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What’s in a plan?

October 26, 2018





As a historian working in the NHS I always think we don’t spend enough time looking at the past in deciding how best to develop our plans for the future. I was therefore delighted to read, last week, the Nuffield Trust’s excellent publication Doomed to repeat? Lessons from the history of NHS reform which set out the stark lessons of what we have consistently failed to address in the last 30 years of NHS plans and reforms. As well as the disturbing experience of seeing my working life suddenly pass before my eyes in the two-page summary of previous reforms, I was struck by a familiar litany of issues: not enough public engagement, forgetting about workforce until too late, putting too much trust in reorganisation, optimism bias, misreading the unintended consequences of financial incentives. There are many ways in which the NHS is better than it was 30 years ago, but I couldn’t help being left with a sense of how little that had to do with many of the top down initiatives.

I am not trying to wash my hands entirely of having any part of this state of affairs. I have spent a considerable amount of my career in, or working with, central Government and have contributed, in my time, to the writing of many top down plans and reforms. One always produces them with the best of intentions and sometimes central actions do achieve some good. However, while it is sometimes quite possible to see the problems from the centre, it is much harder to design and ensure the delivery of effective action to address them.

So, what are my hopes of the forthcoming 10 Year Plan? I have four.

First for a message of continuity in where we are trying to get to. The underlying “sense of direction” of the 5 Year Forward view towards a more integrated and population focused system of care still strikes me as the right one. We have a long way still to go to realise that vision, but we have done a lot to bring our organisations, services and staff round to that way of thinking. While, inevitably, there will be some changes in tactics and terminology we need to continue in the same direction.

Second is for a sense of realism about how quickly we can move and what will be possible within the resources which have been made available. While I am grateful for the size of the settlement the NHS received there needs to be a sense of honesty that the figures being made available are at the lower end of what expert commentators thought was necessary. There is limited scope for doing new stuff and while everyone must remain committed to the need for efficiency we must accept that heroic assumptions about what can be achieved in terms of efficiency gains, even if we are successful in developing more integrated care, are unhelpful. As part of this I think there needs to be some public realism, which politicians must support, about what will be possible and a recognition that some areas of care will not be able to develop or expand.  As society I think, we need to have, for instance, a much more open debate about what should be provided at the end of life.

My third point and the corollary of realism is a clear sense of priorities. There are three which stand out for me: the long term commitment to addressing parity of esteem for mental health (for which yesterday’s report by the IPPR Fair Funding for Mental Health set out the implications); the systematic strengthening community, primary and care services and investment, of focus and resources, on prevention. These for me are all 10-year priorities but as with the closure of the long stay hospitals a systematic focus on these areas will deliver the transformation in our health and care system we desire.

Finally, my hope is that the plan will recognise the crucial role of NHS staff in delivering change and that it will put their welfare at the centre, in a genuine way, in the centre of things. This is see workforce not just in terms of numbers but crucially in terms of the values and commitment of staff which sit at the centre of good quality, empathetic care. Despite technological change the NHS in 2030 needs to be more rather than less of a human institution than it is now.

We will have to see if those hopes are realised. My sense is that the political nature of the NHS will inevitably mean that we will have another plan or set of reforms before the next 10 years are out. However, let’s hope that this one learns some of the lessons of the past.






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