Cowper’s Cut: The NHS Long-Term Plan For The Time Being is all about the pinot

To borrow Donald Rumsfeld’s concept, there is an important taxonomy of known knowns, known unknowns and unknown unknowns.

Let’s start with the first category. We know that even with the extra funding on its way over the next five years, the NHS does not have the money required to meet current demand. We know that demand is rising. We also know that social care has more or less collapsed, hugely increasing pressure on the NHS.

Given these knowns as our starting point, writing a long-term NHS plan is like having group sex: almost entirely a question of whom you are going to disappoint first.

It’s all about the pinot

So it’s probably just as well that in reality, the NHS Long-Term Plan is less about the plan and more about the pinot (Plan In Name Only, Theresa). Much as the Appless Mr ’Ancock is secretary of state, this document is a Long-Term Plan For The Time Being.

The NHS Commissioning Board’s boss Simon Stevens probably feels reasonably content with the way in which the Long-Term Plan has been received, at least in the media.

It is notable to see The Economist unambiguously and unironically approving the plan’s telling the government to legislate to put the 2012 act out of its misery. Yes, the same The Economist which is usually the biggest fan of markets and competition.

Likewise, we saw the Financial Times accurately observing that “the results of the Treasury’s ‘savings now’ approach have been dire. The short-term ‘efficiencies’ it has demanded have generated higher long-term costs. By refusing properly to fund social care Mr Hammond has loaded the burden on to the NHS, where elderly ‘bed-blockers’ are looked after at much greater expense. The Treasury’s squeeze has seen a flight of expensively trained medical staff. In 2016, only half of newly qualified doctors decided to join NHS training schemes. The figure in 2011 was above 70 per cent. Rising numbers of doctors and other professionals are leaving medicine completely. Nothing much will change until the NHS begins to fill an estimated 100,000 vacancies”.

Climate change

I have written often before and doubtless will again about Stevens’ political savvy, but with the Long-Term Plan, we may be seeing his masterclass.

Politicians no longer even pretend to be making the weather in the conversation about NHS and social care funding and performance. Nature abhors a vacuum, but Mr Stevens didn’t even leave a gap for such a vacuum to emerge: as I was the first person to point out, the entire health policy and politics agenda of government was outsourced to him five years ago.

The Long-Term Plan is another subtle subversion by Mr Stevens, as the Five Year Forward View was. Both of them are best understood as a blend of climate change accelerants for the NHS and social care funding debate and as financial bid documents.

Munchkin backside on a plate

As I wrote for the British Medical Journal, the regaining of the national waiting standards was notable by its absence. The four hour target in accident and emergency, 62 day urgent GP referral for cancer to start of treatment and 18 weeks for elective care have all been more honoured in the breach than the observance, and the Long-Term Plan made no specific commitment that these would get back on target.

Last Monday, on the day of the plan launch chancellor Philip Hammond wrote for the Daily Mail that “the leaders of the NHS must now get on and deliver. The country will rightly be looking to them to ensure this great institution is developed to make it safer, more effective and more efficient”.

Recent leaks to the Financial Times confirmed Treasury sources’ deep unhappiness with the Long-Term Plan, quoting one as saying “the fundamental question is how you cut demand in the NHS, rather than just increasing spending… The allocation of funds to the NHS was contingent on them having a proper plan which delivers value for money”.

Very few people in or around politics ever win in a fight with the ‘Treasury’ (or to give them their full official title, the Treasury Munchkins).

The need to re-achieve national NHS waiting targets had been repeatedly briefed and leaked to the media by HM Treasury’s charming Munchkin community as a plan must-do.

Mr Stevens has successfully handed the Munchkins their collective backside on a plate, and there is nothing they can do about it. As the iridescent health economist John Appleby wittily noted on Twitter, the Long-Term Plan is much more a parentally-driven thank-you note for a child’s birthday present than it is a meaningful longer-term strategic document.

Secondly, the caveats. As I wrote last week, The FYFV was launched with Stevens’ five tests on NHS and social care funding, but he has actually had them written into the Long-Term Plan.

The document states that “when agreeing the NHS’ funding settlement the government… committed to ensure that adult social care funding is such that it does not impose any additional pressure on the NHS over the coming five years.

“… this Plan sets out new commitments for action that the NHS itself will take to improve prevention… while recognising that a comprehensive approach to preventing ill health also depends on action that only individuals, companies, communities and national government can take to tackle wider threats to health, and ensure health is hardwired into social and economic policy.

“Indeed, the extra costs to the NHS of socioeconomic inequality have been calculated as £4.8bn a year in greater hospitalisations alone.

“Action by the NHS is a complement to, but cannot be a substitute for, the important role for local government… in recent years it has also become responsible for funding and commissioning preventive health services, including smoking cessation, drug and alcohol services, sexual health, and early years support for children such as school nursing and health visitors. These services are funded by central government from the public health grant, and funding and availability of these services over the next five years which will be decided in the next Spending Review directly affects demand for NHS services”.

Mr Stevens has hidden his caveats in the plainest of sight. This is a remarkable way for public policy to be made. Not only is The Sun King of Skipton House publicly telling the government what it’s going to do for the NHS, he is also starting to walk them up to an inevitable, and inevitably expensive, move on the funding of local government and social care.

From the Oliver Twist to the Stevens Pivot

If your messages have been about resourcing, resourcing and resourcing, as Mr Stevens’ have in recent years, then how can you best prevent the launch of your Plan becoming an uncomfortable discussion about missed targets and deficits?

It’s simple: you make sure the national media briefings are all about the big disease areas.

That, ladies and gentlemen, is how you segue seamlessly out of doing the Oliver Twist. If you wanted a name for this particular move, you could call it the Stevens Pivot.