It’s no good having shiny new objectives if you don’t know how you are going to achieve them.

Over the next few weeks there will be a lot of discussion about what the NHS should be aiming for in its new contract with the people. Rather than try to elbow into that discussion, I thought, (after a very helpful discussion with Sam Jones) it might be more useful to talk through some of the main issues about how the NHS is ever going to achieve something different from today..

Because the main point I always make about the NHS – and was when our main aim was improving maximum waiting times back in 2000-2007- is that if the NHS wants to achieve something different in working with the public then it is going to have to work differently from the way it does presently.

I recognise that this differs from other narratives. There are those who believe that what the NHS needs is more money to buy more resources (the same sorts of resources that we have at the moment). More output needs for more resources. More resources will buy more of the same sort of activities. This is a coherent narrative and by and large is one believed in by many parts of the NHS.

After all, so the reasoning goes, they are doing a good job; they are about to get more resources; so all that is required is for those extra resources to be added to existing ones to deliver more units of the same outputs.

The clash of narrative is between those that argue for more and those that argue for different.

The five year forward view (now launched nearly four years ago) made a strong case that the public need for health care was different and was going to become even more different in the future. Since the need was going to be different, it was essential that the supply of NHS services would also have to be different to meet these new needs.

It was a strong argument and even had a response to the “how” question. How would the NHS create different services to meet these different needs? These were the new models of care that had to be developed from 2015 onwards.

A lot of effort went into developing new models of care but, let’s be honest,

the majority – no the vast majority – of care being delivered today is still supplying services using old models of care. Service delivery fragmentation is still the norm; coordination of care around individuals the exception.

So having the correct analysis is a good start but the crucial step is to deliver new forms of services to follow that analysis.

Between 2014 and 2018 most of the services delivered by the NHS have not become a new model of care. Even more oddly most of the organisations that performance manage the NHS and that claim to agree with the forward view, are operating as if it never happened.

What this tells me about developing the contract for the next 10 years is that successful arguments – even those that organisations sign up to – mean very little when it comes to radical change.  Policy on its own seems to achieve little. Plans even less. Unless a strong moral purpose is transmitted by the people arguing for change to the public and the staff, then little will change. We need moral purpose and we need a means of delivery.

We are 6 weeks away from the end of October and the budget is on the 29th . As I mentioned last week it’s certain the budget will contain extra funding for the NHS but less than certain that – if this requires tax rises – the Government will be in a position to whip their MPs into the voting lobby.

For the next six weeks I will work through some themes on the ‘how’ of delivery.

This week I’ll discuss the importance of developing personalised coordinated care, and next week I’ll talk about waste. A time when the British people are giving the NHS more money seems an appropriate time for the NHS to make sure it is tackling waste and duplication.

In the week beginning 1st October we will look at the importance of using data and technology differently rather than simply believing that the NHS can in some way duck out of this massive social change. Just last week the Royal College of Surgeons issued a statement worrying about how all of the new health promotion devices that count our steps and take our heart rates will encourage the worried well to go to the doctor. Complaining about the impact of individualised technology on the ways in which we look after ourselves seems to me a bit like complaining about gravity. Gravity has some good points – it stops us floating off into space – and some bad points – we fall. But it’s sort of ‘there’ and can’t be wished away. Technology, like gravity, is here. Gravity plays a big part in falls and both the NHS and the wider society really need to limit their number – but railing against gravity won’t prevent them. Gravity is here to stay – and so are individualised technology and data.

We will explore the centrality of involving patients in the development not only of their health and their health care during the week of the 8th October. The 2014 five Year Forward View was very strong on this.  But now the very future of the NHS depends on it happening.

The following week I will return to what the NHS can do about inequality. In June I reported on the BMJ’s analysis of the policy to reduce inequalities of life expectancy between 2003-2010. This policy had an impact in reducing inequality of life expectancy which means we know how to do it. But here’s the problem. The NHS – and most of British society – understands the moral wrongness of inequalities of health outcomes but they believe that – like the poor – they are always with us.

Not true.  We know what to do. It’s just that we don’t have the motivation to do it.

After that we will explore the workforce in more detail. Back in June I wrote several articles on workforce issues and since then both the evidence and the situation have got a little worse.

A point I made earlier was that we are not in a position to roll forward the current model of care for the extra millions of consultations that will be needed over the next 10 years. Both the nature of the staff and what each group of them does will have to change. Betting the future of the NHS on the idea that in 2028 the international terms of trade for trained staff will be the same as they are now would be foolhardy in the extreme. By 2028 India will not be exporting trained staff. Britain may.

Finally in the week beginning the 29th October I will explore the need for a narrative for these changes and consider what sort of narrative might work.  Usually the NHS, exhausted by having spent all its effort in writing a plan, hurls it at its bewildered staff who look at the words and wonder what on earth it has to do with them.

As I said above plans achieve very little in developing people’s motivation for change. A new story of how you live your life does.

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