Lesson 1: Avoid the temptations of the grand plan

Nigel Edwards argues the need for evidence over groupthink in NHS planning, while stressing the importance of local thinking and for sufficient time to make change happen.

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Published: 16/10/2018

Over the last two decades a vast amount of effort in the NHS has been expended on writing plans outlining how health services need to change. But the track record of putting these plans into practice has been far less impressive, and new proposals are often developed a short way through the lifespan of their predecessors.

This constant cycle of planning and revision has much to do with the way national plans have been constructed in the first place. Both the environment that health care is provided in and the organisations that provide it are highly complex and heterogeneous. A look at the historical evidence suggests that planning approaches designed with insufficient realism and understanding of this are likely to fail.

Make sure your solution is based on evidence, not groupthink

Many instances of a problem being identified and an appropriate solution being put forward do exist, but an organisation as large and complex as the NHS remains susceptible to groupthink. At times it has misread the various forces at play within a system or misinterpreted the available evidence – both of which can lead to a misdiagnosis of the problem.

The presumption that moving care out of hospitals and into the community would save the overall system (rather than merely the bodies buying care) money is a case in point. The goal of delivering health care closer to people's homes is not a new one and has been an aspiration of numerous policy initiatives within the NHS for many years. But once faced with a £22 billion gap in health service finances, a widely held hope took hold that moving care out of hospital would deliver on a ‘triple aim’ of improving population health and the quality of care for patients while reducing overall costs.

However, an in-depth review of this policy by the Nuffield Trust found that while out-of-hospital care may be better for patients, initiatives for achieving this are unlikely to be cheaper for the NHS in the short to medium term. Many of the learning points from the research pointed strongly towards a need for greater understanding before a policy is implemented and more detailed research to support change as it takes place (Imison and others, 2017).

There needs to be a clear and evidence-based link between the problem and the proposed solution. The use of techniques such as logic models by national and local organisations has improved this (Department of Health and others, 2015), but they only help up to a point. Complex problems are not very amenable to simple solutions or one-size-fits-all policies. In the same way, focusing too much on improvements relating to specific types of care or a particular disease area such as cancer carries a risk of neglecting more systemic improvement and of crowding out improvements in less high-profile areas (Atun and others, 2008).

Unfortunately, the process of introducing policy has often lacked some key mechanisms which would help gather evidence and expertise. Sheard (2018) looked back as a historian on almost 70 years of NHS policy on waiting times, finding that initiatives from the 1970s to the 2000s were marked by a lack of clear evaluation phases and a failure to consult communities of experts who had been working on these issues.

Don’t ignore the importance of local context

Across the country, health care is delivered from different starting points. The cultural context differs hugely, and variations in the way existing services are configured make writing national policy difficult. These differences may seem trivial when they are viewed from afar, but they often represent significant barriers to success.

This may mean that a preferred national policy solution is not suited to a local context. Taking a micro-level example, the chief executives of NHS England and NHS Improvement sent out a letter in 2017 instructing trusts to ensure that every hospital in England should use hospital-based GPs to triage and redirect patients as they are first seen in A&E (Iacobucci, 2017). The approach seemed well suited to hospitals serving populations that use A&E extensively for primary care concerns (Khan, 2015). But it was unlikely to be as effective in areas where those GPs see a high proportion of emergency cases on the same day. Frimley Park Hospital, which piloted the scheme, argued that the high proportion of patients with complex needs arriving in their A&E department meant that GPs would actually be more effectively used for managing discharge of patients, at the ‘back door’ of the hospital (Gregory, 2017).

Even if a proposed solution is well designed, the local context may mean that it cannot be implemented. The success of plans to employ GPs for hospital-based screening depends on recruiting GPs with the right skills and experience and being able to provide an appropriate working environment within a well-functioning team. With GPs leaving the service faster than they can be replaced and around half of general practices reporting a vacancy in a recent survey by the British Medical Association (2018), there is a strong possibility that such national proposals will be stymied by local realities.

This does not mean that policymakers should always accept the plea that local context makes change impossible, though – and at times this has been cited as a reason for maintaining the status quo. Those arguments are more likely to be legitimate when changes are more complex; rely more on local relationships, local leaders or local staffing levels; or affect how different organisations work together.

Don’t set the people doing local planning up to fail

An exercise in 2013/14 encouraging clinical commissioning groups (CCGs) to work with their neighbours by forming into clusters called ‘units of planning’ aimed to ensure proposals for a given area were coherent. It also hoped to maximise the value for money of any resources being drawn upon (NHS England, 2013).

But accounts from those involved suggest the project used a great deal of time and effort to create plans that were largely shelved, and the lack of reporting on any outcomes emerging from the work only serves to underscore its evident failure. A lack of clear overall direction, the imposition of planning areas that were not geographically meaningful, the lack of mechanisms to ensure collective ownership of the plan, and an excessive dominance of financial targets have been noted as significant issues.

It is interesting to note that these same issues have emerged in the cases of some Sustainability and Transformation Partnerships, the regional care bodies set up more recently to evolve the planning of care by bringing different parts of the NHS and social care system together (Edwards, 2016). From our experience of working with trusts, commissioners and STPs across England, we can see a lack of ‘in-house’ planning expertise within the health service has been an issue for many local systems and has led to strategy work being outsourced to management consultants.

