The RCPCH welcomed the announcement of the NHS Long Term Plan as an opportunity to place the needs of infants, children and young people at the heart of England’s health services. The health of children and young people is crucial to the future wellbeing and prosperity of this country, but England’s child health outcomes currently lag behind the rest of Western Europe. While there have been specific improvements and progress made in certain areas, this has not led to the kind of system wide changes that are needed to improve outcomes and ensure a healthier future for children across England.
That’s why we’re pleased to see infants, children and young people placed front and centre of the Plan, published in January 2019. The Plan contains a number of measures which will, if implemented, make a real difference to the health and wellbeing of children and help to achieve our vision for the NHS, that:
- by 2028, children and young people in England will have better physical health, mental health and wellbeing
- children and young people, and their parents and carers, will experience a seamless service delivered by an integrated health and care system
- there will be a skilled workforce that listens to them, responds, and meets their needs.
The Plan was produced through consultation with health professionals, patients and the public. The RCPCH &Us Network was instrumental in ensuring that the views of children, young people and their families were influential in the Plan’s development. Now that it is published, we will ensure that RCPCH &Us continue to be engaged in the new NHS Assembly, due to be established in 2019.
This briefing outlines the key proposals for child health, integrated care and workforce contained in the Plan. The RCPCH will continue to work closely with NHS England, NHS Improvement and other key stakeholders to ensure that these proposals are acted upon and implemented.
In its Long Term Plan, NHS England pledges to:
- create a Children and Young People’s Transformation Programme which will, in conjunction with the Maternity Transformation Programme, oversee the delivery of the children and young people’s commitments in this Plan
- move to a 0-25 years service and towards service models for young people that offer person-centred and age appropriate care for mental and physical health needs, rather than an arbitrary transition to adult services based on age not need
- publish a workforce implementation plan in 2019 and establish a national workforce group to ensure that such workforce actions agreed are delivered quickly
- strengthen its contribution to prevention and tackling health inequalities, basing its five-year funding allocations to local areas on more accurate assessment of health inequalities and unmet need.
- accelerate action to achieve 50% reductions in stillbirth, maternal mortality, neonatal mortality and serious brain injury by 2025
- invest in expanding access to community-based mental health services to meet the needs of more children and young people
- improve its understanding of the needs of people with learning disabilities and autism and work together to improve their health and wellbeing, including piloting the introduction of a specific health check for people with autism, which if successful will be extended more widely
- increase investment in intensive, crisis and forensic community support will also enable more people to receive personalised care in the community, closer to home, and reduce preventable admissions to inpatient services.
Children and Young People’s Transformation Programme
What do we want to see?
The development of a Children and Young People's Health Strategy to be delivered by a funded transformation programme led by a dedicated programme board.
What does the Plan promise?
The NHS will create a Children and Young People’s Transformation Programme which will, in conjunction with the Maternity Transformation Programme, oversee the delivery of the children and young people’s commitments in this Plan.
What do we want to see?
An NHS that gives children the healthiest start and continues throughout their life course.
What does the Plan promise?
The NHS will provide a targeted support offer and access to weight management services in primary care for people with a diagnosis of type 2 diabetes or hypertension with a BMI of 30+ (adjusted appropriately for ethnicity), where the NHS can have a significant impact on improving health, reducing health inequalities and reducing costs. By 2022-23, the NHS also expects to treat up to a further 1,000 children a year for severe complications related to their obesity, such as diabetes, cardiovascular conditions, sleep apnoea and poor mental health. These services will prevent children needing more invasive treatment.
Over the next five years, investment to ensure that children with learning disabilities have their needs met by eyesight, hearing and dental services, are included in reviews as part of general screening services and are supported by easily accessible, ongoing care.
The NHS will prioritise improvements in childhood immunisation to reach at least the base level standards in the NHS public health function agreement. The programme will also work closely with other areas of government and key programmes such as the Healthy Child Programme.
