On the same page? Taking a closer look at the Long Term Plan and the Planning Guidance

The NHS Long Term Plan was recently published to much fanfare. Productivity in the blog industry has since sky rocketed, with most commentators tending to agree that the Plan has many merits, despite a noticeable lack of detail on workforce planning and very few references to the growing issue of multimorbidity.

A 10-year plan, many of the proposals contained in it will need that long to come to fruition. But as that represents two political cycles – maybe more in these uncertain times – the next challenge for NHS leaders will be to manage expectations and agree a realistic course for the next few years. To give confidence to patients, politicians and taxpayers, while also giving those actually delivering care the space they need to make change happen in a sustainable way.

Of particular interest to me has been the extent to which the Long Term Plan (LTP) complements the also recently published Operational Planning Guidance for 2019/20 – which arguably could be described as the NHS’s ‘short-term plan’.

Working in tandem?

Trailed in late December and updated after the LTP was published, the planning guidance sets out the expectations of ‘the centre’ for the NHS in the coming 12 months. And, when set alongside the LTP, it raises some interesting issues.

First, the tone. The ‘next steps’ section of the LTP describes “a new way of working” for the NHS. “The revitalised culture of support and collaboration will be underpinned by a new approach”, with “a reorientation away from principally relying on arm’s-length regulation and performance management”.

It is, frankly, hard to see this reorientation in the planning guidance. Although there is much focus on the need for local systems to agree plans collectively, and to align commissioner and provider expectations (an exhortation that has appeared in many previous sets of annual guidance, to little obvious effect), the relationship between the system and the centre remains couched in directive language. Organisations “must” and “will be expected to”. And “if the agreed trajectory is missed, then the regional team will intervene… with the potential to draw on the full range of statutory and regulatory powers.” Hmm.

It is entirely fair to recognise that NHS England and NHS Improvement together employ many people who work hard and in a genuinely supportive way to help local organisations deliver improvements in frontline care. But as the recent NHS Providers report on their annual survey of regulation says: “Regulation and oversight continues to stretch trusts’ capacity and impact heavily on time and resources.”

There’s a lot of appetite for a ‘new approach’, but it seems that old habits die hard.

Second, the content. The LTP has a very strong focus on delivering ‘joined up’ and ‘personalised’ care, a focus on the quality of care as measured by clinical outcomes, and an emphasis on prevention, including changes to improve the experience of children and young people. So we’d expect to see all these things translate into the planning guidance, wouldn’t we?

Well, I’m afraid we’d be disappointed.

Although there is a clear expectation that operational plans will be agreed across organisational boundaries, it takes a lot more than a plan based on organisations to deliver care that is truly integrated around the individual. A recent QualityWatch assessment of the development of integrated care shows that progress has, at best, stalled. Patients and carers are feeling less supported and less involved in their care than they were seven years ago, and there are significant variations between different groups of patients. 

I have long held the view that integration is a state of mind, not an organisational construct, and I have found no reference in the planning guidance to needing to prepare for very significant work – within and between organisations, and with staff working at all levels – to enable this cultural and practical shift.

Indeed other commentators, such as Don Redding and David Gilbert, have noted how little there is in the LTP about any real shift in approach to engaging with patients as equals. A passing reference to personal health budgets offers no measurable target for improvement in 2019/20.

The planning guidance does set out some short-term and measurable expectations on mental health and cancer services, but next to no other condition-specific expectations. Improvements on health inequalities, maternity and children’s services are shunted off into ‘longer-term deliverables’.

Look beyond NHS walls

Paul Corrigan has written an excellent series of blogs on the need for a narrative behind the LTP, which eloquently describe the need to look beyond the walls of the NHS and connect with staff, politicians and the wider public far more strongly than is currently the case.

If the NHS is not able to build these connections and show how it is responding in the short term to the daily needs of people and their families as they interact with health and care services, it may not even get the chance to keep a consistent plan through even one electoral cycle.