful approaches. Paediatrics and Child Health. 2016; 26(5), 194-199
10) Watson M C and Cheater S. Lessons from history – public health successes. British Medical Journal Rapid Response 9th September 2018. https://www.bmj.com/content/362/bmj.k3653/rr-2
11) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761. https://www.bmj.com/content/352/bmj.i761
12) BMA. Funding for ill-health prevention and public health in the UK. May 2017. http://bit.ly/2quLN3K
13) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279. https://www.bmj.com/content/360/bmj.k1279.full
14) Health Foundation, King’s Fund, Nuffield Trust. The health and care workforce in England: make or break? 2018. https://www.health.org.uk/publications/the-health-care-workforce-in-england
15) House of Commons Committee of Public Accounts. Mental health services for children and young people. HC 1593. 2019. https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/1593/15...
16) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185. https://pdfs.semanticscholar.org/c1b6/3555f6b033effdc0062235adb7bab3de43...
17) Thompson, S. R., Watson, M C. and Tilford, S. (2018) The Ottawa Charter 30years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 56(2), 73-84
18) Ham C. The future of social care. Fundamental changes are needed to establish a sustainable system. BMJ 2019;364. https://www.bmj.com/content/364/bmj.l252
19) Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, Hanson P, et al. Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. Health Serv Deliv Res 2018;6(21)
20) Greenhalgh T, Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, Hanson P, Campbell-Richards D, Ramoutar S, Collard A, Hodkinson I. Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study. J Med Internet Res 2018;20(4):e150
Competing interests: No competing interests
I note, reading the coverage of the NHS England Long Term Plan in this week’s BMJ, no reference to the inclusion, for the first time, of respiratory disease as a clinical priority. Despite being responsible for a similar health burden to heart disease and cancer, respiratory diseases and by extension people with respiratory disease, have been relatively neglected.
National Service Frameworks and their successors, associated networks and targets have had obvious impacts in cardiology and cancer, while respiratory outcomes in the UK have stood still. This new system-wide mandate to bring attention to bear on lung disease is hard won, long-overdue and much to be welcomed.
Competing interests: No competing interests