The 10 Year Plan: a work in progress

The Government’s 10 Year Plan Health Plan for England (10YP) has met a mixed reception. It has been critiqued by a wide range of individuals and organisations, but little by way of alternatives has emerged. In our 2022 policy document ‘Primary Care & Public Health: A Vision for Revitalising General Practice‘ Doctors in Unite proposed a new vision for health care based on Neighbourhood Health Communities. The 10YP has proposed a Neighbourhood Health Service based on Neighbourhood Health Centres. While there are similarities in the names, there are substantial differences in the content of the two proposals. 
 
The purpose of this paper is to draw out the distinctions between the two approaches and to articulate a clear alternative vision for a public National Health Service that will tackle health inequalities and promote health and well‑being. In the past DiU (then named the Medical Practitioners Union) played a key role. We were involved in campaigning for the creation of a National Health Service, proposed the GP Charter in the 1960s and led the way in promoting salaried options for GPs and GP commissioning as an alternative to fund‑holding in the 1990s. Though a small organisation, we have been able to shift the direction of public opinion and policy formulation.
 
We need to define our key red lines. Where the 10YP is vague, we can show clarity. We must identify where it could fail to meet people’s needs. We should seek to do so via three channels: 
 
 – within the profession, especially via the GPC networks
 
 – within Unite the Union
 
 – where possible, by engaging with policy makers
 
CONTEXT 
 
The 10YP is to be delivered, for the moment at least, with a more generous NHS settlement than was available during the years of austerity. This remains below historic annual increases, and is only assured for the next few years. The Plan is more a bridging exercise across a continuing funding gap than a viable vision for the future. It appears driven by a pragmatic search for ‘what works’ rather than a coherent overall strategic view. Its declared aims are the three big shifts espoused by Health Secretary Wes Streeting: 
 
 – from hospital to community 
 
 – from analogue to digital 
 
 – from sickness to prevention 
 
The 10YP states four founding principles of the NHS: i) to provide universal care, ii) free at point of delivery, iii) based on need, iv) funded through general taxation. However it omits a key fifth principle of a publicly provided service. This omission allows the Plan to use the language and appearance of NHS reform, while the reality of market forces can be poured in. It is permeated by the perceived transformative potential of IT, the application of AI, use of wearable monitoring devices, and disease‑risk profiling via genomics. In his introduction the Prime Minister says new technology will liberate staff from time‑wasting administration and make booking appointments and managing care as easy as online banking or shopping. 
 
While IT has had some advantages in the access and use of these services, there has been a price to pay. IT‑based banking and shopping have become remote, impersonal, transactional services linked to a widespread loss of local banks and community shops. 
 
Such a model is totally inappropriate for health care, where personal interactions and long‑term relationships are at the core of a quality service. The Plan is riddled with references to ‘choice’ and ‘league tables’, which could mean that accessing health care will become similar to using comparison websites – totally at odds with the Government’s pledge of “rebuilding general practice”. 
 
Instead of having more doctors in our surgeries and local communities, we will be offered “a doctor in our pocket”. We are led to believe that IT, AI and other technological innovations will by themselves create more time for clinicians, which will in turn lead to a downward revision in the workforce numbers proposed in the former Tory workforce plans. 
 
Central to this has been the proposal for the development of a Neighbourhood Health Service predominantly based on a network of Neighbourhood Health Centres across England. The centres are envisaged as being open 12 hours a day, six days a week. 
 
Beginning in the most socially disadvantaged areas (10YP p. 139), this will provide care in communities, and convene professionals in patient‑centred teams to end fragmentation. Over time it will combine with a new genomic population‑health service that provides predictive and preventive anticipatory care. 
 
These health centres will be provided overwhelmingly by the private sector. Services in these centres will be provided by “Integrated Health Organisations” (IHOs) which would command all of the health budget for a particular community. While some IHOs could be NHS foundation trusts, there seems to be plenty of scope for non‑NHS providers to be involved (10YP p. 79). 
 
Instead of building on care continuity and the development of personal relationships over time, it is proposed that patients will be “empowered” by having “personal health budgets” and “patient power budgets” – further steps to reinforce a transactional, market‑based NHS. Patients are being seen as consumers, exercising a sense of choice as they move across a service guided by a range of performance indicators including league tables.
 
In some parts of the country, especially in London, local health organisations and officers are working to become early Neighbourhood Health Service pilots. Despite efforts to generate support for pilots, there is little evidence of enthusiasm for this among the frontline workforce, including GPs. If anything, frontline staff are retreating to attempt “damage limitation”.
 
RED LINES AND STEPPING STONES 
 
In responding, we must identify red lines for opposing the worst of the Plan, and look for the stepping stones we can use to offer a realistic and principled way forward. 
 
The lack of an overall implementation plan is a massive black hole. This must be seen against the background of the expectation that the GP contract in England will be renegotiated in the not‑too‑distant future. The 10YP acknowledges (p. 30) that the attractiveness of the contractor model is in decline and alternative contracts need to be considered, without specifying what the range of options are. 
 
Much of the shift to community care seems to focus on an enhancement of a corporate “Neighbourhood Health Service” rather than identifying its components and seeking to strengthen that capacity. This is particularly obvious in relation to present GP practices, whose existence is scarcely acknowledged in the Plan. It could be deduced that the 10YP does not see any long‑term future for general medical / general practice services. Instead, they could potentially be absorbed into the new community health centres where they will be delivered via IHOs, which could easily be organisations from outside the NHS or public service. In some respects this model resembles the polyclinics proposed in 2007 by Lord Darzi. For most parts of the UK such a model is not consistent with “rebuilding general practice” or strengthening local primary‑care services. 
 
We are told that services should be digital‑by‑default, at the patient’s home where possible, in neighbourhood health centres when needed, and in hospital if necessary – but where are general practices in this scenario? 
 
DiU believes that where they are working well, GMS practices should be supported and strengthened. They should be located close to their patient catchment population and not be so large as to militate against ease of access or continuity of care for patients. Linked to this should be an end to the APMS contracts and a requirement that GMS partnerships be composed of frontline NHS staff (not only GPs). 
 
Where GMS practices are failing or not meeting local needs, the local NHS organisation needs to step in to provide support. This could be either by providing supporting salaried staff (including GPs) or by establishing additional public‑service GP practices. These doctors would work to national terms of service, including pay. 
 
The 10YP reiterates the need to transfer capacity to a community setting to deliver its programme. Over the course of the Plan, the share of expenditure on hospital care will fall (p. 137), with proportionally greater investment in out‑of‑hospital care. This is not just a long‑term ambition; the shift in investment will be delivered over the next three to four years as local areas build and expand their neighbourhood health services. 
 
In achieving this shift it recognises a mismatch between need and funding across different communities and in an ageing society, particularly in areas with disproportionate economic and health challenges. Funding mechanisms will be reviewed, including the Carr‑Hill formula for general practice (p. 137). The shift to “community” and “prevention” is welcome, but addressing the social determinants of health and well‑being is given far less prominence than the emphasis on genomics, AI, big data and wearable technologies. 
 
The contribution of public health is virtually invisible. The Plan speaks of creating a new genomic neighbourhood service, but support for community development and the establishment of “Marmot areas” does not feature. 
 
OUTSTANDING ISSUES
 
The 10 Year Plan is a work in progress. Reaction to it will evolve over time as the new NHS it is creating takes shape. Future concerns include: