Recovery Watch: What’s the point of the NHSE winter plan?

NHS England’s winter planning priorities letter received a very mixed reception when it was sent out to local leaders on Friday.

The official responses issued by the main managerial lobby groups NHS Providers and NHS Confederation were relatively standard issue for this kind of affair.

Both welcomed the early publication of “the letter” – it’s important to note that this is not the full winter plan. That will hopefully come later, perhaps alongside a ”winter pressures fund” which the centre is still trying to secure.

Friday’s letter lays out the cornerstones of the plan. Early publication letter is doubtless a positive departure from previous years. NHSP and Confed also welcomed the broad principles, while highlighting that staff shortages would remain the biggest challenge and that everyone is in for a long, hard slog.

A hostile reception from the masses

However, a far more hostile response awaited in the lengthy comments section beneath both HSJ’s stories on the guidance, which set out six key metrics and eight main focal areas for winter (further details here).

Of the over 60 comments across the two stories at time of writing, the bulk were either critical of the plans, or just expressing exasperation at the idea that any sort of performance management could shift the dial this winter.

Usually, in such HSJ comment sections, there is hostility, but also some support for system leaders facing a ridiculously tough job. The latter was conspicuous by its absence across these two stories.

One anonymous commenter, identifying themselves as a chief operating officer, said: “I don’t normally comment [on HSJ stories], but the letter that we received this morning has been a standing joke across the trust.

“I don’t think it’s joke, just more of the same and demoralising. I’m not bashing for the sake of it as we have had some amazing support from the likes of ECIST, the regional NHSE team and elements of the nursing and medical directorate.

“If the regional directors and their teams were allowed to get on with their job without interference, then I really don’t see the point of this national UEC team. Perhaps they could take the hit as part of the 6,000 jobs that need to go. We would notice but for all the wrong reasons.”

Another comment which echoed the sentiments of many others said: “Fantastic news…. When does the workforce arrive to deliver this?”

A chief concern was that the wide breadth of asks would leave leaders spread too thin.

Of course, below-the-line comments never represent the full spectrum of views, and it’s often those who are most frustrated who respond in this forum.

Equally, it’s unsurprising that NHS managers are taking any excuse to vent their spleen line right now, given the extreme pressure the system is under, and perhaps the letter was just a lightening rod for the growing frustration and despair.

But having spoken to several local leaders myself since, I think national leaders would be complacent if they simply dismissed this all as below-the-line carping.

A tricky bind for NHSE 

It prompted me, as a thought experiment, to pose the question: ‘What’s the point of the NHSE winter plan?’

The winter plan is a standard part of NHSE’s annual central guidance set list, and rightly so: if there wasn’t one, the NHS would be accused of being rudderless.

But the problem with these plans, as health policy expert and former government special adviser Richard Sloggart observed, is that the long lists which inevitably result from having to cover such an increasingly wide range of problems facing the service means “in practice [they end up being] pretty undeliverable/unrealistic”.

So, in many ways, NHSE is in a tricky bind: it has to have a plan, but when it lists all the things that needs doing, it’s accused of being unrealistic. If it omits anything from the list, then it’s criticised for neglecting whatever area doesn’t make the cut.

That does not of course absolve system leaders from critical feedback on this year’s effort.

As one senior trust chief executive told me: “It’s not a plan. It’s at best a performance framework. The metrics are sensible, safety-focused ones, but their delivery is not compatible with the workforce and financial challenges ICSs and trusts are facing.

“Fixing emergency care flows is contingent on improving access to other services (social, community, primary and mental health). That will need multi-year investment well above inflation.”

While, NHSE would no doubt argue they have set out multi-year plans too, one can understand why it is frustrating for local leaders to be told ”here’s the winter performance management regime”, with no acknowledgement they stand little chance of achieving the goals, because doing so would require far more resource than you’ve got.

Nuffield Trust chief executive Nigel Edwards also raised questions about the plan. He told me: “Looking at the objectives, the questions we need to ask are to what extent the plan goes beyond the sorts of things people are already doing, and whether the plan is really high powered and radical enough, given the scale of the truly enormous problems the system is facing right now?”

Mr Edwards added that the “repeated application of solutions that have demonstrated not to be working is also a concern”.

“A number of the solutions in here, like more same day and emergency care and more acute frailty units have been tried repeatedly for a few years. At what point do you say we need to try something new?”

He also raised concerns about “a lack of real focus on community services”. “If you want to shift your seven-day plus don’t meet the criteria patients, it’s not all about social care. There are a whole bunch of other community services which need to be put in place,” he said.

While acknowledging the difficult bind the winter plan presents, it would be sensible to sharpen it up in future with better local buy-in to a plan developed by the wider NHS and care system, rather than just another diktat dropping in from on high.

Then again, while the system as a whole remains so comprehensively under-resourced and understaffed, no amount of planning, no matter how inclusive, can hold back a tidal wave demand this winter, and everyone would do well not loose sight of that.