Published on 24 June 2004, and running to 80 pages, the latest report from the Department of Health focuses on the next four years of the NHS Plan, up to 2008.

This summary is purely a “factual distillation” of the report, to give you an indication of how health matters are planned to develop over the next four years.

The main goals of the plan are:

• Delivering a greater degree of care in the community, to help those with long-term conditions to better manage their condition without having to visit hospital
• More choice for patients in when, where and by whom treatment is provided
• A continuing drive to reduce waiting times
• Greater priority to be given to the prevention of disease
• By 2008, up to 15% of procedures to be offered by independent providers

Looking back
Not surprisingly, the first section of the report looks back on progress since the NHS Plan was launched; falls in the number of deaths from long-term conditions, shorter waiting times, a move towards offering healthcare without the need for hospital admission, more staff working in better conditions; these are the recent historical findings, liberally backed up with a range of statistics, charts and graphs.

Offering a better service
The core part of the report addresses the main areas where attention will be focussed during the next four years.

Reduced waiting times
By 2008, it is planned that maximum waiting times between GP referral and hospital treatment will be 18 weeks. For patients with suspected cancer, maximum waits by 2005 will not exceed 8 weeks from referral to treatment and 4 weeks from diagnosis to treatment.

Waits for consultations, diagnostic procedures and tests are included within this pledge for the first time.

In the longer term, other professionals such as speech and language therapists and NHS dentists will be brought within this target.

Patient choice
As part of a progressive programme, patients will be able to choose from 4 to 5 alternative hospitals for their treatment, by the end of 2005; by 2008 this choice will be expanded to any healthcare provider, not necessarily the NHS, so long as the provider meets the standards laid down by the Healthcare Commission and the charges do not exceed those which the NHS would have paid. PCT’s will be responsible for implementing choice programmes depending on local circumstances, so issues surrounding the ethnic make-up of the population, and hence communication, as well as the mobility of the population, will come into the equation in future.

It is planned that patients will have more choice from a wider range of services in primary care, with the NHS working with new partners; this will create a flexible, convenient service reducing disruption for commuting workers and providing a much needed benefit to those in deprived areas

Changes to the rules surrounding the prescribing of drugs will make it more convenient for people to receive the medication they need, without involving a visit to their GP

There will be greater choice within maternity services, with women getting quicker access to specialist advice and support

Training programmes on palliative care will be expanded, providing patients with a greater choice in how to be treated in their final days

Allowing patients a greater voice
Patients will, in the longer term, have access to HealthSpace, an electronic service provided via the internet, which will enable them to record their personal preferences with regard to healthcare matters. In time, this service will be linked with the patients’ personal electronic health record

Listening to patients
If the concept of greater choice is to succeed, then listening to patients will become increasingly important. The Healthcare Commission will oversee patient surveys and feedback on five major areas of activity: access and waiting times; high quality, well co-ordinated and safe care provision; better information and greater choice; better relationships between patients and staff and clean, friendly, comfortable environments. The DoH will pay particular attention to minority and disadvantaged groups.

High quality service
Clinical excellence within the NHS is nothing new of course, and all NHS bodies will continue to strive for optimum quality and safety when delivering care. NICE will continue the work of producing clinical guidelines and the Healthcare Commission will put in place the inspection systems to ensure that standards are maintained.
So far as the wider review of regulation is concerned there will be:

• Reform of the GMC and other statutory professional regulatory bodies overseen by the Council for the Regulation of Healthcare Professionals
• Reform of post-graduate medical training overseen by PMETB
• Re-accreditation procedures linked to annual appraisals of staff
• Development of the NHS University to provide ongoing training for all NHS staff
• Following consultation, proposals to introduce regulation of other health care professionals
• Continued work with the General Social Care Council to develop effective regulation of social care professionals

Better support for patients with long-term conditions
Split into three levels of need, the objective is to provide the patient with personalised, effective support to enable them to take better charge of their condition:

Level one – self management: Referred to as the “Expert Patient Programme”, trained non-medical leaders will help patients to live more fulfilling lives. The programme has been tested by many PCT’s and will be effective nationally by 2008
Level two – disease management: More proactive management, in the form of regular check-ups within the setting of primary care, has shown that patients suffering from heart disease, COPD, asthma, diabetes and depression experience slower rates of progression. There will be incentives for GPs to seek out those patients who can benefit from this form of care
Level three – case management: Patients who suffer from multiple long-term conditions will be offered a service, probably delivered by community matrons, whereby their needs are assessed in some detail, and then addressed by a combination of local GPs and primary care teams. These new “community matrons” will represent a new form of specialist clinician, who will work with patients, GPs and social care providers. By 2008 all PCT’s will offer this model of care by which time it is expected that there will be approximately 3,000 community matrons in place

Care closer to home
Patients will receive the care they need closer to home, being served by GPs with a special interest, and specialist nurses. Schemes piloting referral management systems have been successfully implemented and will be extended

Social Care
Social care services and the NHS will focus on proactive services which prevent problems from occurring, allowing patients a greater degree of independence at home. There will be further integration of social care and healthcare commissioning, resulting in better use of resources. The single assessment process will play a central role in ensuring that social and health needs are recorded as one and available to all care providers. It is planned that people will receive “direct payments”, allowing them to purchase the services and equipment they need, rather than relying on what their council provides, thereby further enhancing choice.

