This article examines the NHS Long Term Plan and the NHS Mental Health Implementation Plan, both launched in 2019. Note that much of it applies directly to England only.

What the NHS was

On 5 July in the significant year of 1948, the National Health Service was born, a few months before Prince Charles. Its founding intention was to remove the need for the people of Britain to live in fear of ill health, at a time of great uncertainty, shortages and poverty. The Labour Party had already had a long-standing commitment to ‘a national health service’ when it was elected to office in Britain’s immediate post-war general election in 1945. Aneurin Bevan (pictured above), the then Secretary of State for Health, announced a plan for a fully nationalised Health Service to be accomplished within weeks.

The first NHS pamphlet that landed on doormats assured the public: ‘It’s not a charity; you’re paying for it, mainly as taxpayers’. Hospitals were places for the British people to feel ‘safe’, ‘reassured’, and where the sick were made better. Hands were held; wards were full of uniformed nurses and doctors dedicated to the foundational maxim of the medical profession—First, do no harm. Pride and vocation were central and pivotal in attracting the right candidates to clinical settings; indeed, it was considered a privilege to be trained by the NHS.

The NHS was the pride of the people, a jewel in the British crown, a revered national treasure. It has transformed the lives of those who would never have been able to afford care for themselves or their families. For those of all ages living in Britain today, it has always been there in our darkest of moments, when we most needed it.

 

The Blair overhaul

A vision of a ‘new NHS’ in a ‘new Britain’ governed by a ‘New Labour’ was born when Tony Blair, who became Prime Minister in 1997, announced a radical modernisation of the NHS as it approached its fiftieth anniversary. A subsequent White Paper began the process of providing ‘new and better’ services to the public. The NHS Plan: A Plan for Investment. A Plan for Reform (2000) was the biggest overhaul the NHS had ever seen since its birth in 1948.

So what would this new service offer?

A nurse-led 24/7 helpline’. New technology to link GP (family doctor) surgeries to specialist units. Blair pledged to make the NHS become a more modern, dependable service that would continue to be the envy of the world. Administration of patients’ needs would be centralised. An Integrated system of care would be quick and reliable. Local doctors and nurses would understand the needs of their local communities and would be empowered to shape services for the future, guaranteeing patients standards of excellence in order for them to have the confidence in the services they received. (Note the change in language from ‘care’ to ‘service’.) He promised more investment into technology and offered incentives and sanctions to improve quality.

Here are some of the promises made in that time of vision-casting (remember the situation we find ourselves in today, bearing in mind the targets that follow):

• 20,000 extra nurses
• 7,500 more consultants
• 2,000 more GPs
• 7,000 extra NHS beds, to include 5,000 care places as a stopgap for the elderly to prevent ‘bed-blocking’ in acute hospital beds
• A maximum four-hour wait to be seen at Accident & Emergency
• Maximum waiting times for operations to be cut from 18 months to six months by 2005
• No patient would have to wait more than three months for treatment on the NHS
• 100 new hospital schemes
• Overhaul of consultants’ (treating physicians’) and GPs’ contracts, incentivising them to meet targets and criteria. (They would also have to remain in the NHS exclusively for seven years after qualifying before being allowed by law to practice privately.)
• The creation of ‘senior sister’ posts to take over responsibility for ward cleanliness (we, the regular nurses, always used to be responsible for that!) and to be given powers to discharge patients without consulting a doctor
• A ‘modern-day matron’. (The role as set out is a million miles from the old-fashioned hospital matron, and very misleading.)
• 500 one-stop shops where members of the public would be able to see dentists, social care professionals and GPs under one roof

Blair also promised that from 2002 onwards, any operation which was cancelled for a non-medical reason (such as lack of bed availability) would trigger a guarantee of surgery within 28 days, even if that meant the NHS having to fund private surgery within a private hospital.

Similarly, from 2002, all patients would be able to see someone in their local primary care team within 24 hours and a trained GP within 48 hours. Therapist consultants (akin to what are now known as physician assistants) would be made available to end traditional demarcations between nurses and doctors. Moreover, day treatment centres would be built to ease the burden on hospitals. These treatment centres would be able to perform minor surgery on an outpatient basis.

