How can an NHS plan really make a difference?

The Secretary of State launched a public consultation on the English NHS’s new 10-year plan last week with the words that the health service is “broken, but not beaten”. But if it is broken, it is not for a lack of plans. 

The 2014 Five Year Forward View and 2019 Long Term Plan were comparable national exercises that sought to achieve basically the same as the three shifts envisaged this time – from hospital to home, from cure to prevention and from analogue to digital. A set of smaller plans more recently aimed to improve access to care, which typically shows up as the public’s top concern, across A&E, planned care, and general practice.

But something went wrong in the translation from goals to reality. All these plans, with all the right intentions, failed to deliver multiple key goals and left us with the “broken” NHS of today.

While we wait for the engagement process to inform the aims of this plan further, what can we learn from these experiences and those in other countries about what might make a plan able to actually achieve its goals? 

Staff and local leaders need to be on board

A common stumbling block of structural reforms for integration across the UK has been that culture and mindset did not automatically move towards cooperation just because hospitals, community services and social care moved into shared organisations. This often ran alongside hospitals pushing to maintain or even increase their budgets. A study on integrated reforms in the Basque Autonomous Community in Spain found similar issues, even as staff did find combined structures, supported by single finances, to be useful.

The many different and separate ways that leaders are monitored, managed and graded by central bodies against narrow goals, like hospital waiting times, risk contributing to divided cultures. Actually sharing power and devolving decisions may be effective. Denmark’s reforms saw local leaders given key devolved roles. Clinicians advised both locally and nationally with significant input, bringing them on board as well.

The patient safety elements of Scotland’s 2007 Better Health Better Care Action Plan instituted what eventually became a “Scottish Patient Safety Programme”. This placed a heavy emphasis on cultural outreach to clinicians, a leadership style that engaged with individual teams at the front line, and specific briefings and meetings in wards and offices to make people think more about safety. With other elements described below, this showed signs of lasting success, leading to significant improvement in stillbirth and mortality.

Move resources, not just structures

For around 20 years, all four UK governments have also hoped that changing NHS governance structures – typically uniting payers, providers, and different parts of health and social care – would lead to shifts in funding and join up care better. However, this has had limited results in achieving their stated aims, and have generally not translated into any change in spending or activity away from hospitals.

Denmark’s 2007 reform plan appears to have been successful against its stated goals of productivity and shifting care into the community, to the point where planners initially underestimated the number of hospital beds freed up. It did change governance structures, but also simply redirected resources and incentives. The process explicitly reduced the number of physical hospital sites, invested large sums to expand and rebuild those which remained. It made local councils pay when their citizens were admitted to hospital or treated as outpatients, incentivising them to avoid this.

Within England, the system of distributing hospital funding based on the number of units of treatment introduced in 2002’s “Delivering the NHS Plan” is now widely perceived to have been effective in shifting resources into the hospital sector and driving up its activity. Initially a successful measure to improve waiting lists and access, this effect continued to the point that later leaders would come to regret it. Similar patterns were seen in many other European countries.

Don’t sign up to hospital savings that won’t happen

One of the most common drivers of failure within England has been assuming unfeasibly high savings from initiatives to “integrate” care or move it away from hospital. The 2014 Five Year Forward View assumed a sustained rate of savings of 2 to 3%, reflected in its accompanying financial settlement, which was not delivered. This contributed to years of annual savings assumptions for trusts that proved unachievable, resulting in cutbacks to the budgets which were actually meant to support reform and change.

The NHS has learnt to claim high savings as a way to get immediate cash from the Treasury, and will feel under more pressure to be “ambitious” with a new government. In reality there is little evidence that caring for patients closer to home saves money by freeing up more hospital spending than it costs in new spending elsewhere. It may gradually enable an expansion of services with less investment than expanding hospitals, delivering better value and productivity – but this is not the same as actually freeing up cash in a world where patients are literally queueing for each hospital bed made available. My colleagues will explore these dynamics more in a later article.

Keep support stable, and make sure managers and data are there to respond

A stable, consistent policy course tends to be best for change. This allows for the security to invest in appropriate buildings and equipment, and studies suggest that it builds credibility with staff and better results.

But inaccurate budgeting has meant that funding intended for strategic goals and reforms under the Forward View, the last Long Term Plan and the Elective Recovery Plan has often been raided. Many smaller pots have only ever lasted a few months.

In general, plans, reforms and initiatives have recently followed one another in very quick succession in the English NHS. The duration of this plan creates an opportunity for stability, but only if the government subsequently stays the course.

This is associated with a pronounced lack of data and managerial capacity needed for major change. Major national integration initiatives have often then proved to be very difficult to fully evaluate, plagued by a lack of data outside hospital, methodology changes, and the fact that there are so many different initiatives going on at any one time. This means we never fully understand whether or not they worked. The patient safety process that began with Scotland’s 2007 plan, and showed promising results, instead emphasised bringing in a “quality improvement” approach that constantly learnt from data on which initiatives improved safety.

As Lord Darzi noted in his recent report, operational management capacity in the NHS also seems strained and likely inadequate. Improving data and increasing the number of front-line managers are not exciting goals for politicians to announce, but they may be prerequisites to achieve their long-term hopes for the NHS.

Set targets that are plausible

Excessive optimism about waiting times targets has also been a point of failure in many of these plans. It is easy for the Treasury and ministers to feel that they are doing something helpful by encouraging the NHS to aim high. But in reality, aiming higher than is really possible is likely to have either no effect or a negative one. 

The continued pressure on NHS trusts to meet commitments to recover A&E waiting times expressed in the Forward View encouraged needless admissions to get people out of emergency rooms, and pulled attention away from those waiting so long that they were well over the target. A study of NHS trust performance found that while the NHS was meeting or close to meeting the 18-week target, patients close to the target were being squeezed in under it. But once it was unable to meet it, the target ceased to have a discernible effect.

Waiting times goals should be based on actual calculations of productivity and output, rather than setting unmodelled aspirational targets as a one-off.

Confront the difficult choices

Plans also present an opportunity to confront the fact that no health care system can do everything, and to establish consensus around rationing. Otherwise, these decisions will be taken locally and unofficially and may flow against the policy intention. The public engagement process provides a good opportunity to decide as a society on some difficult questions.

The 2000 NHS Plan, which heralded a period of massive spending increases to drive waiting times and clinical improvements, emphasised that it came alongside the introduction of NICE to “help the NHS to focus its growing resources on those interventions and treatments that will best improve people's health…  pointing out which treatments are less clinically cost-effective”. Additional money could otherwise have simply spiralled into an uncontrolled drugs budget.

A difficult choice facing the NHS today remains how strongly it prioritises covering high cost drugs versus everyday services, at a time of rapid innovation when controversial decisions not to cover new but very expensive drugs exist despite a strongly rising drugs budget. The government’s manifesto commitment to reduce the regional gap in healthy life expectancy also raises the question of whether we should have clearer prioritisation towards people in the worst health. 

The health service will not have enough money or staff to deliver everything that people might ask of it in the current consultation. But the public are intelligent enough to recognise this – and if citizens’ assemblies or deliberative events are held, they should not shy away from the difficult questions.