Older people and long-term conditions
It is a goal that well-targeted and co-ordinated community based healthcare, community equipment and social care will provide a personalised form of care which will reduce the need for stressful and disruptive admissions to hospital

Mental health
The use of combined medical and social care programmes are well established in providing a personalised package of care. The priority will be to ensure better availability of early intervention and prevention services

A healthier and fitter population
The promotion of health and the prevention of ill-health will assume a much higher profile, with the NHS becoming a health service and not a sickness service. Continued campaigns to reduce smoking, obesity and sexually-transmitted diseases amongst others will feature heavily in the White Paper, Improving People’s Health, due to be published later in 2004. There will be emphasis on the need for the NHS to work in partnership with other agencies

Health and inequalities
All NHS organisations will form active partnerships with their local communities to promote health and reduce inequalities, especially amongst minority ethnic groups. The findings from the two Wanless Reports will be acted upon, with the NHS engaging with people and communities to make progress a reality.
Public health priorities will focus on developing and implementing plans for tackling infectious diseases

Partnerships working in practice
Not surprisingly, a commitment to work together will be an important part of the underlying effectiveness of the latest Plan. The DoH has committed itself to working with all the other government Departments and agencies to ensure the correct culture is in place which will result in the goals being realised.

Having reported on progress to date and the goals for the future, the final section of the Plan focuses on implementation.

Making it happen - New capacity
New hospitals will continue to come on stream, funded through a combination of direct investment and partnerships with the private sector. Investment in primary care will also continue, through the Local Infrastructure Finance Trust (LIFT) initiative, aimed at providing new primary care facilities particularly in deprived areas.

New providers
By 2008, the concept of locally controlled and run NHS Foundation Trusts will be a reality, making community based public services available to all. Private sector involvement will continue to increase, particularly in the area of treatment centres, where up to 15% of a range of surgical procedures and diagnostic tests will be delivered, paid for by the NHS

Expanding and diversifying services
Within primary care the introduction of case management, utilising community matrons and an increase in the number of GPs with a special interest will be areas of attention. There will be an increase in the number of NHS Walk-in Centres. In the next two years it is planned to open more “instant access GP-led primary care centres”, based in major cities throughout England. It is anticipated that greater choice will come about through GP practices collaborating with each other and PCT’s to offer new models of integrated care. PCT development will be aided by learning from and adopting managed care programmes already used overseas.
There will be continuing expansion in diagnostic services, with local delivery and choice for the patient being paramount.

New approaches, capacity and diversity in social care
The DoH will continue to work with councils to invest in new capacity and diversity in social care. New “extra care” housing is being developed, specifically designed, safe homes with in-house care teams.
Independence at home will be aided by councils providing up to £1,000 worth of assistive technology.
For those people eligible for assistance from social services, the concept of “direct payments” is being extended, which will enable people to arrange care and support that is tailored to their individual needs.

The quality mark
With such diversity and expansion in the range of services becoming available, the DoH is committed to ensuring that quality and standards do not fall. The Healthcare Commission and The Commission for Social Care Inspection will have the respective responsibility for health and social care.

More staff working differently
Over the next four years there will be an increase in staff numbers across the entire skills base. The NHS will work with the Royal Colleges and other professional bodies to ensure that regulatory frameworks are regularly updated to reflect new working practices. GPs with a special interest represent one tangible result to date. Nurses, specialist nurses and midwives will take on greater responsibility for not only prescribing certain medications, but improving the overall “patient experience”.

Learning, education and training
A flexible, well trained workforce, using competency based learning modules, is the goal over the next few years. The NHS will bring together programmes such as Lifelong Learning, Recruitment and Retention, Pay Modernisation and the Changing Workforce to ensure NHS staff are equipped to deliver. Employment opportunities will be expanded to encourage entrants to the NHS from other walks of life. E-based learning will be expanded, allowing many NHS professionals to access competency based modules, something which the NHS University will lead on.
Launched in April 2004, Modernising Medical Careers will lead to major changes in postgraduate medical training.

New contracts
The Agenda for Change programme is introducing new contracts for many professional groups within the NHS – these will continue to be rolled out to other professionals in the near future. They are intended to provide a sound platform for developing, recruiting and training the workforce. The new contracts will allow for flexible employment arrangements, allowing staff to have part-time roles and career breaks, leading to a better work/life balance which will encourage more staff to stay.