The plan included covert inspections of hospitals every six months for cleanliness standards, to which inspectors the local responsible NHS Trust board member would be accountable for monitoring standards.

To monitor the performance of hospitals, a traffic light system would be implemented.  This would name and shame the local NHS Trusts and individual hospitals who were failing to meet the standards required. As a punishment for those flagged as red, they would not be awarded their funding, and (as with failing-schools policy in the same era) they may be taken over by a Trust with a green flag.

 

The May-Johnson era and plans for the 2020s

We now fast-forward to 2022 to see in real time where we are, compared with that vision of a quarter of a century ago.  How did that plan work out, and what has since superseded it? Let us not forget the NHS is Europe’s biggest employer.

The concept of an NHS Long Term Plan was launched in 2018, and a delighted Theresa May announced at the start of 2019 that the NHS Long Term Plan (linked above) had at last been published and that her vision was being piloted at Alder Hey Children’s Hospital in Liverpool.

There are fully six main aims of the Long Term Plan:

1. A more integrated health system that views health holistically. ‘Patient-centred care’. Organising care around the patient.
2. A health service that focuses much more on prevention and early diagnosis (think: monitoring and genetic data) in order to address the needs of the ageing population ‘problem’.
3. Better support of the workforce and recognising them as the lifeblood of our NHS (clapping for them, I am guessing).
4. The NHS to make more use of technology, fully leveraging new possibilities to give the patient more ‘control’ over their own care. Monitoring conditions from home and accessing the GP by smartphone.
5. Prioritising mental health and making it as important as the care of physical health.
6. Reduced variation between organisations across the NHS, so that world-class care is available everywhere in the country (which, most directly, means England only, given how the NHS is run).

 

It is important to stress that the funding settlement reached at this time applies to NHS England’s budget only. This means that some major areas of NHS spending that are included in the Department of Health and Social Care’s allocation—such as the capital budget, and the education and training budget—are not covered by it. Local authorities’ public health spending and social care are also excluded from the settlement.

Consequently, and as its very name indicates, it is a plan for the NHS, not a plan for the whole of the nation’s health or the whole care system. While the Long Term Plan seeks to strengthen the NHS’s contribution in areas such as prevention, population health and health inequalities, the plan is explicit that real progress in these areas will also rely on action elsewhere.

The little-talked-about NHS Confederation currently controls a £150 billion budget to oversee the running of the NHS, which has now transcended the initial ‘N’ in its name to become an international organisation.  Similarly, the NHS Business Authority holds £35 billion of the pursestrings with which to oversee the general procurement and administration of the NHS. It is worth noting that the NHS Business Authority is the department handling vaccine damage payments, in collaboration with loss adjustors Crawfords.

The NHS has numerous ‘partners’ within the private sector who take pride in displaying the familiar blue and white NHS logo.  Often, those availing themselves of NHS services are unaware that the service provider is not, at its heart, the public NHS.

Under the Long Term Plan, Integrated Care Systems will replace Clinical Commissioning Groups as the local cores that administer public funds in healthcare. This handover began April 2021. They will play a key role in working with local authorities to make shared decisions with providers, based on population health, service remodelling, and implementation of the Long Term Plan.

Digital services will significantly expand and undergo a huge overhaul. The NHS website is one of the most visited websites nationally, recording over 500 million visits a year. A digital NHS ‘front door’ through the NHS App will provide advice and check symptoms (as if we might lie or be unaware of our own bodies) with healthcare professionals (we have no idea whether these are medically qualified). Virtual services are now run via computers and smartphones. To access any NHS service, it is likely that patients will need to be in possession of a Digital NHS Pass, without which computer says no.

Currently, in the wake of the Covid-19 pandemic, the NHS has 6.5 million British residents on its waiting list, and this backlog is predicted to rise to 15 million (over a quarter of the taxpayers who fund it) within the next three years. Patients with life-ending conditions such as cancer and other terminal illnesses are currently parked on a waiting list while their remaining time ticks away.