Beware optimism bias and pressure for quick results

Complex change requires continual negotiation and often takes place in unpredictable ways and at varying speeds. People need to build new relationships and establish different ways of working, and the logistics of getting clinical staff together are challenging. There is little that can be done to compress the time that is needed for these tasks.

The ‘planning fallacy’ (or optimism bias) has become a very familiar element of NHS policy proposals over the last 20 years. Alongside natural optimism and ebullience from the people leading changes (who often overestimate the speed with which change will take hold), there remain other important reasons for taking a more cautious approach.

The Better Care Fund, an ambitious government project aiming to improve the integration of health and social care services by pooling local authority and NHS budgets, is a relatively recent example of optimism bias in practice. A key expectation of the initiative was that avoidable emergency admissions could be reduced by 3.5% in one year by focusing on care for older people and helping them to manage their conditions in the community (National Audit Office, 2014). The planning process for the Fund was delivered a blow when the timescale for preparing plans was shortened from 11 months to five months during the process. Instead of a reduction, emergency admissions increased in 2015/16, the first year the Fund was introduced (National Audit Office, 2017).

Likewise, a key aim of the New Care Models programme has been to reduce admissions and reduce the time spent by patients occupying hospital beds. There is some evidence of this occurring, but progress has been much slower and patchier than hoped (The Health Foundation, 2017).

Ultimately, this is not surprising. Equivalent changes in the United States took longer and consumed far greater resources (Jha, 2016). But the electoral cycle in this country has a strong and malign impact on planning in the NHS, and folk wisdom would suggest that it is only possible to achieve major change in the two to three years following an election. This is at odds with the fact that plans often favour major changes such as hospital closures, which require financial input and long decision-making processes, both of which delay implementation. So it is important not to allow pressure to achieve rapid short-term change lead to hubris and rash promises.

References

Atun RA, Bennett S and Duran A (2008) When do vertical (stand-alone) programmes have a place in health systems? Policy Brief, World Health Organization. www.who.int/management/district/services/WhenDoVerticalProgrammesPlaceHealthSystems.pdf

British Medical Association (2018) ‘Rota gaps widespread and delivery of care has worsened, warn doctors in new survey’. Press release, BMA. www.bma.org.uk/news/media-centre/press-releases/2018/january/rota-gaps-widespread-and-delivery-of-care-has-worsened-warn-doctors-in-new-survey

Department of Health, Department for Communities and Local Government, Local Government Association and NHS England (2015) How to…understand and measure impact: Better Care Fund. https://www.england.nhs.uk/wp-content/uploads/2015/06/bcf-user-guide-04.pdf.pdf

Edwards N (2016) Sustainability and Transformation Plans: what we know so far. Discussion paper, Nuffield Trust. www.nuffieldtrust.org.uk/resource/sustainability-and-transformation-plans-what-we-know-so-far

Gregory J (2017) ‘NHS England pilot area found front-door A&E GPs 'did not work'’. Pulse, 20 December. www.pulsetoday.co.uk/news/commissioning/commissioning-topics/urgent-care/nhs-england-pilot-area-found-front-door-ae-gps-did-not-work/20035884.article 

Iacobucci G (2017) ‘All emergency departments must have GP led triage by October’. BMJ 356, March. doi: https://doi.org/10.1136/bmj.j1270

Imison C, Curry N, Holder H, Castle-Clarke S, Nimmons D, Appleby J, Thorlby R and Lombardo S (2017) Shifting the balance of care: Great expectations. Research Report, Nuffield Trust. https://www.nuffieldtrust.org.uk/research/shifting-the-balance-of-care-great-expectations

Jha A (2016) ‘ACO Winners and losers: a quick take. Blog, An Ounce of Evidence/ Health Policy. https://blogs.sph.harvard.edu/ashish-jha/2016/08/30/aco-winners-and-losers-a-quick-take/

Khan H (2015) ‘How hospital-based GPs can ease the A&E crisis’. The Guardian, 15 December. www.theguardian.com/healthcare-network/2015/dec/15/hospital-gps-ease-ae-crisis

Maybin J (2007) The reconfiguration of hospital services in England. The King’s Fund

National Audit Office (2014) Planning for the better care fund. Report. www.nao.org. uk/report/planning-better-care-fund-2/

National Audit Office (2017) Health and social care integration. Report, https://www.nao.org.uk/wp-content/uploads/2017/02/Health-and-social-care-integration.pdf

NHS England (2013) Everyone counts: planning for patients 2014/15 to 2018/19. Guidance document. https://www.england.nhs.uk/wp-content/ uploads/2013/12/5yr-strat-plann-guid-wa.pdf

Rivett G (1998) From Cradle to Grave: The History of the NHS 1948-1987. The King’s Fund

Sheard S (2018) 'Space, place and (waiting) time: reflections on health policy and politics'. In Health Economics, Policy and Law. Cambridge University Press.

The Health Foundation (2017) The impact of providing enhanced support for care home residents in Rushcliffe. Briefing. https://www.health.org.uk/publication/impact-enhanced-support-rushcliffe

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