The Starting Well Core initiative is supporting 24,000 dentists across England to see more children from a young age to form good oral health habits, preventing tooth decay experienced by a quarter of England's five year olds.
Commissioning public health services
The NHS will consider whether there is a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses, and what best future commissioning arrangements might be.
Improving population health
During 2019, the NHS will deploy population health management solutions to support ICSs to understand the areas of greatest health need and match NHS services to meet them. Over the coming years these solutions will become increasingly sophisticated in identifying those groups of people who are at risk of adverse health outcomes and predict which individuals are most likely to benefit from different health and care interventions, as well as shining a light on health inequalities.
Maternity and neonatal care
What do we want to see?
An NHS that supports interventions to reduce the number of deaths in infants, and maximises women’s health before, during and after pregnancy
What does the Plan promise?
Through the Long Term Plan, the NHS will accelerate action to achieve 50% reductions in stillbirth, maternal mortality, neonatal mortality and serious brain injury by 2025. This will be done by the following.
Reducing infant deaths and improving safety
Rolling out of the Saving Babies Lives Care Bundle (SBLCB) across every maternity unit in England in 2019. Supporting the establishment of Maternal Medicine Networks, which will further ensure women with acute and chronic medical problems have timely access to specialist advice and care at all stages of pregnancy.
Expanding the SBLCB in 2019. This will include a focus on preventing pre-term birth, which will minimise unnecessary intervention and define a more holistic approach to risk assessment during labour, alongside further improvements to cardiotocography monitoring, and reductions in smoking during pregnancy. To care for women with heightened risk of pre-term birth, including younger mothers and those from deprived backgrounds, the NHS will encourage development of specialist pre-term birth clinics across England. The SBLCB will also encourage clinically appropriate use of magnesium sulphate – estimated to help reduce the number of pre-term babies born with cerebral palsy by up to 700 per year.
By spring 2019, every trust in England with a maternity and neonatal service will be part of the National Maternal and Neonatal Health Safety Collaborative. Every national, regional and local NHS organisation involved in providing safe maternity and neonatal care has a named Maternity Safety Champion.
Continuing to improve how it learns lessons when things go wrong and minimise the chances of them happening again. The Healthcare Safety Investigation Branch reviews all term stillbirths, early neonatal deaths and cases of severe brain injury in babies, as well as all maternal deaths. A Perinatal Mortality Review Tool is now used by all maternity providers, supporting high quality reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death.
Redesigning and expanding neonatal critical care services to improve the safety and effectiveness of services and experience of families. In particular, the NHS will address the shortage of neonatal capacity through the introduction of more Neonatal Intensive Care Cots where the Neonatal Critical Care Review has identified under capacity and improve triage within expert maternity and neonatal centres so that the right level of care is available to babies as close to the family home as possible.
Enhanced maternity care
Continuing to work with midwives, mothers and their families to implement continuity of carer so that, by March 2021, most women receive continuity of the person caring for them during pregnancy, during birth and postnatally.
Continuing to expand the roll-out of maternity digital care records. By 2023-24, all women will be able to access their maternity notes and information through their smart phones or other devices.
Improving access to postnatal physiotherapy to support women who need it to recover from birth.
Enhancing the experience of families during the worrying period of neonatal critical care. From 2021-22, care coordinators will work with families within each of the clinical neonatal networks across England to support families to become more involved in the care of their baby and invest in improve parental accommodation.
Perinatal mental health
Increasing access to evidence-based care for women with moderate to severe perinatal mental health difficulties and a personality disorder diagnosis, to benefit an additional 24,000 women per year by 2023-24, in addition to the extra 30,000 women getting specialist help by 2020-21. Care provided by specialist perinatal mental health services will be available from preconception to 24 months after birth (care is currently provided from pre-conception to 12 months after birth), in line with the cross-government ambition for women and children focusing on the first 1,001 critical days of a child’s life.