GPs are still not giving all patients face-to-face appointments, continuing to insist on telephone appointments and online exchanges. Such face-to-face consultations as are made available will be virtual by default and rarely in person. The founding NHS principle of equity of access appears to have disappeared, as many elderly and vulnerable people are unable to navigate the internet. Waiting times for ambulances are increasing, and queues for Accident & Emergency departments ever growing.

So what does the Long Term Plan actually mean in real terms for us? Are we to see the NHS rise like a phoenix from the ashes, or has it gone extinct, as mysteriously as the dinosaurs?

Implications of the NHS Long Term Plan and Mental Health Implementation Plan for the British public

1. We all have to take responsibility for our own health—look after ourselves—but are nevertheless still subject to guidance by our government, advising us on what we can and cannot do, eat, take, think.
2. Hospitals are not as we remember them; there will be restrictions and criteria on who is admitted and for how long.
3. Home is now our hospital, in the form of Virtual Wards, where we will be monitored ‘remotely’ (using biosensors).
4. Artificial Intelligence will be the nurse and doctor of the future, the treatment being meted out by robots. Human contact will be minimal.
5. We will all have our own ‘digital twin’ (to personalise and tailor medicine to us individually).
6. Centralisation and digitalisation are a one-way street.
7. Genomic testing, genetic engineering and genomic medicine are here to stay.
8. Experimental novel pharmaceuticals will constitute personalised medicine, including more mRNA injections.
9. The United Kingdom is on target to become the global Life Sciences superpower.
10. Community pharmacists will gradually replace GPs as primary treating medics.
11. Telemedicine will be practised in virtual outpatient appointments.
12. There will be much early diagnostic testing, specifically for cancers, with lung cancer a priority. The five top reasons for premature death are, in order: smoking, high blood pressure, obesity, alcohol, and drug use. (The authorities who compile such lists make no mention of serious adverse reactions or medicine-caused—iatrogenic—death.)
13. By 2023, all patients admitted to hospital will be offered smoking cessation products following the Ottawa Smoking Cessation Protocol.
14. Personal budgets will be in place for many by 2023/24.
15. Urgent Care Centres (replacing Accident & Emergency) and in-out-recover-at-home treatment with no overnight facilities will be the new ‘normal’ for acute cases and traumas. This mode of treatment will be known as same-day emergency care (SDEC).
16. Initiatives will proliferate to cut down obesity, induce cessation of smoking and alcohol abuse, and manage diabetes. (Watch for possibly New Zealand-style incremental prohibition of tobacco, restrictions on alcohol and high-calorie foods to those with a higher body mass index and/or a given age.)
17. Patients will be told to stop smoking in pregnancy.
18. A new ‘nursing’ will arise where apprenticeships, online qualifications and earn-and-learn support is the regular route to qualification rather than the exception. International recruitment will be expanded, knowledge of colloquial English will not be tested for, and incentives will be put up to recruit more professionals and retrainees to work in hard-to-fill localities and specialities.
19. We will all be ‘graded’ on the Electronic Frailty Index, allowing earlier detection and intervention to treat undiagnosed disorders, such as foreseen risk of broken limbs and heart attacks. Our frailty score will have an unclear (to us) relationship with our likelihood of being refused treatment and of having a Do Not Attempt Resuscitation note placed in our medical records.
20. Wearables will be pushed, connecting home-based on-the-body monitoring equipment (smart watches, fitness bracelets, vital-signs sensors, digital scales and implants/devices) to enable the NHS and whoever has access to its data centres to predict and prevent events that may lead to a hospital admission. Note that implants and devices will be regulated through the MHRA as ‘medical devices’.
21. Location trackers will be handed out to provide ‘freedom’ and reassurance for people with confusion or dementia, or to discharge them early from hospital. (This was being trialled a full decade ago.)
22. Personal Health Records will will become integrated into the NHS’ services, such as NHSx (now NHS Digital), while digitisation proceeds apace.
23. The Dementia Connect Programme will expand.
24. Under the 100 Day Mission, novel emergency pharmaceuticals will be rolled out within a hundred days of the requirement first being expressed. This includes diagnostics, therapeutics and vaccines.
