In his first public statement as Prime Minister, Boris Johnson referred to ‘upgrading 20 hospitals’ and increasing access to GPs, which adds to a flurry of plans and ideas for the NHS in recent months.
In January NHS England published the ‘Long Term Plan’, and in June this was followed by both an ‘Interim People Plan’ and an ‘Implementation Framework’. Later this year, following the anticipated Spending Review, we can expect a final ‘People Plan’ and a ‘National Implementation Programme for the Long Term Plan’.
National bodies have issued guidance to local systems to plan on a long-term basis many times before – often changing expectations and requiring new five-year plans part way through existing five-year plans. The concepts of planning for ‘population health’ and integrated, personalised services aren’t new, even if the words are. So what makes us think that the Long Term Plan might succeed this time? How can we be reassured that NHSEI (if it still exists) won’t be issuing a new set of planning guidance in a couple of years that looks depressingly similar to the old guidance?
It’s easy to see the obstacles in the NHS’s way. The more successful changes implemented in the health service in the past were often supported by double-running funding, the like of which is simply not available now. Both commissioners and providers are in deficit, which creates a difficult environment for discussions about positive change. The lack of capital funding for the NHS is not only a barrier to modernisation, it also risks creating some real patient safety issues.
But perhaps a more significant issue is the well-rehearsed shortage of staff to deliver services in the here and now, never mind the next 10 years. We know the NHS is going to receive a cash injection – although there is still no hint of the same for social care – but even if it had that money now, in many places the staff simply don’t exist for that money to be spent on.
These are huge issues and require action at national level as well as in local systems.
Contradictions and cosiness?
The history of NHS policy is littered with contradictions. For example, back in 2006 the Department of Health published an ambitious white paper, Our health, our care, our say, which was aimed at driving integration and personalised services. But at the same time, the Department was continuing the push to establish more foundation trusts – organisations designed to be relatively autonomous.
That period also saw the introduction of Payment by Results for acute care, and a focus on targets for improvements in access to acute care – policies that combined to result in increased hospital activity at the expense of community and mental health services. Although in theory, Payment by Results and improvement targets could have been reconciled with integration and personalisation, in practice the foundation trust model and payment systems trumped everything else.
In 2019 we see a much more aligned policy environment. The Department of Health and Social Care has largely delegated NHS policy to NHS England, which is merging de facto with NHS Improvement. Broadly speaking, policies aimed at commissioners and those aimed at providers are significantly more consistent than they have been for many years.
This policy alignment is reflected in the proposed legislative changes set out in the Long Term Plan. Commentators have argued that much of what it seeks to achieve can be done within existing legislation, yet the argument that legislation precludes collaboration persists. The suggestion that new legislation can address this is positive, but there is a risk that collaboration can become cosiness. No partnership is ever going to be able to encompass every organisation that might provide health and care to citizens in a given area. The risk that systems must guard against is that they simply erect new barriers around their organisations, excluding those whose contribution they understand less well – the best collaborations lower walls.
And in the end, organisations don’t do things, people do things. The Long Term Plan will be delivered – or not – through the actions of the 1.3 million staff working in the NHS, the 1.5 million workers in social care, and tens of thousands of people working in public health, wider local authority services, the voluntary and independent sectors, and as volunteers and informal carers. As Rebecca Rosen argued in our Lessons from history series last year, “you need a plan that staff can follow”.
Plus it isn’t just staff who need to be engaged – we mustn’t underestimate the importance of involving the public. As I argued in the same series: “many attempts to change the way in which services are delivered at a local level have foundered in the face of public opposition.”
Leading the way
Leaders across the NHS need to work with their staff and their communities to develop a coherent narrative that not only enables change, but which positively drives it.
We are already seeing leaders in both NHS organisations and local authorities breaking new ground on this. Places like Wigan and West Yorkshire are already making measurable changes to the health of their population, while also delivering financial efficiencies and recognising that they do that best by not simply focusing on the NHS. Rob Webster, Chief Executive for the West Yorkshire and Harrogate Partnership, said recently that “the NHS Long Term Plan is just one chapter in our whole local plan”.
So yes it is possible that this plan will succeed where others have failed. But it won’t be easy. And it will require leaders at a national level – including political leaders – to hold their nerve, to address funding and workforce challenges, and to ensure that they model the supportive and collaborative behaviours that they expect to see demonstrated in practice at a local level.
Buckingham H (2019) “Best-laid plans: will the NHS get it right this time?” Nuffield Trust comment.