Cowper’s Cut: A brief history of NHS plans

Well, I watched the Sunday morning TV politics programmes for some insight into what the 10 Year Forward View will bring us today. Oh, the humanity.

There is scant point in reviewing the performance of Secretary Of State For The Time Being ’Apless ’Ancock, nor that of zombie prime minister Theresa May. I will observe only that Mr ‘Ancock is fast becoming a poor man’s Chris Grayling, and that Mrs May’s “let me be clear”-o-meter is a clear peak of UK productivity.

Nothing either of use or of ornament was revealed by either person, so it seems like a good idea to contextualise the 10YFV in the light of the last two decade’s significant NHS plans.

We start with the 1999 establishment of National Institute for Health and Clinical Excellence as a special health authority, and move quickly to the 2000 double-whammy of The NHS Plan and the Response To the Royal Commission On Long-Term Care that was snuck out with it. Both were equally important to where we are today.

The NHS Plan was a kum-by-ah all-in-it-togetherness fest, which correctly identified the NHS’s workforce and capacity problems and proposed to fix them over a long timescale. That “more staff, working differently” length of vision was possible because of the politics: Labour had the size of Parliamentary majority which takes multiple general elections to turn over, and a highly dominant leader who would win it two more general elections.

It brought a huge promise of extra funding to bring UK spending up to European average levels, the creation of an NHS Modernisation Agency to spread best practice, and a concordat with the private sector. 

The Royal Commission On Long Term Care had recommended making personal social care free, with means tested co-payments for living and housing costs. The government’s response rejected this as too expensive. From this decision stems the social care crisis we have today, which drives up demand pressure on the NHS.

A critical document on NHS funding was the 2002 Wanless Review for HM Treasury, which permitted Gordon Brown to become comfortable with the fact that Tony Blair had “stolen my fucking budget” in 2000 with his promise on the David Frost TV show to match European funding levels.

Following this, we got the real delivery plan for the decade in 2002’s Delivering The NHS Plan. It remains perhaps the most concise document setting out the case for reform and the clear methods to be used.

DTNHSP set out the principle of having statutory independence and semi-autonomy from Whitehall control that was foundation trusts. This also heralded the shift of funding, with 75 per cent of the NHS budget routed via primary care trusts, and a national payment tariff under Payment By Results (in reality, payment for activity). And it created the principle of an independent quality regulator, the Commission for Health Improvement, which went on via various names to become what is today the Care Quality Commission.

The Health And Social Care Act 2003 that delivered foundation trust status (with the permission to retain surpluses, until they were renationalised via recent years’ back-door expedient of cutting national tariff prices below the cost of producing care) also gave us the FT gatekeeper-cum-regulator Monitor, latterly nominally merged with the subsequent Trust Development Authority into NHS Improvement. Monitor used to be somebody…

In 2004, The NHS Improvement Plan promised a greater focus on quality and an extension of The NHS Plan’s emphasis on patient choice and competition of care providers.

In 2008, once Gordon Brown had finally succeeded Tony Blair as prime minister, we got High-Quality Care For All, Lord Ara Darzi’s review of the NHS.

HQCFA’s emphasis was on improving care quality and safety, with a strong focus on prevention. It also introduced the idea of primary care based polyclinics, offering a range of diagnostics and services in local communities but outside hospitals. It promised a “right to choice” in the first NHS Constitution, a right to choose your GP, published quality accounts for providers and a “best practice” tariff.

The end of Labour’s time in office saw the arrival of the Conservative-Lib Dem coalition government from 2010-15, which brought us the Andrew Lansley era. Lord Lansley (as he now is) had been the Conservatives’ shadow health spokesman since 2006, and aimed to bring about the biggest structural NHS reform programme ever in Equity And Excellence, Liberating The NHS which was given legislative force in the Health And Social Care Act 2012.

This created what was then the biggest quango in the world, the NHS Commissioning Board (the artist latterly known as NHS England), and reduced NHS bureaucracy by replacing 150 odd primary care trusts with 220 odd clinical commissioning groups. Monitor’s role, backed by the Competition Commission (latterly the Competition and Markets Authority), was to promote competition in the unsubtle drag of preventing anti-competitive behaviour.

Clinical commissioning, choice and competition were the intended intellectual drivers of the Lansley vision of a denationalised NHS. There was a Responsibility Deal for public health, which delivered precisely zero.

And then in 2014, a successful pursuit by prime minister David Cameron and chancellor George Osborne saw the enthronement of Sun King of Skipton House Simon Stevens as NHS England’s new boss, which heralded the arrival of the Five Year Forward View.

The FYFV promised a variety of new care models to experiment so as “to back diverse solutions and local leadership” with “meaningful local flexibility”, and to deliver a “radical upgrade in prevention and public health”. The FYFV also heralded greater integration of NHS services, and promised a triple aim of better outcomes; better experiences for patients and staff and better use of resources.

Déjà vu all over again

And tomorrow we will have a new effort – a 10 Year Forward View, if you will. No embargo copy has been given to me, and therefore I can only give a guess about where it will sit on The Cowper Spectrum – From Meh To Bullshit.

But hopefully the above brief summary will give you some hints about things that have worked in the past (a dominant government and prime minister do seem to be clearly vital, so best that we have modest expectations for this one).

There are some important interconnections to notice. The FYFV was, as I noted on its publication, a subtle subversion of the competition elements of the Lansley reforms. Indeed, while the 2012 act passed into Parliamentary law, it is also fair to say (as I frequently have done, here and elsewhere) that it didn’t really happen. Clinical commissioning, choice and competition have been driving pretty much nothing significant over the past five years.

The FYFV, and its associated five funding tests, is best understood as an aspirational financial bidding document. As I noted back in the day, Simon Stevens clearly had a deal with Mr Cameron and Osborne to get as far with NHS financial efficiency as possible, and in return there would be a Stevens Ask in the bank.

Then came the Brexit referendum, and then went the Camborne supremacy – and of course the Stevens Ask went with them.

If there is any point in a 10YFV that seems set to be a detailed-workforce-strategy-free plan (and thus firmly at the ‘meh’ end of things), then it is that the 10YFV was a tool for Simon Stevens and Jeremy Hunt to walk Mrs May up to a significant increased funding commitment which in reality, will at best deliver the NHS enough money to carry on delivering the kind of care that it is doing now and eliminate the underlying deficit of about £4bn a year.

That is what, in a best case scenario, this funding settlement may perhaps do by 2023-4. We don’t yet know whether it will be enough to keep the system upright until then, and we should not pretend that we do.

Simon says

Plans are hard to do, as I wrote. Lord Lansley’s legacy is that, as I was the first to note back in 2015, the Conservative Party has offshored its health policymaking function to Simon Stevens.

The FYFV has on the whole not really happened yet, because of Simon’s shrewd five tests, the two on public health and prevention have remained significantly unmet. I wonder how many Stevens tests the 10YFV will involve, or whether we will get more words about prevention and public health while the actual reality this financial year is real-terms cuts.

We shall see.