The Long-term plan lacks money and staff...

Following the launch of the NHS long-term plan in early January 2019, we look at the reactions of medical associations, think tanks and financial experts to see how achievable they believe the plan to be in the light of the NHS funding crisis. 

party spending over time ifs

The long-term plan has been drawn up based on the autumn announcement of an extra £20 billion. However, the average annual real growth rate of health spending from various governments since the birth of the NHS is 3.7%. This means that the spending of this Conservative Government remains well below the average.

The overwhelming response across the board on the plan is that the aims of the long-term plan are welcome and laudable, but the plan is undeliverable with the planned funding levels and with the current crisis in staffing levels.

Here's the response from the experts...

Services and Providers

Chris Hopson, the chief executive of NHS Providers, focused on the staffing crisis and noted in The Guardian This plan cannot be delivered whilst trusts still have 100,000 workforce vacancies. We need urgent action to solve what trust leaders currently describe as their biggest problem. It’s a major concern that we will have to wait longer to get the comprehensive plan that is needed here.

Unions and associations

Dame Donna Kinnair, Acting Royal College of Nursing (RCN) Chief Executive, said: “We welcome the ambitions outlined in the plan, and it deserves to succeed. But translating good intentions into better treatment and care for patients relies on having the right number of nurses with the right skills across our NHS.......the NHS’s biggest asset is its staff. It is strange then that this plan offers no money for nurses to develop the specialist skills patients need. And it is equally concerning that online courses are presented as a magic bullet to solve the workforce crisis. "

The Royal College of Midwives (RCM) noted the issue of a lack of funding and a lack of staff. Gill Walton, RCM chief executive said: The issue of funding services also rears its head. There are some commitments in the plan to postnatal care yet this is an area that has long been underfunded. Key elements of the plan also talk about prevention of poor health such as reducing the numbers of people smoking. But we are seeing budgets for public health services such as smoking cessation cut. It is therefore vitally important that sufficient funding is made available and that we have the right numbers of midwives and other staff in place. It is not just about a shortage of midwives, but also a shortage of other health professionals which can impact on midwives.  The whole system has to be staffed adequately otherwise the system falls down."

Chair of the British Medical Association (BMA), Dr Chaand Nagpaul, noted in a statement the lack of detail on how the aims of the plan were going to be realised and the lack of sufficient funds: “While the Government has highlighted plans to expand capacity and grow the workforce, very little has been offered in the way of detail. Given that there are 100,000 staff vacancies within the NHS, the long-term sustainability of the NHS requires a robust workforce plan that addresses the reality of the staffing crisis across primary, secondary and community care. This will require additional resources for training, funding for which has not been mentioned in the long-term plan."

Ultimately, there is a need for honesty about how far the £20.5 billion over five years will stretch. This is well below the 4% uplift that independent experts have calculated is required, and below historic spending levels since inception of the NHS. World class care requires world class funding and the investment in the long-term plan will still leave the UK falling behind comparative nations like France and Germany.

Responding to the announcement of the long-term plan UNISON head of health Sara Gorton said: “Finding the NHS more staff, and holding on to those it already has, is key to the success of the government’s plan. The plan is honest about the scale of the staffing challenge. But nothing will happen without more money to attract new recruits and train existing employees. The government must act now, or its plan will fall at the first hurdle."

Unite national officer for health Colenzo Jarrett-Thorpe said: “This new cash is, in reality, putting in the funding that the government removed a decade ago. ‘Smoke and mirrors’ is the name of the game. The money that is now coming on stream is not enough to meet the ambitious targets to save the almost 500,000 lives outlined in the long term plan. The NHS is like a Rolls-Royce that needs constant care and attention – the Tories, since 2010, have neglected its annual maintenance. The NHS requires an immediate cash injection to meet increasing demand. That’s the grim reality.

Comments made after the announcement of the £20.5 bn in extra funding are also still applicable.

