The people's plans?

New NHS England guidance has been coming thick and fast in recent weeks. But during a crucial time for the service as it gets back on its feet after the shock of the pandemic, can the long list of expectations on services and managers really be reasonably met? A new blog from Helen Buckingham argues that expectations have been set worryingly high.

Blog post

Published: 12/08/2020

August is traditionally a ‘quieter’ month for NHS managers – a lull following the operational pressures of winter and the frenzied activity required in spring to agree annual plans and contracts. But 2020 is unusual in many ways, and already this August NHS England has published two major documents requiring immediate attention – the People Plan for 2020/21 and the Phase 3 letter (with accompanying guidance), which together set out the expectations on local systems for the rest of this year into the next.

At first glance, both documents signal a shift in approach from NHS England. Both make much of the level of engagement which underpins them, so that the priorities set out in each can reasonably claim to be built ‘bottom up’, from staff, patients and the public.

But the risk of such an approach – welcome though it is – is that without a clear recognition of the need to prioritise, the result becomes a shopping list of everything that matters to somebody. And in a service which, despite the commitment to ‘whatever it takes’, remains constrained by the resources available to it, not everything on the shopping list is going to be affordable or available everywhere.

A herculean task

It’s hard to argue against the general premise of either document. NHS staff absolutely have a right to be demonstrably respected, valued and supported, and to work in an environment which is compassionate and inclusive. Patients, especially those whose care was disrupted significantly by the pandemic, have a right to expect that their needs are met. But is it realistic to expect that all the asks in the People Plan and the Phase 3 letter can actually be delivered over the next 6–12 months?

The Phase 3 letter contains in excess of 40 measurable targets to be met. Here are a few examples:

  • delivery of inpatient activity at 80–90% and outpatient appointments at 100% of the activity levels for the previous year
  • completion of all outstanding Learning Disability Mortality Reviews
  • a drive to ‘111 first’
  • the biggest flu vaccination programme in the history of the NHS
  • increased capital investment in mental health services
  • the completion of all Continuing Health Care assessments, including retrospective ones for patients discharged at the height of Covid-19.

We and others have written extensively about the challenges the NHS will face in a return to anything like normal levels of activity. Within hospital and community services, the ongoing need for heightened infection control measures has significant implications for productivity. The ability of the NHS to ‘bounce back’ compared to other countries is significantly hampered by the effects of 10 years of austerity. For colleagues in social care, the effect is even more marked.

Notwithstanding the warm words of thanks to staff which top and tail the letter, the spectre of ‘old-style’ performance management looms large. Systems are expected to return plans to show how all the targets will be achieved in draft by 1 September – exactly one month from the date of the letter – and in final form by 21 September. Despite the fact that the financial framework that will need to underpin those plans for the remainder of the year remains unclear, systems are told that they must achieve their targets and achieve financial balance across the system.

What’s more, all this must be achieved while leaders “continue to look after each other and foster a culture of inclusion and belonging, as well as action to grow our workforce, train our people, and work together differently to deliver patient care” as set out in the People Plan for 2020/21.

Holes in the plan?

There is much to be welcomed in the People Plan, even if many of the recommendations repeat those in earlier documents.

It sets out many examples of good practice across the NHS and exhorts leaders everywhere to learn from those. There is real focus on the physical and psychological wellness of staff, and on addressing systemic inequalities which have only been thrown into sharper focus by Covid-19.

But it explicitly excludes discussion on plans to expand the workforce significantly, and to ensure that education and training is fit for the long term – for that, we must wait for the outcome of the forthcoming Spending Review.

Throwing down the gauntlet

So the challenge these documents give to local leaders is to take the same staff who are acknowledged to be physically and psychologically weary, and to inspire them with the confidence that their needs will be met over the coming months, helping them push through and “harness the same ambition, resilience, and innovation in the second half of the year as [they] did in the first”.

It’s quite an ask. Dame Marianne Griffiths, Chief Executive of Western Sussex and Brighton University Hospitals NHS Foundation Trusts, has described it as unprecedented in the history of the NHS. 

NHS England state that they will “work with… stakeholders… to track and challenge progress” against the priorities set out for the remainder of the year. They also reference the excellent five principles which National Voices have set out for the next phase of Covid-19 response. The first of those is to “actively engage with those most impacted.” And in the context of the last few months, those affected include staff, as well as patients.

People who work in the NHS want to be able to serve patients well, and the last few months have proved how much they can accomplish with care and creativity. But leaders at both national and local level will need to work hard to have open and honest conversations with both staff and patients about what matters most to achieve in the coming months.

Without that, there is a risk that in attempting to meet the very real needs of both patients and staff, leaders may feel that they are failing both – at a time when success has never felt so important.

Suggested citation

Buckingham H (2020) 'The people's plans?' Nuffield Trust comment.