A year after the publication of the Five Year Forward View, Simon Stevens set out five tests for George Osborne as he prepared the 2015 spending review, which the NHS England chief hoped would fund his vision.
As just three years later we approach the publication of another “sustainable long-term plan” and “multi-year funding settlement”, HSJ sets out the nine tests it must pass to win the backing of an NHS that is growing increasingly sceptical and tired of plans whose aspirations run too far ahead of reality.
No big new ideas – but be clear what is on offer: No silver bullets have been discovered since the publication of the forward view. Its vision of enhanced out of hospital services remains the correct one. Stick to it but spell out in detail by service offer what the extra money is going to buy.
Do not strain credibility by overpromising: For example, by promising reductions in emergency admissions or letting the suggestion run that hospitals will somehow “do less”. A growing population of older people will keep hospitals busy with a more complex patient mix. The point is not to “shift” care from one place to another but to recognise a greater proportion of the rising demand can be more effectively and efficiently delivered in the community (and via technology).
Be transparent on the money: This means three things. First, do not raid other health related budgets in the name of “frontline NHS care” as happened in the 2015 spending review. The cupboard is bare. Honour the commitment not to transfer capital to revenue as well.
Second, be alert to where the money will be spent. Should the government wish to commit big sums to enhanced pay and a more generous deal on medicines prices – both of which are currently subject to negotiation – be clear this will set a higher baseline for new funding to improve and expand care.
It may also make sense to reset cumulative deficits and debt.
These and other demands could potentially restrict investment in existing “priority” areas such as restoring emergency and elective care as quickly as possible.
Finally, where the case for investment in service change, as opposed to increased spending on existing services, is felt justified, make sure the necessary funds are both ringfenced and arrive early enough to make a difference. Capital expenditure would be a good place to start. The prime minister promised to deliver £10bn of capital funding during this parliament but so far there is only line of sight to around £3bn.
Be realistic about how long it will take for the public to spot the difference: There will be pressure to suggest most of the improvement in the performance of the NHS will be achieved by the end of this parliament in 2022. Plenty of progress can be made over this period, but there are many reasons why most of the benefits will not be felt until after 2022. This is partly because the new money is unlikely to come on stream before April 2019, but also because it will take time to bring about service changes through meaningful consultation, secure and spend capital funding, and train the necessary workforce.
Stitch social care and public health into the fabric of the plan: Two of Mr Stevens’ five tests concerned social care and public health. It was a wise and bold move to keep the government honest in these areas but it left them too much wriggle room. This plan must spell out how adequate social care and public health funding is an integral part of the delivery of the new plan.
Make sure change can be delivered within the constraints of existing legislation: NHS England and the Department of Health and Social Care have stretched the inadequate legislative framework to breaking point and beyond. They did so to drive progress but it is now proving counterproductive and giving rise to confusion, challenge and disillusionment. Accept that reform will have to be delivered by organisations already in existence and make sure the plans do not place too much reliance on non-statutory structures like sustainability and transformation partnerships, integrated care systems or indeed improved joint working between separate system managers and regulators.
Sort out the incentives: Willing change in the NHS is never enough. What will motivate the NHS to tough out the next few years and, just as importantly, demonstrate the behaviours that will be needed to deliver integrated care? Key will be a sense of “fairness”; that everyone – individually and organisationally – is sharing appropriately in the pain and progress. This is a journey the service must go on together, even at the cost of some of the best not achieving what they could if the system enabled and encouraged them to act with only their own interests in mind.
Maintain the commitment to a greater proportion of the NHS budget being spent on mental health: A once in a generation step change to access to mental health services like that achieved on elective and emergency care in the last decade, and which goes significantly beyond the existing ambition, would give the service an eye catching and era defining achievement it could be justifiably proud of.
Be honest with the public: This will be the hard one. In summary, much of what is written above is about the NHS and government being straightforward with the public. Explaining they will have to pay more tax and that, for the time being, it will take too long to see your GP, etc, but also that the service now has clear route to providing improved care, the money it needs to deliver and, most crucially of all, hope for the future.
- Acute care
- Department of Health and Social Care (DHSC)
- Government/DH policy
- Mental health
- NHS England (Commissioning Board)
- Older people’s services
- Policy and regulation
- Public and patient involvement
- Public health
- Simon Stevens
- Social care
- Sustainability and transformation plans (STPs)
- Theresa May