The Covid-19 pandemic being experienced around the world has brought into sharp relief the need for health systems to have resilient infrastructure in place and plans developed for the deployment of physical capacity, workforce, equipment, drug therapies and consumables to tackle the virus. Health systems with a track record of national and regional planning have been shown to be more able to respond at speed and at scale to put combatting actions in place.
However, in the NHS the term ‘planning’, both as an activity and in the description of a role, has somewhat lost its focus over the last 20 years. Over that time, planning has been replaced by activities and roles that are given labels such as strategy, commissioning, development or commercial – all of which involve some element of planning, but a definition and description of health service planning in the NHS in England doesn’t exist.
The proposition of this long read is that focus should be put on rebuilding a capability for planning in the NHS, and that strategic planning, service planning and capital planning should become clearly defined roles with expectations, experience and competences associated with them. Developing this expertise would allow better approaches to plan the future configuration, design, development and delivery of both services and facilities, and with less recourse to external help and more local ownership of plans.
Planning as both a function and a process was evident across the NHS from its inception in 1948. Through successive structural reforms of the NHS from 1948 through to 1982, planning was a key part of NHS administrative and management structures at a regional, area and more local district level. The Hospital Plan of 1962 was a national ‘capital’ plan to deliver a district general hospital to serve populations of approximately 150,000. There was also a requirement on regions throughout the 1970s and 1980s to produce 10-year planning horizon strategic plans and three-year operational plans.
This planning framework was supported by a redistributive funding formula to address historical imbalances in the provision of services and facilities, given historical higher levels of provision in London. This was supported by the work of the Resource Allocation Working Party (RAWP), which used a regression-based formula to balance allocations across the country on a weighted capitation basis. Capital RAWP was a means for distributing capital, also on a weighted capitation basis, intended to support investment in those regions that had been historically under-capitalised.
This planning framework and allocation process encouraged the development of professional planning functions on a regional basis. There was a less well-resourced central planning function at government departmental level (then the DHSS), as the focus was on the regions. These regional departments combined planning, public health and capital planners (often drawn from clinical staff) and did build up a strong cadre of expertise that produced service plans and capital plans for their regions, with transparent prioritisation frameworks to underpin planned investment in services and buildings across the regions. These staff often worked closely with workforce planners.
These planning functions developed tools and methodologies for decision-making using available data to have a good understanding of current and planned activity levels (hospital admission rates, referrals and so on), epidemiology, disease patterns, demography, current and planned beds and other capacity requirements, including radiotherapy and high-cost imaging requirements (CT and MRI). It was this approach to planning that led to the initial developments of many national datasets (including Hospital Episode Statistics) and robust information governance processes.
However, this building up of planning expertise began to be dismantled following the National Health Service and Community Care Act 1990, with the introduction of self-governing NHS trusts who were free from direct regional health authority and district health authority control. Planning as a regional function was all but completely abandoned by 2000, with the cementing of the commissioner-provider split and an increasingly regulatory approach to the management of the system. The planning done by commissioners had a different focus – on population health, rather than on the shape of the delivery system. The often fragmented nature of commissioners made it more difficult to focus on these issues.
With these developments, the process, rigour, tools and techniques of health service planning was lost, and have not been adequately replicated in any other function or process across the NHS. There was a parallel dismantling of the operations research capability in the Department of Health. Although not perfect, the planning function did enable informed and transparent decisions to be made on the prioritisation, delivery and the results of investment. Like many processes and initiatives, it was discarded rather than evolved and now, at a time when much of the process tools and techniques of planning would add value to the operation of the NHS, they are non-existent. Unfortunately they will take time to rebuild.
Now more than ever there is a strong argument for some level of national strategic planning. Having a national picture on capacity, its utilisation and the variances in capacity available, as well as the demands being put upon it, can greatly assist when modelling potential surges in activity or the impact of new technologies and drug therapies. This modelling of demand and supply on a national basis can build a picture of the capacity requirements needed at varying levels of utilisation (e.g. bed occupancy) and support national policy. Such strategic planning at a regional level can then in turn inform priorities for investment and help shape the pattern of service delivery, and determine what may be needed to build in resilience to health systems.
A strategic planning framework can also put in place clear criteria for the prioritisation of major investments such as capital build projects. Having clear nationally recognised benefit criteria can support a transparent prioritisation process so that a mid-term (one to three years) and longer-term (three- to 10-year) planning horizon for capital investment can be developed. This would save much time, activity and duplication over the business case and approvals process if investment levels were prioritised, and the ‘what’ was already determined before the business case deals with the ‘how’ in detail.
A national capital plan over a 10-year planning horizon, showing how the capital stock will be modernised and transformed, will build confidence in the NHS and across the design and construction industry that the priority of investment in the NHS is real.
Service planning is not a term used in a consistent and universally understood way in the NHS. Some types of planning activity happens under the label of ‘transformation’ of varying levels of concordance with the evidence, and there is also little shared learning between organisations.
