‘The future whispers while the present shouts’ is a memorable phrase by former US Vice President Al Gore.

Given coronavirus (COVID-19), pressures on the NHS and social care have clearly never been more urgent or challenging. Even before the pandemic, almost everyone involved in the health and social care system seemed to be absorbed by day-to-day struggles, leaving the future to ‘take care of itself’.

That was a conclusion of the 2017 Lord’s Select Committee report on the long-term sustainability of the NHS and adult social care. The committee noted that even if short-termism was understandable, it presented a serious problem. The report recommended better, independent long-range planning to quantify the demands on the NHS and social care, the resources needed to meet these demands, and analysis of key policies to shape each. After all, taken as a whole, the NHS is the UK’s largest single ‘industry’ – what industry as significant as this would not conduct long-range planning of key resources?

Responding to the Committee’s report, on 16 October the Health Foundation is launching the REAL Centre (Research and Economic Analysis for the Long term), and dedicating £20m of investment to its work. The Centre will provide independent projections to help identify future health and care needs, taking into account evidence of how policies have impacted in the past. The aim is to help health and social care policymakers make decisions grounded in facts and with a view to the future.

Why do we need this, some might say? The NHS has existed for over 70 years without it, there’s been huge progress and the NHS is consistently top of pops in the list of public support. Why can’t we just go from year to year as we have done, maybe with an occasional five year forward view? The future is so uncertain, projections are nearly worthless, surely? And the coup de grâce, ‘The Treasury won’t allow long-term investment decisions as it will box them in.’

Well, to quote another American, Dwight D. Eisenhower, ‘Plans are worthless, but planning is everything.’ What he meant is that the discipline and rigour of planning are more important than plans in shaping decisions, whether those decisions are incremental or longer term strategies. And, of course, this is crucial given that some of the key assets that make the NHS and social care system work and be sustainable include the number and skills of the workforce, capital and kit, and investment in science and technology. These need a longer term horizon to plan than from year to year.

Part of planning is to use information to set out the issues, uncertainties and possibilities in order to prepare better and improve today’s decisions. The work of the REAL Centre will include projecting forward Rumsfeld’s known knowns (such as demographic change), and looking at the possible impact of known unknowns (such as the impact on demand for care of climate change, or new technology, possible new policies, or indeed the sudden emergency of a new virus like SARS-Cov-2) and unknown unknowns (Taleb’s black swan events, for example). The latter two categories, especially the last, are the most uncertain, but can be devastating, as we have seen, and require imagination to begin to think about so we are prepared. This isn’t just about anticipating risk, but also seeing potential opportunities and acting on them.

The REAL Centre will develop its work by first looking at the hard data we have, analysing how past policies have shaped supply and demand for health and social care, and identifying what core resources (funding and staff) would be needed to meet the demand for care over the next 10–15 years.

On planning the investment needed, the REAL Centre will model various options as to what might happen. Doing this well needs imagination, creative space away from the here and now, tools to help prise us out of our usual thought patterns, and a more diverse array of perspectives to spot issues and reduce silo mentality. All this requires investment, and in turn a commitment to the value of planning for the long term.

The Health Foundation’s work in our Shaping Health Futures programme is looking at how long-term planning is currently done across government, and within the health sector, and will be reporting over the next year. Our well-attended webinar last month with Jonathan Boston, Jill Rutter and Sally Davies explored what it would take for governments to focus more on long-term strategy and planning. And it is a question I will return to when interviewing the Chair of the Health and Social Care Select Committee, Jeremy Hunt, on what it takes to be a good Secretary of State for Health and Social Care, in our new podcast series to be broadcast in late October.

Join us to turn that whisper into a shout!

Jennifer Dixon (@JenniferTHF) is Chief Executive of the Health Foundation.

Further reading


The REAL Challenge: Beyond crystal balls and COVID-19


Catch up on the inaugural REAL Challenge Lecture by Sir Andrew Dilnot in which he outlined how...

REAL Centre


REAL Centre


The Health Foundation’s REAL Centre is here to support better long-term decision making in health...

REAL Centre

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