Expanding access to evidence-based psychological therapies within specialist perinatal mental health services so that they also include parent-infant, couple, co-parenting and family interventions; offering fathers/partners of women accessing specialist perinatal mental health services and maternity outreach clinics evidence-based assessment for their mental health and signposting to support as required; increasing access to evidence-based psychological support and therapy, including digital options, in a maternity setting. Maternity outreach clinics will integrate maternity, reproductive health and psychological therapy for women experiencing mental health difficulties directly arising from, or related to, the maternity experience.
All maternity services that do not deliver an accredited, evidence-based infant feeding programme, such as the UNICEF Baby Friendly Initiative, will begin the accreditation process in 2019-20.
Developing the expert neonatal nursing workforce. This will mean extra neonatal nurses and expanded roles for some allied health professionals to support neonatal nurses.
Children and young people’s mental health services
What do we want to see?
An NHS that promotes the mental and emotional health and resilience of children and young people.
What does the Plan promise?
Funding and investment
Funding for children and young people’s mental health services will grow faster than both overall NHS funding and total mental health spending. This means that children and young people’s mental health services will for the first time grow as a proportion of all mental health services, which will themselves also be growing faster than the NHS overall.
Over the next five years, the NHS will continue to invest in expanding access to community-based mental health services to meet the needs of more children and young people. By 2023-24, at least an additional 345,000 children and young people aged 0-25 will be able to access support via NHS funded mental health services and school or college-based Mental Health Support Teams. Over the coming decade the goal is to ensure that 100% of children and young people who need specialist care can access it.
Over the next five years, the NHS will also boost investment in children and young people’s eating disorder services. As need continues to rise, extra investment will allow the NHS to maintain delivery of the 95% standard beyond 2020-21.
Access to support
Children and young people experiencing a mental health crisis will be able to access the support they need. Expanding timely, age-appropriate crisis services will improve the experience of children and young people and reduce pressures on accident and emergency (A&E) departments, paediatric wards and ambulance services.
Mental health support for children and young people will be embedded in schools and colleges. The Children and Young People’s Mental Health Green Paper set out proposals to improve mental health support in schools and colleges. Over the next five years the NHS will fund new Mental Health Support Teams working in schools and colleges, building on the support already available, which will be rolled out to between one-fifth and a quarter of the country by the end of 2023. The NHS work with schools, parents and local councils will reveal whether more upstream preventative support, including better information sharing and the use of digital interventions, helps moderate the need for specialist child and adolescent mental health services. It will thereby test approaches that could feasibly deliver four week waiting times for access to NHS support, ahead of introducing new national waiting time standards for all children and young people who need specialist mental health services.
In selected areas, the NHS will also develop new services for children who have complex needs that are not currently being met, including a number of children who have been subject to sexual assault but who are not reaching the attention of Sexual Assault Referral Services.
The NHS will extend current service models to create a comprehensive offer for 0-25 year olds that reaches across mental health services for children, young people and adults. The new model will deliver an integrated approach across health, social care, education and the voluntary sector, such as the evidenced based ‘iThrive’ operating model which currently covers around 47% of the 0-18 population and can be expanded to 25 year olds. In addition, NHS England is working closely with Universities UK via the Mental Health in Higher Education programme to build the capability and capacity of universities to improve student welfare services and improve access to mental health services for the student population, including focusing on suicide reduction, improving access to psychological therapies and groups of students with particular vulnerabilities.
Children with long term conditions
What do we want to see?
An NHS that integrates care for children and young people with complex or multiple needs.
What does the Plan promise? - Learning disability and autism
Action will be taken to tackle the causes of morbidity and preventable deaths in people with a learning disability and for autistic people. This will be done by improving the uptake of the existing annual health check in primary care for people aged over 14 years with a learning disability, so that at least 75% of those eligible have a health check each year. The NHS will pilot the introduction of a specific health check for people with autism, and if successful, extend it more widely. The NHS will expand the Stopping over medication of people with a learning disability autism or both and Supporting Treatment and Appropriate Medication in Paediatrics (STOMP-STAMP) programmes to stop the overmedication of people with a learning disability, autism or both and continue to fund the Learning Disabilities Mortality Review Programme (LeDeR), the first national programme aiming to make improvements to the lives of people with learning disabilities.
