Cowper’s Cut: Planning permission

A curmudgeon, cynic and pessimist might suggest that the NHS is not particularly fantastic at planning.

Fortunately, I am notoriously none of those three things. So, here goes: the NHS planning function has very high productivity.

This isn’t much of a surprise in an NHS system which (to borrow the late, great Professor Alan Maynard’s great phrase) has seen an awful lot of redisorganisation over recent decades.

If you’re constantly renaming the planning and funding local units, and making everybody apply for their jobs back after abolition, the system is going to do A Lot of planning.

But is it any good?

The quality of that planning, of course, is another matter. 

And as the recent book of essays and event from the Nuffield Trust this week showed, the word “awful” is not casually chosen here.

In not totally unrelated planning news, Matt “The App” Hancock this week confirmed the production of new ideas for the forthcoming social care green paper. He also stated his view that social care should not become free at the point of use according to need and not ability to pay.

So, the taxpayer will not be on the hook for social care.

What makes a plan work?

I can only recommend reading and thinking about the Nuffield Trust’s book of essays, but a few things stand out from that set of ideas and conversations.

First, there have been 13 significant structural reorganisations of the NHS this millennium. That is probably 12 too many. In contrast, the NHS’s structure was largely unchanged from its creation in 1948 to the 1974 reorganisation.

Second, Nigel Edwards memorably observed that Kyrgyzstan is currently taking 18 months to develop a 10 year healthcare reform plan, while we are attempting to do so in three months. Although the extant Kyrghmen healthcare infrastructure may be less “developed” (and have fewer vested interests who can block change), this is a key point about the haste vs speed relationship.

Third, as I have noted in these columns a few times, Dr David Bennett (ex of the Number 10 Policy Unit and then Monitor) pointed out that there is a lack of a serious theory of change behind much of the reforms. Last week, I cited ICHP boss Axel Heitmueller’s recent HSJ comment piece pointing to the Cabinet Office’s 2006 attempt to create one: it still bears re-reading.

The permissive society

Well planned and well implemented change is obviously mutltifactorial, but I would suggest that there is one vital factor: the permission of the system being changed.

Consent matters. There are some very good people involved with developing the plans. How much the system is genuinely co-producing the messages must be open to question, and clearly varies by theme and locality.

Change is rarely easy. Hearts and minds matter.

If producing the 10 year plan is (as I suspect) largely driven by the demand of our dear friends the Treasury Munchkins, then perhaps it is time for NHS Commissioning Board boss Simon Stevens, the Sun King of Skipton House, to hold a seminar with the Treasury Munchkin community on the opportunity costs of planning with excessive haste – largely, the risk of a wisdom deficit that can’t be netted off by any surplus of political nous.

PS – On the £84bn NHS funding increase nonsense I wrote about in recent columns, ‘Sumproduct Phil’s’ maths homework got marked by Full Fact. It concludes that “there is a way of calculating the figures that gets £84bn, but it’s unhelpful and contains some potentially misleading figures”. Quite.