Steve How and Oli Hudson, of Wilmington Healthcare, explore the NHS Long Term Plan’s vision to deliver more preventative, joined-up services for key illnesses
The NHS Long Term Plan acknowledges that while cancer survival is at an all-time high and deaths from cardiovascular disease have halved since 1990, more needs to be done to improve patient care and outcomes in these and other areas.
Consequently, the plan not only furthers the NHS Five Year Forward View’s focus on cancer, mental health, diabetes, multimorbidity and healthy ageing, it also looks at other areas including cardiovascular and respiratory conditions.
Here we explore some of the changes that will be happening in five major health conditions highlighted in the Long Term Plan, and how they will help the NHS to take a more holistic and preventative approach to care.
Cardiovascular disease (CVD)
Cardiovascular disease (CVD), which covers a wide range of conditions such as coronary heart disease and stroke, has been identified in the Long Term Plan as ‘the single biggest area where the NHS can save lives over the next 10 years’. Detecting patients at risk of CVD and preventing the disease from occurring will be key to helping the NHS achieve its ambition.
In line with this, pharmacists and nurses in Primary Care Networks (PCNs) will be supported in identifying and treating relevant cohorts of patients. There will be a big focus on lifestyle improvements for at-risk patients, particularly weight management, as well as social prescribing.
CVD prevention and diagnosis is one of the seven national service specifications of the new PCN Directed Enhanced Service (DES) Contract for GPs. The contract will support PCNs in delivering a range of new services that are all linked to Long-Term Plan priorities, as well as core GP services. CVD case finding will start by 2021.
A new national CVD prevention audit will feed into the above activities. It will extract routinely recorded but anonymised GP data, making it easier for PCNs and other NHS organisations to determine what needs to be done to improve outcomes for their patients and populations.
Many CVD services will be delivered in PCNs by community teams that are likely to include physician associates, clinical pharmacists, specialist heart failure nurses and possibly consultants.
There will also be a major structural change in stroke services, where hyper acute specialist stroke centres with new clot-busting technology, will be replacing existing stroke-receiving units.
Diabetes accounts for 10 percent of NHS spend. In fact, the condition has become so prevalent that some drugs have seen 20 percent market growth in recent years. To help tackle the disease, the NHS plans to double the size of the NHS Diabetes Prevention Programme for type 2 diabetes.
As with other disease areas, there will be a big emphasis on engaging patients in managing their health and also on disease prevention. Aligned with this, weight management services will be critical, particularly in light of recent studies which have shown that if patients lose weight rapidly and significantly, it is possible to go into remission for type II diabetes.
The Long Term Plan shows how technology will help to move diabetes services out of hospitals and support self-care. For example, newly diagnosed patients will be offered expanding provision of structured education and digital self-management support tools, including HeLP Diabetes – an online self-management tool for those with type II diabetes. The Plan has also pledged that patients with type I diabetes will benefit from life-changing flash glucose monitors from April 2019.
There will be a big focus on foot care and podiatry too; hence there will be big opportunities for wound care specialists.
All NHS staff will be encouraged to follow NHS RightCare and Getting It Right First Time (GIRFT) to reduce unwarranted variation in diabetes care and improve services. There is a specific GIRFT workstream around diabetes.
The NHS aims to increase the number of cancer diagnoses at stage one and two from 50 percent of patients now to 75 percent by 2028. Changes will include modernising the Bowel Cancer Screening Programme and making the Faecal Immunochemical Test for haemoglobin easier for patients to use. The NHS will also implement HPV primary screening for cervical cancer across England by 2020. In addition, Sir Mike Richards, the former cancer tsar, is leading a formal review of screening programmes and diagnostics capacity.
The NHS plans to introduce a new faster diagnosis standard from 2020 to ensure that most patients receive a definitive diagnosis or ruling out of cancer within 28 days of referral from a GP or from screening. Supporting Early Cancer Diagnosis is one of the seven national service specifications of the new PCN Directed Enhanced Service Contract for GPs.
The new diagnosis standard will be underpinned by a radical overhaul of the way diagnostic services are delivered for patients with suspected cancer. Starting this year, new Rapid Diagnostic Centres (RDCs) will be rolled out across the country to upgrade and bring together the latest diagnostic equipment and expertise. Cancer Alliances will also work with Integrated Care Systems (ICSs) to aid swift access to a consultant’s opinion.
Chemotherapy, which has been owned by NHS England since 2010, will move to ICSs; while PCNs will be involved in diagnoses, screening and home chemotherapy.
New technology will be key, including Proton Beam Therapy which will be scaled up; mapping genomes and matching patients to genomes; personalised medicines and CAR-T cell therapy.
The Long Term Plan states that hospital admissions for lung disease have risen over the past seven years at three times the rate of all admissions generally and remain a major factor in the winter pressures faced by the NHS.
The NHS will build on the existing NHS RightCare programme to reduce variation in the quality of spirometry testing – a key test for lung function – across the country. PCNs will support the diagnosis of respiratory conditions, while more staff in primary care will be trained and accredited to interpret test results.
Pulmonary rehabilitation, which involves activities such as breathing exercises and learning how to cope in an emergency, is one of the most expensive elements of the respiratory pathway. It will be run by multidisciplinary teams using digital tools, such as My COPD, which is a toolkit for Clinical Commissioning Groups (CCGs).
Pharmacists will play a big role in managing respiratory care in PCNs. This will include medication reviews, educating patients and also advising on the use of inhalers – a critical task given that 90 percent of people use their inhaler incorrectly, according to the NHS.
They will also support patients to reduce the use of short-acting bronchodilator inhalers and switch to dry powder inhalers where clinically appropriate, and uptake of new smart inhalers, as clinically indicated.
In the Long Term Plan, the NHS makes a new commitment to funding mental health services for children and young people, and pledges that this area will grow faster than both overall NHS funding and total mental health spending.
There is also a realisation that children’s mental health goes beyond the NHS; hence we expect to see multidisciplinary teams working in schools as the first point of contact for pupils.
The NHS promises to continue to expand access to IAPT services for adults and older adults with common mental health problems, with a focus on those with long-term conditions.
Digital services, such as mobile apps, are expected to play a big part in delivery and access to mental health care services, especially for children and young people.
We expect to see PCNs developed to support out-of-hospital care, with community mental health teams aligned to PCNs to help overcome the existing divide between primary care and mental health teams. It will also be increasingly important for the NHS to take a joined-up approach to mental and physical health issues.
With a greater emphasis on understanding population dynamics in order to define needs, it will be increasingly valuable for the NHS to assess the state of variation in current care provision and improve data sharing.
While the detail varies in each health condition, there are many common themes, particularly with regards to illness prevention and the associated need to risk stratify patients; engage them in their treatment and encourage them to make lifestyle changes, where appropriate.
There is also a desire to deliver many services for these conditions in the community via integrated teams in PCNs. Consequently, it will be essential for pharma to think about how its products can deliver benefits across the whole care system by, for example, cutting the number of patient follow-ups required, which in turn reduces pressure on the NHS workforce.
Pharma also needs to think beyond the pill to determine how it can support the NHS in delivering more holistic, preventative care services. This might involve, for example, risk stratifying cohorts of patients or developing cost-effective tests to predict disease and develop associated care pathways that enable proactive action.
Steve How and Paul Midgley are part of Wilmington Healthcare’s Consulting Team. For information on Wilmington Healthcare,