The long term plan for the NHS in England is not short of proposals. Its 50,000 words harbour a multiplicity of initiatives to enhance primary and community care, strengthen the role of the NHS in preventing ill health, improve outcomes for major conditions, grow and better support the health care workforce, and make more use of digital technologies.

The plan is just that — a plan — and so is understandably lighter on the detail of implementation, which local health and care systems are now tasked with developing. It makes much of its pragmatism and achievability, noting that almost everything in it is already being implemented successfully somewhere in the NHS. But identifying the solutions is often only half the battle — the challenge is to get solutions working well for staff and patients everywhere. The decisions that policymakers and system leaders make in the next few months will be critical in determining how far this will be achieved over coming years.

Translation from plans to patient benefit is a journey fraught with pitfalls, and will require thoughtful approaches to implementation that support clinicians in leading the changes they can see are needed locally.

As The BMJ and Health Foundation’s current series on Quality Improvement in health care is exploring, it is easy to underestimate the difficulty of making change happen in a complex adaptive system such as the NHS. Patients and health care professionals have intrinsic motivation to improve care, though will make decisions on which initiatives to engage with based on their judgements as to how a given idea fits with their aims and ways of seeing the world, and often have considerable power to support, actively resist, or passively let pass solutions suggested from outside.

Furthermore, what has worked once in one place won’t necessarily work the same way, or get the same results in a different context. That means that many of the kinds of changes the plan proposes can’t be directed solely from positions of national or organisational authority, but instead also require clinical professionals to work alongside patients in identifying and understanding problems, designing, testing and adapting solutions, and evolving new ways of working.

As such, it will be important that local plans don’t mandate a 'copy and paste' approach to the solutions outlined in the plan, but ask what conditions and support will enable clinical teams to implement solutions effectively.

These conditions will include the development of organisations and teams with sufficiently aligned aims and objectives, able to harness professional motivation and will, involve patients in the design and delivery of care, access useful information and intelligence, and apply good operational management and quality improvement methods to solve problems. Action to boost workforce supply, morale, and retention will also be critical — without sufficient staff, expending precious time and emotional energy on leading service improvement risks being perceived as an unaffordable indulgence in the face of operational delivery pressures.

The plan has many of the right instincts in this area, setting out plans to boost improvement capability, and articulating a 'reorientation' away from reliance on arms-length regulation and performance management to supporting service improvement 'across systems and within providers'. This shift in ways of thinking could be critical, given evidence that national improvement initiatives can be interpreted by organisations and staff as tools for accountability and blame

A new Chief Improvement Officer will set an important tone, and have critical decisions to make, including about the balance between the resources held centrally for improvement and those invested in building improvement capacity and capability in local organisations and teams.

Local capacity and capability will be vital, particularly as the NHS undertakes the challenging work of supporting health care professionals working in different organisations to improve care together as part of Integrated Care Systems. In the end, delivery on the promise of the NHS Long Term Plan will not be decided in plans and papers, but will instead rely on translation of its ideas into the thousands of conversations had, decisions taken, and choices made by health care professionals and patients every day in meeting rooms, corridors, clinics, theatres, and wards across the NHS. 

Will Warburton (@willwarburtonHF) is Director of Improvement at the Health Foundation.

This blog was first published in The BMJ.

Further reading


BMJ Quality Improvement series

A joint series of papers exploring how to improve the quality of health care delivery, produced by...

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The improvement journey

May 2019

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