It was always my plan that this week I would write about the differences between a plan and a narrative as a way of bringing about the changes in patient outcomes that the NHS needs. Others have been thinking the same way – and with much better research than I.
Last week Nigel Edwards and the Nuffield Trust published an excellent comment series that examined the last 20 years of plans and reports. They don’t say that all planning is a waste of time, but they do say that there are a number of clear lessons to learn from the last 20 years about what, and what not, to do.
This week I really want to concentrate on one of these – which is how well do NHS plans articulate with the reality of implementation and do they change anything on the ground?
Lacking the breadth of Nuffield Trust’s 20 years of research I really just want to use a few examples to show how, within the NHS, there is a grave danger that ‘planning’ becomes an easy substitute for ‘doing’.
The Sustainability and Transformation Partnerships (STPs) – and their clever children the Integrated Care Systems (ICSs) – have been around for a while now and their main product has been plans. Having been performance managed on how good they are at producing plans (and indeed some are much better than others) the plans have been improved by this process. But this emphasis on planning (and improving planning) has meant that a considerable amount of time and effort has gone on at that level and rather less on at the level of changing the way in which patients are provided with healthcare.
Indeed, some NHS leaders have been heard to say that 17 million people are now covered by integrated care (the number that lie within the aegis of all the ICSs put together). But this is not true. 17 million people are covered by plans for integrated care but I would be really very pleasantly surprised if there were even a million actually receiving it.
‘Planning’ does not equal ‘doing’. And improved planning does not equal improved doing.
In November or December, nationally, we are going to have a new NHS .long-term plan. I am a supporter of this because I do think the NHS needs to say what they will provide in exchange for the extra money they are getting.
But my heart sinks at the prospect of the next step after publication of the new national plan being the production of 44 local STP long-term plans. If that proves to be the case then next year will be spent first writing the new STP plans, then having them performance managed from the centre, and finally – in the last few months – improving them. Which would mean that by January 2020 let’s say 34 plans will have been accepted as good and 10 will be in the remedial stage of being further improved.
The NHS will have spent another year writing more plans and nothing will have changed on the ground. The public will have given the NHS a 3.4% increase and in exchange they will have had some documents published. This would be an excellent result if the NHS was a publishing house. But it isn’t. It’s a health service, and it is at the sharp end of the health service that both money and time will be spent.
If you’ve only got 10 years spending one of them writing is not a good use of scarce time.
The other problem is that the plan producers really believe that plans tell people what to do. If you look at the last 4 years you will see hundreds of NHS plans that start by saying “the NHS Forward View says we must…” as if quoting from that sacred text means that the argument for change is won. It isn’t. There are probably 2-300 people who really believe in the NHS forward view as a driver for change, but the rest of the workforce need the moral argument for change laid out and to be persuasive.
This brings me to another experience about the last few years of plans. A while ago everyone was told that what their plan needed was a “compelling case for change”. So in order to be complete every plan had to have a section – about a quarter of the way through – called the “compelling case for change”.
Over this period I have talked to a number of people who were planning a document about change. On many occasions they have said to me that “the problem with our compelling case for change is that very few people agree with it”. And of course that’s because people have got used to talking about the need for a “compellingcaseforchange” without deconstructing the idea that it needs to be – er – well – compelling.
What NHS patients do not need in 2019 is a year spent with document after document saying “the NHS long term plan tells us to… This will not drive the change that is necessary.
What the NHS will need in 2019 is a strong moral argument for doing something different.
It will need a narrative for change. Very few people change how they work because of a plan. Many more will do so if there is a good story to place new practice in context and tomorrow I’ll outline what that might look and feel like.