Will the scale of ambition scupper delivery of the 10 Year Plan?

“My advice to a new secretary of state is really simple. Buy time. The best political trick I ever pulled off was to publish a 10-year plan.” Alan Milburn, Secretary of State for Health, 1999 – 2003

After a year in government, with today’s publication of the 10 Year Plan for health, Wes Streeting will know that it is now time to deliver.

This plan is built around a vision that most people working around health care – and most patients – can get behind. Waiting times are often too long, and care is too fragmented, leaving people disempowered, confused, and trying to join dots between services. Too often, patients are expected to fit their needs to the system, rather than the NHS flexing to deliver truly personalised care. That the plan tackles these challenges head on should be welcomed.

Much to like

There’s much beyond this to like in the plan. Ambitions to give local areas greater control over how local NHS services are run are sensible, as are initiatives to keep staff in the NHS workforce. Tackling under-funding of GP surgeries in deprived areas will be key to NHS efforts to reduce health inequalities. And if the government succeeds in creating a single patient record – allowing people’s medical notes to be shared across all relevant NHS organisations – we can expect genuine improvements in care coordination and patient empowerment.

This plan is rightly ambitious – proposing a panoply of changes and initiatives – across vast swathes of the health service. But plans should be judged on their delivery, and the disconnect between the scale of ambition articulated and funding available to make planned changes may be the plan’s undoing.

Our analysis of NHS finances is clear. The 2.8% annual increase announced by the Chancellor in June’s three-year Spending Review is barely enough to keep up with current levels of activity – let alone deliver more care, or transform services. The plan describes a mix of routes for the NHS to save money: moving more care into communities, expanding use of tech, preventing ill health and reducing the ability of NHS trusts to overspend their budgets. But there is little robust evidence to suggest that moving care to communities will save money (and certainly not in the short term), and a recent OBR report featured a range of studies showing that technological developments in the health sector tend to push up costs. Unless heroic productivity improvements are delivered, cutting services seems the most viable route to reducing trust deficits.

Previous attempts to deliver more care in communities have faltered on the altar of finances: successive plans have failed to deliver on promises to shift more money and more staff to delivering community care. Pledges to boost GP numbers will need to be followed by the funding to pay for them, and promises to improve access to general practice are likely to fall short without increasing the proportion of the NHS budget it receives. But – beyond a pledge that a greater proportion of the NHS budget will be spent on community care – there is no clear articulation of how this will be achieved. 

Concerning contradictions

The plan also contains some worrying contradictions. There is righteous concern that the patient voice is too often unheard or overlooked. But Healthwatch – the independent body tasked with understanding the needs and concerns of people using health and care services and speaking out on their behalf – is to be scrapped. And a plan which aims to reduce health inequalities but is full of digital ambition lacks clarity on how the risk of digital exclusion will be mitigated.

Despite assurances from the Secretary of State that "we are not embarking on another top-down reorganisation", the plan lands as the central architecture of the NHS is being overhauled. Since announcing that he would develop a 10 year plan, Mr Streeting has also announced 50% cuts to local health boards, and the abolition of NHS England – reducing central NHS staffing to well below 2013 levels. Though there may be some logic to running these processes in parallel, this leaves central and local NHS management tasked with delivering both the 10 year plan and their own restructuring: the scale of the challenge shouldn’t be underestimated.

As the NHS moves to deliver this new plan, Mr Streeting may be mindful of more of Mr Milburn’s advice: "in my experience, in any walk of life change always takes longer than people think".