Has the 10 Year Plan failed to learn lessons from history?

The latest long-term plan for health in England is full of ideas. Most are good, some might even happen. But while most of the commentary and media coverage around the plan’s publication have focused on the proposals themselves – from neighbourhood health centres to a revamped NHS App – there has been far less attention on the real challenge: how any of these ideas are going to happen.

Previous experience suggests that it is a lot easier to propose ideas to reform complex systems than to implement them. And reading the long shopping list of ideas in this plan has left me wondering whether some of the implementation lessons from previous NHS plans have really been taken on board, and how straightforward delivery can be without a coherent theory of change.

Bright and shiny versus the basics 

NHS reformers throughout history have tended to focus on the potential for new and exciting technology to transform care, often despite evidence that this can take longer than expected and increase costs.

There are signs of this in the 10 Year Plan. Much faith is put in the power of AI – as yet untested in many of the forms it is proposed in the plan. But, to its credit, this plan is better at recognising the importance of getting some basic things right than its predecessors. It acknowledges the need for better admin systems, decent buildings, working IT, and staff with the right tools.

Some of the new technologies mentioned in the plan such as the expanded NHS App and back-office automation will help fix these issues, but some others are more speculative. Policy-makers will need to take care not to focus on the novel at the expense of the foundational, and for the basics to continue to get the attention they deserve once implementation starts.

Understanding why change hasn’t happened

The plan has a lack of curiosity about why previous initiatives – many of them strikingly similar to what is being proposed – have failed to take off. Major shifts in outpatient care, a move of funding from acute to other services and a large expansion in personal budgets have all previously been announced. Neighbourhood health centres seem to be a similar concept to the short-lived Darzi centres of the late 2000s. The NHS App was introduced in 2019 but, while many have downloaded it, still only 6% of patients routinely use it to contact their GP practice.

These ideas often falter because they don’t account for local context, or they are solving problems that weren’t clearly defined in the first place. Top-down solutions can work, but usually only when the problem is simple, the intervention is clear, and context doesn’t matter too much. That’s not the world the NHS usually operates in.

Weak evidence for savings

The plan cites quite a bit of evidence for a variety of new models – from virtual wards to enhanced community services – and the potential savings that might be available by moving care out of hospital.

But even if it were possible to replicate these elsewhere, the research evidence behind admission prevention, hospital at home and multidisciplinary care shows that they are not always necessarily cheaper and are generally based on recouping the full costs, which cannot be realised as savings. This sort of transformation takes time, and it usually needs upfront investment, not to mention addressing decades of failure to shore up social care. Without that, the plan’s promise of “financial sustainability” may prove more hopeful than realistic.

Approach to change I: Taylorism

It is not clear what the unifying theory of change is that sits behind the 10 Year Health Plan overall, but much of its dependence on work redesign seems to hark back over 100 years to the ideas of Frederick Winslow Taylor. Taylor’s scientific management doctrine leads to a view that health care consists of tasks that can be broken up and distributed to less skilled or experienced people, or – as the plan hopes – to AI.

In theory, this allows professionals to work at the “top of their licence” all the time. In practice, the evidence is shaky. It’s not always safe, not always cheaper, and not always popular with the public. If this approach is going to pursued in the NHS, it is going to be very difficult to get it right, as the recent controversy about physician associates has shown.

Approach to change II: the deficit model

Beyond the Taylorist approach to the specifics of work redesign, there seems to be a somewhat pessimistic view of how to get staff and managers to change. Targets, performance management, incentives, freedoms and punishments are written through the plan – suggesting a view that staff are seen as an obstacle and that managers need prodding to be proactive. This is unlikely to be the best way of getting people on board.

To be able to change, people need to be able interpret the signals about what is required. The plan seems to have a mix of mechanisms: integration, choice, competition, capitation, provider independence and more. These can operate simultaneously in different parts of the system, but not so easily together. Clarity on which instrument is being used where and for which problem will be important as the plan moves towards implementation.

Change amid organisational restructure

The plan blames a “loss of a clear governing philosophy – and with it, any kind of rules-based framework, clear accountability or effective incentives” for the well-documented decline in NHS productivity, quality and innovation.

The solution proposed is a new operating model “with fewer, clearer targets”. While there is undoubtedly a need to reduce the burdensome and overly centralised approach that has plagued the NHS for too long, this new operating model will largely be made up from people experiencing a major organisational change and there is not a reserve army of new change agents waiting to step in.

Setting targets is not the same as solving problems, and good intentions and determination are not a substitute for having a method. A clear, coherent theory of change is still missing from this plan – as it was from its predecessors. But this time, if there is to be a serious attempt at delivery, this – along with a good dose of humility – will be essential. Change on this scale, in a system this complex, cannot be commanded from the centre.