UNISON General Secretary, Dave Prentis, further echoed the welcome calls from staff for the extra funding, but he also reiterates that it is not "the long-term funding package health workers will have been hoping for" and he calls for commitments to future funding for above inflation wage rises for NHS staff. Going even further, he comments: “More importantly, the NHS needs a funding guarantee, not a pledge borne out of fantasy economics and the dubious prospect of a Brexit bonanza to see it out of the woods.”

Unite the Union's statement included reference to the failure to address the growing problems of staff shortages due to pay cuts, increased pressures on staff and recruitment issues. Not addressing social care also presents issues for the future of health and social care services. Gail Cartmail, the assistant general secretary, says: "The NHS is suffering from years of underfunding and while the promised additional money is welcome it is the absolute minimum needed to begin tackling the funding crisis.

TUC respond to the announcement with a statement concluding 5 key issues:

  • Funding increases are not enough.
  • What strings are attached?
  • Where is the money coming from?
  • There is no sensible workforce strategy.
  • It does not address social care.

Think tanks and commentators

Chief executive of the King's Fund, Richard Murray, speaking to the Guardian said a number of questions remained unanswered. “While NHS leaders have done what was asked of them within the constraints of the funding settlement provided by the government, some significant pieces of the jigsaw are still missing. A number of decisions – notably on hospital waiting times – have been postponed, indicating that trade-offs and difficult choices lie ahead. Whether the plan can be delivered relies critically on tackling workforce shortages. While the plan recognises this, commitments to increase international recruitment depend on decisions about immigration policy and we will need to wait for solutions until a new workforce plan is published later this year.

The Health Foundation believes that the long-term plan is "a pragmatic plan with an ambitious vision to improve NHS care, but making it a reality will be extremely tough given growing pressures on services, widespread staff shortages and continued cuts to other parts of the health and care system."

The organisation notes that "without a solution to the growing crisis in social care, people will continue to suffer, and more pressure will be piled on the NHS. Without additional funding for public health, which runs services that are essential for keeping people healthy and reducing health inequalities, NHS plans in these areas risk stalling. The Health Foundation has calculated that an additional £3.2bn a year is required to reverse the impact of cuts to the public health grant and ensure that it is re-allocated according to need."

Commenting on the NHS Long Term Plan, Nuffield Trust Chief Executive Nigel Edwards said:

"The goals of this plan look right.....what worries me is how difficult it will be to roll out such wide ranging changes. There are several big pitfalls ahead. The extra funding will actually be below the historic average and what experts thought was needed. It’s enough to move forwards, but with little room for manoeuvre. If we face a no deal Brexit, the extra costs and tasks required would eat up the first instalments, stopping progress dead in its tracks.

"The last few years have seen repeated cuts to public health and social care. The reforms we all know are needed to the way we pay for care have been kicked into the long grass again and again. If this goes on, the NHS will be stretched still further as it looks after more people who couldn't find the help they needed......The biggest obstacle of all is the lack of key staff. Our calculations with The King’s Fund and Health Foundation show a shortfall of 250,000 by 2030, which would make delivering even current services near impossible."

Essentially, the money is not enough...

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funding settlement graph

In summary...

The general consensus of responses to the long-term plan is that without extra funding and a workforce plan that solves the current staffing crisis the plan is undeliverable.

The IFS reported in May 2018 that for the NHS continue to cope with the current demands, provide the same level of service as it does today and deal with the backlog of funding problems funding needs to grow by around 4% a year for the next 5 years. To make meaningful progress on staff shortages, mental health provisions and waiting times the NHS will need funding growth of around 5% a year over that same period.

However, this extra funding announced by Theresa May accounts for an annual real-terms increase of only 3.4% - well off the suggested growth rates put forwards by the IFS and leading think tanks.

This extra funding will be just enough to keep the NHS on its feet but does not provide a long-term solution for improving services and keeping up with increasing demands.