Modernising management
The NHS is committed to ensuring that excellence in management will back up clinical excellence, providing the necessary infrastructure for the service to prosper and deliver its goals. Staff will receive incentives to embrace change, together with the business drivers that encourage leadership at local and national levels.

Getting IT to work for the patient

• The National Programme for IT will create an NHS electronic highway, eventually providing a seamless information source linking patients, GPs, hospitals and community health services.
• The NHS Care Records Service will be developed, enabling all health professionals secure access to patient records. To be implemented in phases, beginning in the summer of 2004, both clinicians and patients will benefit from being able to access patient information wherever it is needed, resulting in more accurate and speedy diagnosis.
• “Choose and Book” is the name given to the new service for GPs and primary care service providers, linking them to all hospitals and other secondary care providers. The system will provide patients with the opportunity to leave their surgery with a hospital appointment already booked. This system is due to be fully operational by the end of 2005.
• E-prescribing, due to be fully operational by 2007, will eliminate considerable duplication, provide greater accuracy and safety for the patient.
• “HealthSpace”, an internet provided service, will give patients the opportunity to record personal health facts in a section of their own personal care record. Information concerning blood groups, current medication and allergies are examples of the type of information that can be recorded.
• NHS Direct, NHS Direct Online and NHS Digital television will all provide general health advice to the population, in forms which will benefit all sectors of society.
• Telecare is being developed, a system likely to benefit less mobile people at home who live with long-term conditions. It is envisaged that Telecare will enable patient conditions to be remotely monitored by both GPs and hospitals, not only providing earlier warning of deterioration but also reducing unnecessary admissions and visits to the GP.

Aligning incentives with patients and professionals

• PCT’s will commission from a range of providers, using incentives contained within the new General Medical Services and Personal Medical Services contracts to ensure high standards are delivered.
• PCT’s will use, amongst other indicators, a payments by results system to commission services from those best able to provide them. Such an approach will be used alongside patient choice and local capacity demands.
• Performance measuring techniques will be developed through the DoH working with SHA’s and PCT’s, who will further develop explicit criteria for referral and treatment thresholds and trigger points within service level agreements and contracts.

Practice-level commissioning
The DoH is continuing development of devolving commissioning responsibilities to GP practices. From April 2005 GP practices that wish to engage will be given indicative commissioning budgets.

Social care commissioning
The DoH will continue to develop existing payments by results programmes within the social care community, working towards a closer relationship between health and social care sectors.

Developing direct incentives

• The practice of payment by results, introduced within Delivering The NHS Plan in 2002, will continue to be implemented with the expectation that by 2008 the majority of hospital and community healthcare will be paid for through a national tariff.
• The NHS is fully aware of current imbalances in the present payment by results system, and is committed to working towards a system that adequately reflects payment based on performance. Quality, access and choice will be the key determinants, not price.
• The NHS is piloting the use of fee-for-service payments direct to clinical teams that can augment their contracted income in return for higher levels of clinical care.

Performance assessment and management
With growing devolution of power from the top down came a new system of planning, management and performance assessment. The NHS will further develop this system to work more in line with local commissioning. Work will continue with the independent inspectorates of the Healthcare Commission and the Commission for Social Care Inspection to ensure the performance rating system continues.

National to local
The NHS will drive the devolving of decision making to as near the point of delivery as possible – involving commissioners, service providers and patients. Improving choice and the responsiveness of the system is key to the overall Plan. Over time, PCT’s will control over 80% of the budget.
Stewardship, regulation and inspection
The DoH will promote effective stewardship of the nation’s health and will remain the ultimate body answerable to Parliament.
Regulation will fall to the Healthcare Commission and the Commission for Social Care Inspection.

Future objectives and steps
There are four major objectives:

• Health of the population – health promotion and prevention programmes, to keep people in better health for longer
• Chronic care management – support self-care and treatment in the community setting, avoiding hospital wherever possible
• Access to services – fair and prompt access to care
• Patient/user/carer/experience – promoting maximum exchange of information and provision of choice

There will be a new Planning and Priorities Framework process covering 2005-2008, which will lock in the commitment to reforms set out in this Plan; from there, locally determined targets will be established.

The Healthcare Commission will work towards a redesigned performance rating system, which will incorporate healthcare standards.

The DoH, SHA’s and the Healthcare Commission will work closely together to ensure that disincentives and conflicting priorities do not arise.

Where will the NHS be in 2008?

• Patients will have more choice and control over how they are treated
• Service providers, be they NHS or independent, will be empowered to respond to patients needs and choices
• Commissioners at the primary care level can commission what their patients actually need
• The SHA’s will develop local strategy and planning, as well as performance managing PCT’s
• Independent inspectorates will ensure standards are being maintained
• The DoH will set national strategy and continue to account to Parliament.

Alex Mair
Chief Executive