Integrating systems and models of care
The whole NHS will improve its understanding of the needs of people with learning disabilities and autism, and work together to improve their health and wellbeing. NHS staff will receive information and training on supporting people with a learning disability and/ or autism. Sustainability and Transformation Partnerships (STPs) and integrated care systems (ICSs) will be expected to make sure all local healthcare providers are making reasonable adjustments to support people with a learning disability or autism. Over the next five years, national learning disability improvement standards will be implemented and will apply to all services funded by the NHS. These standards will promote greater consistency, addressing themes such as rights, the workforce, specialist care and working more effectively with people and their families. By 2023-24, a ‘digital flag’ in the patient record will ensure staff know a patient has a learning disability or autism. The NHS will work with the Department for Education and local authorities to improve their awareness of, and support for, children and young people with learning disabilities, autism or both and work with partners to bring hearing, sight and dental checks to children and young people with a learning disability, autism or both in special residential schools.
To move more care to the community, the NHS will support local systems to take greater control over how budgets are managed. Drawing on learning from the New Care Models in tertiary mental health services, local providers will be able to take control of budgets to reduce avoidable admissions, enable shorter lengths of stay and end out of area placements. Where possible, people with a learning disability, autism or both will be enabled to have a personal health budget (PHBs). By March 2023-24, inpatient provision will have reduced to less than half of 2015 levels (on a like for like basis and taking into account population growth) and, for everyone million adults, there will be no more than 30 people with a learning disability and/or autism cared for in an inpatient unit. For children and young people, no more than 12 to 15 children with a learning disability, autism or both per million, will be cared for in an inpatient facility.
Increased investment in intensive, crisis and forensic community support will also enable more people to receive personalised care in the community, closer to home, and reduce preventable admissions to inpatient services. Every local health system will be expected to use some of this growing community health services investment to have a seven-day specialist multidisciplinary service and crisis care. The NHS will continue to work with partners to develop specialist community teams for children and young people, such as the Ealing Model, which has evidenced that an intensive support approach prevents children being admitted into institutional care.
The NHS will focus on improving the quality of inpatient care across the NHS and independent sector. By 2023-24, all care commissioned by the NHS will need to meet the Learning Disability Improvement Standards. The NHS will work with the CQC (Care Quality Commission) to implement recommendations on restricting the use of seclusion, long-term segregation and restraint for all patients in inpatient settings, particularly for children and young people. As well as focusing on the number of people in inpatient settings, the NHS will closely monitor and – over the coming years – bring down the length of time people stay in inpatient care settings and support earlier transfers of care from inpatient settings. All areas of the country will implement and be monitored against a ’12-point discharge plan’ to ensure discharges are timely and effective. The NHS will review and look to strengthen the existing Care, Education and Treatment Review (CETR) and Care and Treatment Review (CTR) policies, in partnership with people with a learning disability, autism or both, families and clinicians to assess their effectiveness in preventing and supporting discharge planning.
Access and support
Over the next three years, autism diagnosis will be included alongside work with children and young people’s mental health services to test and implement the most effective ways to reduce waiting times for specialist services. This will be a step towards achieving timely diagnostic assessments in line with best practice guidelines. Together with local authority children’s social care and education services as well as expert charities, the NHS will jointly develop packages to support children with autism or other neurodevelopmental disorders including attention deficit hyperactivity disorder (ADHD) and their families, throughout the diagnostic process. By 2023-24 children and young people with a learning disability, autism or both with the most complex needs will have a designated keyworker.
Initially, keyworker support will be provided to children and young people who are inpatients or at risk of being admitted to hospital. Keyworker support will also be extended to the most vulnerable children with a learning disability and/or autism, including those who face multiple vulnerabilities such as looked after and adopted children, and children and young people in transition between services.