Developing a service planning function which builds an evidence base of service interventions and developments that have demonstrable benefit would be of significant value across the NHS. Technology now allows for wide sharing of practice to support adoption of initiatives that are of proven value. Dissemination of the outputs needs to avoid the ‘not invented here’ syndrome, and through consultation and involvement allow for tools and techniques to be widely adopted in a consistent fashion. In particular, there needs to be dissemination not just of what interventions work, but why and how they work, in order to support adoption across a range of settings and contexts.
A service planning role that brings together people with specialisms such as clinical planners, public health physicians, health economists, human geographers and social scientists can build a body of practitioners and experts who can map out the direction of the NHS, share best practice and ensure progress is based on evidence and delivered at scale. This will be particularly important in the recovery from Covid-19 and in creating a more resilient health system, as well as to capitalise on the learning from new practices that have emerged during the response to the pandemic.
In recent times, capital planning has been better resourced in the NHS. This has been due to a continued trickle of capital projects over the last 10 years and the requirement in recent years to produce strategic estate plans and strategies. This, together with a continued bidding round for capital monies, has meant that NHS trusts and CCGs have maintained a form of capital planning linked to estates functions that produce bids against identified capital pots (such as the Infrastructure and Technology Transformation Fund) in the required format.
However, there is more to do to ensure that these bids have a robust underpinning service justification, and there needs to be more visibility of the criteria adopted to prioritise bids and to understand the selection process, or indeed the total capital available for a geography. This has meant that any capital monies identified have often been oversubscribed, leading to an inability to plan a capital programme at a local level.
The limited regional resource available to oversee capital expenditure plans has been enhanced through a transfer of staff from the NHS property companies in NHS Property Services and Community Health Partnerships, where staff have transferred into a regional-based strategic estates advisory function. This capacity has been less planning focused and more about review of bids for capital and some technical advice on individual projects. There is a lack of technical skills and training among capital planners in the NHS. Many have a ‘generalist’ background and have been involved in capital projects through an interest or change of role rather than a chosen professional route.
Now that the NHS is about to embark on the largest hospital investment programme in a generation, it is clear that the NHS capacity and capability for capital planning is not sufficient and needs to be strengthened. There is also an imbalance with the design and construction industry, which has deep professional and technical experience in areas such as sustainability (net zero carbon) use of building information modelling, impact of technology on design, experience of global best practice in hospital design, use of off-site construction techniques, and adoption of robotics for facilities management.
This knowledge resides across the industry, but exists in only small pockets in the NHS. The lack of capital projects over the last 10 years has meant that the NHS has not been sighted on the developments in the design and construction industries that have come on in leaps and bounds. It is therefore difficult to ask for something if you do not know it exists.
A relatively quick way of the NHS building this knowledge could be through developing a collaborative sharing of knowledge and approaches programme between the NHS and industry, so that they better understand the needs of the health service. In turn, leaders in the NHS can better understand how other industries effectively plan, deliver and manage infrastructure. A multi-billion programme of investment in new hospitals will, however, require an internal capacity to be built. Ensuring projects include latest thinking in planning, design, construction and facilities operation will be critical to the success of the investment programme.
For the Health Infrastructure Plan to succeed, it needs to be addressed as a programme rather than as 27 or 40 individual projects. The opportunities for cross-learning and taking advantage of latest approaches to design and construction are significant, particularly around repeatable designs and off-site construction techniques that could see a recognisable design of new hospitals being delivered throughout the UK. The financial, clinical and political benefits of this approach are clear. The opportunity exists with the right resource trained and in place to leave a legacy of this generation to those that follow.
Developing the people
If the need to rebuild this capacity and capability of planning is recognised, engaging with policy organisations and education institutions to help professionalise the disciplines of planning will be necessary. Some of the think-tanks in health care have had an association with health planning in the past and this can be rekindled. A collaboration between NHS, policy groups and universities could, over time, build a resource of trained and educated health planners that can practise the discipline throughout the NHS.
As the NHS goes through the next stage of evolution, and the market economy is dismantled to once more embrace a planned health system, then somebody needs to do the planning.
The next steps to take this proposition forward are to first confirm and establish the need for improvements to planning across the systems and at the appropriate level in NHSE/I. If there is confirmation of the need, the next step would be engaging with health policy think-tanks, NHS leaders and academic institutions that have an interest in health policy and planning. Work is needed to establish the skills, knowledge, experience and competences that are required and the best ways of developing these – whether a training programme at graduate entry level and post-graduate/in-service programme would have merit, and the shape of this.
The role of health policy think-tanks can be to provide a research, training and teaching resource that can help co-design programmes in the categories of planning, as well as liaising with appropriate professional institutes, colleges and Royal Colleges. This will provide training and educational rigour to the development of programmes. There is also the potential for the involvement of academic institutions around the potential to accredit post-graduate qualifications to bring further rigour and discipline to the profession of health planning.
If there is sufficient interest, a summit will be organised to map out detailed next steps and to develop a route map for how planning will once more be engrained in the fabric of the NHS.
Richard Darch is Chief Executive of Archus and a senior associate of the Nuffield Trust.
Darch R, Edwards N and Buckingham H (2020) “Building a planning capability in the NHS”, Nuffield Trust comment.