We are – provided we still have a Government in 3 weeks’ time – just a little way away from the publication of the NHS long-term plan. For much of the last few months I have been blogging about the various activities that will need to be in place if that plan is to have an impact upon the healthcare of the public.
One of the most significant reactions to the series was to the point I made about staff and the public not doing very much at all – just because there is a plan.
Today I want to make that point in another and more critical way.
There will be a lot of people in NHS organisations working late into the night to ensure that the long-term plan has internal coherence and reads well. Evidence will be being marshalled; trajectories and yearly targets will be being calculated and, if there is time in the last week, writers will be trying to make sure that it is a well written document. On publication day this group of very tired people will be looking forward to a rest. Having been in that position myself a few times, I don’t want to belittle their efforts.
But nothing real will have happened. Hundreds – perhaps thousands – of people will read it – will have their own opinions. Some will be very disappointed that their aspect of healthcare improvement – one in which they believe passionately – has not been included. Others will be distraught that the plan has got an argument wrong. The think tanks will start circling to criticise the way in which the document has been argued.
Others, myself included, will be blogging, writing pamphlets and giving talks about the various topics and there will be a flurry of communications about the plan’s intentions.
All of that is a world of, at most, a few thousand people.
And by the very nature of its title – a long-term plan – it will say nothing at all to those people who are looking for real improvements in their, and their loved ones’ healthcare, before the end of this year. The phrase, ‘long-term’, is a clear defence against those people who want improvement now and using it defends the plan from criticism by the person who, before Christmas, goes to see a clinician to ask, “Can I have the better healthcare promised to the country in the long-term plan now?”.
I was in a meeting last week where a mother reported that she had been told that just because her 13 years old had suicidal thoughts, the NHS couldn’t do something about them until her daughter acted on them. (Regular readers will know that the shortage of resources for children and adolescent mental health is not an uncommon experience for parents).
My suspicion is that if this mother sees anything in the plan about an increase in resources for children and adolescent mental health – she will be straight down to the NHS to ask for some of them for her daughter.
She, and others like her, will be told that only a plan has been announced, not a change in service.
Some of this is of course inevitable. It is the difference between the important business of announcing a change in intent and being accountable for it, and delivering that change to real people already in pain and distress.
I have little doubt that when the plan is published its very tired planners, writers and editors will have done a good job. But all of us involved in the NHS must recognise that all that good work just adds to the puzzlement of the mother I mentioned above. Already very distressed that her daughter will get no help until she ‘acts on her suicidal thoughts’ she is now more upset that this ‘plan’ doesn’t change the reasons for her distress one bit.
Some of us spend some of our time believing that what really matters is a good plan. But nearly all of us really really know that what matters most is a better service for that mother and daughter. The plan will take 10 years to deliver. The need is here and now.
I don’t believe in magic and as I have acknowledged previously, I have been responsible for publishing a lot of these plans, but I have also sat in rooms with patients who expect something from them here and now. If you tell them change will happen in 36 months’ time their response will demonstrate how remote we are from the distress in their lives.
What we need to do is to move beyond what usually counts as ‘planning’. In order to deliver a long-term plan for a service for the mental health of children and adolescents we first need a long-term plan for young people with some resource behind it to work through and plan the next ten years.
It will start by calculating how long it will take to train enough staff to meet demand. The trajectory will start by creating and commissioning courses for these professional staff. Then to work out how long it will take to train the additional, trained staff required to teach the courses. If everything works at breakneck speed (something higher education doesn’t really do) the courses would be complete sometime in 2020. Preparing these new staff will take 10 year. (Indeed it takes 12 years to train a child psychiatrist).
This approach to planning is the reality of that used by NHS planners. For them the need for more child psychiatrists becomes a very long-term plan indeed. With luck the daughter will have grown up by the time one of those psychiatrists can help her.
But as a plan to help real people currently in distress we need to recognise that it is not good. This form of planning simply replicates the way in which we have always done things and projects solutions into a somewhat distant future. And that ignores the pain and distress of today.
That’s an example of an NHS planner’s reality – finding solutions in their world could take the 12 years it takes to train a child psychiatrist. The mother may have as little as 12 minutes.
My difficult point is that it can’t be a good plan unless those worlds – that of the planner and the mother – come together more than they do now. Let’s be honest – with enough money replicating past planning strategies to operate in the future really isn’t very hard. But if the plan is to do something about the situation today, for that mother, it needs the imagination to deal with today’s demands – not trajectories for 10 years hence.
The plan for today won’t involve a brand new psychiatrist, but it could involve retaining a teacher, or upgrading a counselling service from a part time service. Is that as good as a child psychiatrist? Almost certainly not. But if the alternative is telling that mother she has to wait for her daughter to act on her suicidal tendencies, then it’s a million times better.
So delivery of the plan in 2018 2019 and 2020 is what I will be looking for. That will take flair and imagination. And over the next two blogs this week I will talk a bit more about delivery.