What does the Plan promise? - Children and young people with cancer
The NHS will develop and implement networked care to improve outcomes for children and young people with cancer, simplifying pathways and transitions between services and ensuring every patient has access to specialist expertise.
From 2019, the NHS will begin to offer all children with cancer whole genome sequencing to enable more comprehensive and precise diagnosis, and access to more personalised treatments. This will reduce the use of harmful medications and interventions, support increased access to clinical trials and reduce the number of young patients who experience lifelong health problems caused by high doses of chemotherapy and radiotherapy. Children and young people in England will also be among the very first in Europe to benefit from a new generation of CAR-T cancer therapies. And children who need proton beam therapy will be able to access the most sophisticated modern precision treatment in the world here in the NHS without needing to travel abroad.
The NHS will actively support children and young people to take part in clinical trials, so that participation among children remains high, and among teenagers and young adults rises to 50% by 2025. More effective consent processes for using data and tissue samples in research will contribute to improving survival outcomes. The NHS will seek the views of patients aged under 16 to ensure it continues to offer the very best services for children and young people. This will be used, alongside other cancer data, to inform service design and transformation.
From September 2019, all boys aged 12 and 13 will be offered vaccination against HPV-related diseases, such as oral, throat and anal cancer.
Over the next five years the NHS will increase its contribution by match-funding clinical commissioning groups (CCGs) who commit to increase their investment in local children’s palliative and end of life care services including children’s hospices. This should more than double the NHS support, from £11 million up to a combined total of £25 million a year by 2023-24.
Redesigning other health services for children and young people
What do we want to see?
An NHS that is tailored and responsive to the needs of children and young people throughout their childhood and as they transition to adult services, such as diabetes and epilepsy services.
What does the Plan promise?
Models of care
By 2028 the NHS will move to a 0-25 years service and towards service models for young people that offer person-centred and age appropriate care for mental and physical health needs, rather than an arbitrary transition to adult services based on age not need.
Local areas will design and implement models of care that are age appropriate, closer to home and bring together physical and mental health services. These models will support health development by providing holistic care across local authority and NHS services, including primary care, community services, speech and language therapy, school nursing, oral health, acute and specialised services.
From 2019-20 clinical networks will be rolled out to ensure the NHS improves the quality of care for children with long-term conditions such as asthma, epilepsy and diabetes. This will be achieved though sharing best clinical practice, supporting the integration of paediatric skills across services and bespoke quality improvement projects.
Critical care and surgical services
Over the next five years, paediatric critical care and surgical services will evolve to meet the changing needs of patients, ensuring that children and young people are able to access high quality services as close to home as possible. Paediatric networks, which will involve hospitals, NHS staff and patients and their families, will ensure that there is a coordinated approach to critical care and surgical services, enabling children and young people to access specialised and non-specialised services in times of urgent, emergency and planned need.
Integrated Care Systems (ICSs) will become the level of the system where commissioners and providers make shared decisions about financial planning, and prioritisation. Beyond 2019-20 the NHS will introduce further financial reforms that will support ICSs to deliver integrated care. Through a process of earned financial autonomy the NHS will give local health systems greater control over resources on the basis of a track record of strong financial and performance delivery, assessed in part through the new ICS accountability and performance framework.
What do we want to see?
An NHS that is properly staffed by motivated and dedicated child health professionals
What does the Plan promise?
Workforce Implementation Plan
The funding available for additional investment in the workforce, in the form of training, education and continuing professional development (CPD) through the Health Education England (HEE) budget has yet to be set by government. A workforce implementation plan will be published later in 2019. NHS Improvement, HEE and NHS England will establish a national workforce group to ensure that such workforce actions agreed are delivered quickly. This will include the new NHS Chief People Officer, the NHS National Medical Director, the Chief Nursing Officer and the other Chief Professions Officers. The group will show how the future challenges can be addressed for the total workforce, as well as looking at each group individually. The group will also include the Chief Midwifery Officer, along with representatives from staff side organisations, the Social Partnership Forum, Royal Colleges, The King's Fund, Health Foundation and Nuffield Trust.