25. The Clinical Assessment Service (CAS) is a single multidisciplinary team that will provide specialist advice and prioritise urgent cases: integrated (fused) ambulance dispatch and out-of-hours GP services. All its members will have access to all your medical records.
26. The five priority emergency hospital admission conditions will be stroke, heart attack, major trauma, severe asthma attack, and sepsis. Other conditions might not be assured an emergency admission.
27. Date of discharge from hospital will be fixed before admission.
28. GP services will be digital.
29. New cell and gene therapies will be elaborated to expand the frontiers of medical science.
30. 90% of the NHS vehicle fleet will use low-emissions engines, and primary heating of NHS buildings with coal and oil will be fully phased out by 2028.
31. The NHS will reduce or even eliminate its need for antibiotics. Antimicrobial Resistance (AMR) is high on the agenda. Dame Sally Davies (Master of Trinity College, Cambridge and former Chief Medical Officer) is the UK AMR Envoy.
32. There will be specialist NHS gambling clinics.
33. Birth Hubs will be one-stop shops for expectant mothers.
34. By 2023/24, all pregnant women will be able to access their maternity notes and information via their smartphones and electronic devices.
35. School- and college-based services will ‘support’ and ‘advise’ young people facing mental health challenges, such as gender confusion, sexuality issues and transgender feelings.
36. Medication of children on the autism spectrum and those with a learning disability will be reduced or even stopped. See page 52 of the above-linked NHS Long Term Plan.
37. Everyone with a diagnosis of a learning disability or on the autism spectrum will have their medical records ‘flagged’, to ensure staff know whom they are seeing.
38. The parents or guardians of all children with cancer will be offered whole-genome sequencing of the child.
39. Children and young people in Britain will be the first generation in Europe to ‘benefit’ from a new generation of CAR-T (chimeric antigen receptor T-Cell therapy) cancer treatments specifically designed for each individual. This involves reprogramming the patient’s own immune system cells, which are then used to target their own cancer. (This is very complex and risky. Proton beam therapy will also be available, but is only effective for a very small number of patients; it uses high- or low-energy proton beams to treat cancer. The UK has made significant investments in proton beam therapy.)
40. There will be 50% inclusion of children and young people in medical research projects.
41. All boys aged 12/13 will be offered vaccination against HPV-related diseases such as throat cancer, oral and anal cancer. To spell out the indelicately obvious, this policy presumes that they are likely to be involved in homosexual practices.
42. The children’s palliative care budget will double from £11 million to £25 million a year. Why?
43. Mobile breath scanners will proliferate in supermarket car parks, ostensibly for the early detection of Covid-19 and lung cancer.
44. The present kinds of asthma medications will be reviewed by pharmacists, and patients will be encouraged to reduce the use of short-acting bronchodilators such as Ventolin and to switch to dry powder inhalers. These are smart inhalers, which use smaller quantities of fluorinated gases that traditional inhalers do.
45. The overhaul of mental health services will include deploying mental health vehicles to reduce the use of ambulances.
46. There will be a drive to increase the number of British people registering to participate in health research, up to one million by 2023/24. Very few countries will have a comparable proportion (>1%) of the population signed up for medical research.
47. 500,000 people’s whole genetic code will be sequenced by 2023/24 by the new NHS Genomic Medicine Service.

In summary, the NHS is undergoing a metamorphosis. Those on low incomes will be offered priority appointments (“levelling up”) whilst those of less modest means will be forced to seek private alternatives—without any rebate on their National Insurance, of course. The two-tiered system is here to stay.

Protect the NHS—from what? Itself? Since when was it appropriate, or indeed ethical, to volunteer an arm for a novel injection to protect the NHS? I thought the founding idea of socialised healthcare was to protect those receiving the treatment, not the system itself. Are we being asked to risk or sacrifice our lives for a non-existent health service? Whom exactly is it serving?

It appears what we are being asked to protect has vanished forever; that it died when no-one was really looking.  Is what is left of the NHS a safe place to be? Do you trust those within the NHS? Does the UK have a caring, gold-standard health system anymore? We all have to decide that for ourselves.