10-year ‘Plan for Change’ or ‘plus ça change’?

So here it is, after almost a year in development, a 10-year plan for health. 

Starting with an amped-up cause – ‘the NHS faces an existential crisis’, the NHS must ‘reform or die’ – the 168 pages are not short of the ambition the Secretary of State feared would be lacking. The plan is chock-full of initiatives – several to a page – almost everything its architects could think of and threaded together with a distinct ‘do it or else’ narrative undertone. On getting to the end, it is easier to sink back in exhaustion than stand up and clap.

Taken as a whole, the broad direction of travel is familiar, not just relative to the Secretary of State’s oft-stated three shifts but to at least 30 years of previous policymaking and ‘big moment’ Plans (capital P) in health – more tech, a shift to care in the community and prevention. The broad direction is right and many of the initiatives look sensible, disregarding some oddities that always creep into plans like this (such as patient-defined payment levels to hospitals) that will be swiftly dropped, if they are pursued at all.

But the more you look at the plan the more curious it seems. 

The first and most obvious curiosity is that in the scramble to produce a plan with government defining vision, realism about delivery appears to have been forgotten. The last plan with similar levels of triumphal ambition was the NHS Plan in the 2000s, but it was backed by New Labour’s 6.8% a year real-terms funding growth, powered by a strong economy. And at a time when local government and publicly funded social care were in better shape. 

In the current world of 2.8% real-terms growth per year to 2028, the real priorities in the 10-year plan are not set out, nor are their timing, trade-offs or implications for resources (money and staff). We are left with a breezy ‘everything, everywhere, all at once’ impression. And this alongside the self-inflicted cost, distraction and motivation-sapping reorganisation of the Department of Health and Social Care (DHSC), NHS England and integrated care boards, plus significant financial deficits that can’t be menaced away. Setting out a vision for the NHS that is unachievable, prefaced by a ‘reform or die’ threat, risks creating problems (if only political) further down the track.

‘A curious lack of coherent thread’

The second curiosity, given that neighbourhood care is the centrepiece, is the lack of reference to previous serious attempts to shift care from hospital into the community. These range from the vanguards and new care models set out in the Five Year Forward View, to the ‘whole system demonstrator’ randomised controlled trial of telehealth and telecare, to the Evercare programme trialled for the NHS by United Health, not to mention the well-evaluated US accountable/integrated care organisations on which the NHS models were subsequently based. The results of these and other initiatives to shift care is mixed at best. Yet, there is no acknowledgment of this in the plan, nor how to overcome the barriers previous shifters faced. 

The third curiosity is the lack of a coherent thread and underlying engine that will power ‘system reform’, aka progress across NHS organisations. Old hands like me look for this first in plans like this. Why? Because you need to build a coherent architecture across the system to support the change. Architecture means the payment system and incentives, the extent of devolution and autonomy, the scope of competition and choice, of regulation, the type of performance management, use of targets etc etc. No coherent architecture and you have different parts of the NHS pulling in different directions, and sluggish change at best (for a primer on this, read the 2004 paper in Health Affairs by the NHS’s chief reform architect, Simon Stevens, even if it was written with charming post-hoc rationalisation).

On this, the plan is a melange with all sorts of stuff going on. Two enduring dualities are worth pointing to here – state versus market and national grip versus local autonomy. 

On state versus market, on the one hand there is a public sector-philic vibe of collaboration and integration of care across an area, heavy links to local government, neighbourhood care with services coordinated under one roof, and new ‘year of care’ payments designed to incentivise care outside hospitals. On the other, a more tart early 2000s market-style emphasis on pay for performance, patient choice and use of private providers. 

And on national versus local, there is an emphasis on decentralisation and more local ‘earned’ autonomy and freedoms (including re-booted foundation trust status) with Dash-pruned regulation. This is accompanied by a stronger performance regime and centrally defined rules. The plan seems equally divided on all four, as if it’s hedging bets on what really works. Mild conspiracy theorists on the left may see in the tea leaves the faint impression of a future with competing Kaiser Permanente integrated provider lookalikes back on the agenda. And mild conspiracy theorists on the right may see a future where the NHS is handed to mayoral combined authorities as part of public sector ‘place monopolies’.

No inkling of assessing impact

Which future, of these two or indeed others, is best should depend on what works most effectively for the population given the NHS’s objectives. In the past, DHSC set aside a centrally funded research programme to evaluate the impact of key reforms like this. It seems almost old-fashioned to suggest it these days, but unless this is done we may never be any the wiser as to what is working and why and dud reforms will be repeated. Given the (rightful) emphasis on tech, a proper assessment of impact is vital, especially given current levels of techno-ecstasy in society, which are not unlinked to the potential for private profit. And, judging by a marked increase in media-grabby overclaims in the past few months on the impact of certain initiatives, independent assessment (without fear or favour) is needed more than ever. But there is no inkling of this in the plan.

The hyperbole of the plan, however well meant, will recede as reality kicks in and issues around winter, access, deficit management, managing the reorganisation and efforts to quell strikes all start to bite. The future of the NHS lies mostly in the hands of frontline managers and clinicians, not of reformers. Upping their motivation and discretionary energy must now be the main task, along with developing a grounded and hard-headed delivery plan for the next 2-3 years. In other words, walking the walk. Without this, the grander ideas in the 10-year plan will be like froth on water and the ‘Plan for Change’ risks being ‘plus ça change’.