Depending on the HEE training budget to be agreed in the Spending Review, the number of medical school places could grow further. The national workforce group will examine further options, including:
- more part-time study options
- expanding the number of accelerated degree programmes which would allow people to train in four years rather than five years to widen access
- greater contestability in allocating the 7,500 medical training places to universities so as to drive improvements in curricula (formal and informal), and the production of medical graduates who meet the primary care and specialty needs of the NHS.
The way doctors are trained and the way they work will be a key component of the workforce implementation plan. The NHS will accelerate the shift from a dominance of highly specialised roles to a better balance with more generalist ones.
Working with the British Medical Association, the medical Royal Colleges, the General Medical Council and providers, the NHS will also address:
- how the wider NHS can support the implementation of HEE’s work to improve the working lives of doctors in training, including providing adequate time for supervision, accelerating implementation of ‘step out and step in’ training programmes and further work to enable trainees to switch specialties without re-starting training
- how to accelerate the development of credentialing, which has been piloted by HEE, to enable doctors to broaden the scope of their practice, both during and after training
- how to reform and re-open the Associate Specialist grade as an attractive career option in line with the HEE led strategy for Specialist and Associate Specialist doctors
- the acceleration of work to ensure doctors are trained with the generalist skills needed to meet the needs of an ageing population, alongside the development of specialist knowledge and skills
- the development of incentives to ensure that the specialty choices of trainees meet the needs of patients by matching specialty and geographical needs, especially in primary care, community care and mental health services
- the consideration of any further proposals from the work on reforming medical education which will support the delivery of the Long Term Plan.
The workforce implementation plan will set out new national arrangements to support NHS organisations in recruiting overseas. The NHS will explore the potential to expand the Medical Training Initiative so that more medical trainees from both developed and developing countries can spend time learning and working in the NHS.
The changes to the immigration rules in 2018, which exempted all doctors and nurses from the immigration cap, have facilitated more responsive routes for recruiting staff in these professional groups. The NHS will work with government to ensure the post-Brexit migration system provides the necessary certainty for health and social care employers, particularly for shortage roles.
The NHS will seek to shape a modern employment culture for the NHS – promoting flexibility, wellbeing and career development, and redoubling our efforts to address discrimination, violence, bullying and harassment.
What do we want to see?
An NHS that uses data and technology to improve outcomes from children and young people.
What does the Plan promise?
A digital red book
A digital version of the ‘red book’ will help parents record and use information about their child, including immunisation records and growth.
Better use of technology
The NHS will work with the voluntary sector, developers, and individuals in creating a range of apps to support particular conditions. By 2020, the NHS aims to endorse a number of technologies that deliver digitally-enabled models of therapy for depression and anxiety disorders for use in IAPT (Improving Access to Psychological Therapies) services across the NHS. This is expected to be expanded to include therapies for children and young people and other modes of delivery, such as virtual and augmented reality, which are already demonstrating early success through the mental health GDE (Global Digital Exemplar) programme.
By 2022, technology will better support clinicians to improve the safety of and reduce the health risks faced by children and adults. An integrated child protection system will replace dozens of legacy systems to include all health care settings including general practice and the NHS will deliver a screening and vaccination solution that is worthy of the NHS' world leading services
The Plan says that integrated care systems (ICSs) will be central to the delivery of the Long Term Plan and by April 2021 they want ICSs covering all of the country. As local systems are in different states of readiness, NHS England will support each developing system to produce and implement a clear development plan and timetable.
Systematic methods of Quality Improvement (QI) provide an evidence-based approach for improving every aspect of how the NHS operates. Through developing their improvement capabilities, including QI skills and data analytics, systems will move further and faster to adopt new innovations and service models and implement best practices that can improve quality and efficiency and reduce unwarranted variations in performance.