Getting what we pay for, means finding a way to deliver with less than enough, states Mike Birtwistle
The ink is barely dry on the #NHS70 birthday card and already many observers fear that the funding settlement will be insufficient for the NHS’ needs or to make good on the ambitious rhetoric coming from the top of the government and the NHS.
Yet this reality check should not diminish from the scale of the achievement of those who negotiated the settlement or the extent of the shift we have seen from the incumbents of 10 and 11 Downing Street.
Even a year ago the prime minister and the chancellor were adamant that the NHS did not warrant a significant injection of funding. After all, why would they have signed off on a Manifesto which declined to provide a funding boost, which would have been as popular as it was necessary?
A new era begins
The new secretary of state for health’s background is in economics. Matt Hancock cut his teeth in politics as an advisor to George Osborne in opposition and so the new secretary of state could be forgiven if he brings a dose of Treasury scepticism about the NHS’ status as special case in public spending.
He is also a highly political animal and will want to extract every pound of political value from the spending commitment.
All of this merely serves to raise the stakes for the NHS. Given the political volte face that we have seen, and the implications that this will have for other spending departments (not to mention Conservative backbenchers who are squeamish about tax rises), it will be imperative for the NHS to use the money well.
This means stabilising creaking NHS services, strengthening performance and improving key health outcomes, which the health think tanks have reminded us are poor on some key measures.
Plan at its unfolding
Eyes now turn to those tasked with developing and delivering the ‘plan’ for the NHS. Remember, the NHS has not been told to go away and get on with it. The plan still needs to be written and then signed off before the Treasury actually releases the new money. There is a lot riding on the next few months.
It is no small task. The plan needs to be sophisticated enough to convince the Treasury that the rumoured conditions attached to the money – achieving cash, releasing efficiencies and the like, will be delivered.
With more time, the mooted NHS Assembly could have played a big role, but it will not be up and running by the time the plan is due
The Department of Health and Social Care’s arm’s length bodies, as well as the DHSC itself, need to feel and be involved and comfortable with the direction of travel. Thinking now taking place in parallel on workforce and social care needs to be integrated, somehow, into the development process.
And then there is the prime mnister’s call for the NHS to be involved too. How can this be achieved when there are only a few months to everything that is required, and over the summer too? With more time, the mooted NHS Assembly could have played a big role, but it will not be up and running by the time the plan is due.
So, for the plan’s development, NHS England may settle on something looking like the NHS Future Forum, which managed to retrofit a consultation process involving several thousand people onto the Lansley reforms in 2011, and over a period of a few weeks.
The NHS Assembly’s true value, then, is likely to come in fostering support for the difficult decisions required to translate any vision into practice. History tells us that the delivery plan for NHS reform is often more significant (and controversial) than the grand policy statement it supports.
Plans and strategies tend to attract the attention, but it is often what follows which has the bigger impact. It was Delivering the NHS Plan that heralded the creation of foundation trusts, payment by results and patient choice in NHS elective care.
The original NHS Plan was silent on all these issues. More recently, sustainability and transformation partnerships did not warrant a mention in the Five Year Forward View, yet quickly became the most important planning unit for the NHS.
Plans and strategies tend to attract the attention, but it is often what follows which has the bigger impact
That many of the STP plans proved to be so controversial is in part due to the absence of discussion or engagement that preceded them. Avoiding this pitfall will be a key task for the assembly.
Non reliance on pinky swear?
Incisive Health recently brought together a group of experts for a series of discussions about how to build a long term plan for health and care that uses the money wisely and builds support for the priorities and changes that will be required.
The consensus was that big changes will be required if these goals are to be met. You can read more about the discussion here.
Although the prime minister’s assertion that she is open to new health legislation will be welcomed by many, the NHS would be wise not to hang its hat on this particular promise. Forging the consensus demanded by the prime minister will be fiendishly difficult and, in any case, the realities of the Parliamentary, legislative and political situation are all against legislation.
The task for NHS England of the next few months is to tread the fine line between number 10’s desire to see a plan which commands enough consensus to avoid cancelling out the political capital bought by the extra money, and the Treasury’s desire to see sufficient disruption to convince it that meaningful efficiencies are going to be found.
Although the prime minister’s assertion that she is open to new health legislation will be welcomed by many, the NHS would be wise not to hang its hat on this particular promise
There may be method in this madness. Any plan which does not attract the support of the professions, managers and patients, all of whom feel overstretched and wearied by change will fail.
Yet it will also be a missed opportunity if the new plan doesn’t seek to disrupt a status quo which even its defenders admit cannot be sustained. In an era of staff shortages, increasing burnout and rising need for services, doing more of the same is not tenable.
And with a spending settlement that is at once both generous and tight, finding a collaborative way to enable disruption is probably the only way to square the money with the rhetoric.