Five tests for the new NHS long term plan

The long term plan can’t just set a bold and ambitious long term vision for the NHS, but must work towards meeting operational and financial targets, says Ferelith Gaze, senior public affairs manager at NHS Providers

The £20 billion NHS funding uplift announced in June, and the accompanying long-term plan, could mark a key point in the history of the NHS. The plan, and accompanying government commitments to consider social care funding, training and public health, provide an opportunity to set out a clear and achievable path for sustaining and improving patient care and cementing political and public trust in the service.

While the headlines might focus on missed targets, the NHS is serving more patients than ever before. Despite being under pressure on all fronts, with growing workforce and financial challenges, NHS trusts have maintained or improved quality of care, become more significantly more efficient and pioneered new models of care in local systems.

But, at the same time, over the last four years, NHS providers have been locked in a debilitating cycle of failure where they can’t meet their financial and operational targets, irrespective of how hard their frontline staff work. The provider sector ended 2017/18 with a deficit of nearly £1 billion, sustained underperformance against constitutional targets, an ageing infrastructure misaligned with care needs, and an overall eight per cent staff vacancy rate.

That’s why it’s vital that the long term plan doesn’t just set a bold and ambitious long term  vision for the NHS. It must also reset the day to day provider delivery task so that the vast majority of trusts, performing well, can meet the operational and financial targets they are set.

With that in mind, NHS Providers and the provider sector have five tests for the plan:

The plan is centred around patients, service users, carers and families.
Are people getting what they need from the NHS?  Have the views, experiences and goals of patients, service users and those around them been heard and reflected in the plan? We know that, for the most part, today’s care models don’t fit today’s care needs. But in addressing that mismatch, there’s a risk of being distracted by organisational structures, whether local, regional or national. The NHS needs to work better for those that use it.

The plan is realistic and deliverable.
The plan will fail or flourish depending on whether or not it is deliverable, now and in the long term.  Performance and financial recovery trajectories and productivity expectations must be realistic. Priorities must be identified, and where difficult choices need to be made, this should be done transparently and openly. We have to be honest about the true scale of the extra demand we will face as our population ages and have a clear plan for how, as a health and social care system, we will meet that demand challenge. So, please, no more heroic assumptions about demand management or productivity gains to make the money balance, as we got with the plan that followed the five year forward view.

The plan is underpinned by a credible workforce strategy.
The single biggest challenge the NHS faces are our current, persistent, and enduring workforce shortages. The long term plan must address this issue head on – how will we sort this shortage, how long will that take, and what constraints must the service operate within, in the meantime. It’s vital that what is asked of trusts is explicitly measured in this context – there’s no point in asking trusts to deliver something they can’t achieve because there are insufficient staff. We also know that there is a strong association between the quality of patient care and levels of staff engagement. The plan needs to set out how we sustainably make the NHS a great place to work. That means a day job that is doable, with staff appropriately rewarded, valued and supported with the right staff in the right place at the right time. Local leaders need to be supported and developed. From top to bottom, the NHS needs to become renowned for having a culture built around learning and openness.

The plan lays the groundwork for a transformed, sustainable, high-performing service.
We all know the NHS has to transform and the new care model vanguards have shown what changes we need and how they can be delivered. England’s population is growing and ageing, and the shift to an emphasis on prevention and providing care upstream through joined up primary, community and social care services will be a significant one. It will need sustained investment in people, capital and technology. The long term plan needs to show how we can rapidly scale up the lessons we have learnt from the new care models and roll them out from Newcastle to Newquay. It also needs to set out how we can do this whilst continuing to provide excellent care in an increasingly pressured environment – rebuild the plane whilst it is flying.

The plan supports local good governance, autonomy and accountability.
Will the ways of working laid out in the plan be sound? We need to restore the principle of subsidiarity – that of decisions being taken as close as possible to where work is delivered – with appropriate lines of accountability. Where these lines blur – as they have done in recent years with central grip tightening over local NHS bodies – then objectives become confused and decision making is stymied. Strong providers, led by strong boards, working within local systems, all accountable to local communities, are the only way to deliver excellent care. The national bodies need to set out in the plan how they will truly realise their stated ambition of moving away from top down regulation and performance management to genuine support and improvement.

In taking the plan forward, NHS leaders must be attentive to the needs and views of patients, staff and the public. There may be some radical changes to be made – some behind the scenes, some clearly visible on the frontline. Given the timescales for developing the plan, it seems likely it may be a high level document. It also seems likely that there will be a continued period of engagement after its November publication, and this is a significant opportunity for any likely changes to be set out, tested and refined.

To take one example: the NHS’ constitutional targets. Despite seeing more people than ever before, the constitutional targets are being missed, with the 4-hour A&E target last met nationally in July 2015. The reasons behind this are complex, but underfunding and workforce shortages are high up the list. With public awareness of this issue so high, should the funding uplift be directed towards recovering performance or other priorities?

There are also questions about the clinical appropriateness of current targets, and whether they achieve the right balance between driving behaviours and measuring patient experience and care quality. Describing the ‘A&E target’ simply as a measure of acute care is clearly misleading. A&E is one of the front doors to the NHS, and is a signifier of patient flow and performance across the local health and care system. It may therefore be that investing in system pathways involving primary care and social care might best alleviate some of the pressures seen in our A&E departments. While some targets may require modification, new targets will be welcome and helpful in some sectors, such as mental health, to draw attention to historically under-funded services for the benefit of services and service users.  

The arguments around this issue are complex and, as the conclusions of the review of clinical standards become clear and are built into the long-term plan and beyond, care will need to be taken to ensure that clinicians lead and champion any proposed changes.

In the end, the key test of the long-term plan is that it must be deliverable – it must stack up for all concerned and generate confidence. The NHS faces an immense risk in putting forward to the public something which will be seen to be its own, funded, plan and then failing to deliver it. Mitigating that risk means keeping a determined eye on the long-term, setting a realistic day to day delivery task and putting the NHS on a sure footing towards transformation and a sustainable service. We must set the NHS up for success.

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