Making the NHS plan work.

2. What could a political frame add to the NHS long-term plan?

Yesterday I made the point that the NHS has been allowed to frame its long-term plan itself and whilst this may be what the NHS has always wanted, there is a loss that comes from the NHS not having its plan framed by politics.

The leadership of the NHS has been trying to shake off politics, or to be more accurate politicians, for decades and one of many paradoxes is that the Lansley reforms which the NHS doesn’t like, have given it the structure where it can try to do that.

This leads to the very odd comment in the Daily Mail from the Chancellor of the Exchequer that “the leaders of the NHS must now get on and deliver. The country will be rightly be looking to them to ensure this great institution is developed to make it safer, more effective and more efficient”

In your dreams Phil.

Imagine that next winter there is a crisis in the NHS. MPs will come to the House of Commons and demand that the government make a statement about what they are doing. If the Secretary of State says ‘nothing to do with me guv, it’s all that Simon Stevens fault’’, there will be much laughter amidst the calls for him to resign.

So for the moment it looks as if the leadership of the NHS have the best of both worlds. They get to write their own plan and, if something bad happens, the public will hold the government to account.

So where’s the downside for the NHS?

However much the NHS long-term plan strives to frame the issues in a wider social context, it remains the NHS framing its own problems and not society imposing theirs.

So if you look at the front page of most STP plans, after a couple of sentences about wider social issues, they will say that the real problem is too many patients in emergency and other hospital beds. That’s what the STP plan is designed to deal with.

As localities develop their own mini versions of the NHS long term plan, that is what they will be trying to tackle – because that is the problem the NHS faces. Unless something is done about that – unless there is a reduction in demand and an improvement in patient flow out of hospitals – they are full.

But that is not the problem the public face. Because of the way we have organised NHS services the increased demand for them that come from an aging population has led to too many older people spending too long in hospital beds and consequently losing their independence too early. Unless we reorganise the way in which we deliver services even this situation will only get worse. The problem we have to solve is the way in which the NHS has organised its services.

This may look like the same problem, but it isn’t.

If society allows the NHS to frame its own plan in its own way, it will frame it in a way to solve its problems and not those of the population.

And then, as I suggested yesterday, when hospitals want much more money next winter they will work with public opinion to move that money away from primary and community services. A ‘plan’, on its own, will not be enough to stop them.

I just want to reflect a bit on my past experience of what politicians framing problems could achieve.

After the 2001 election new Labour was elected on a programme which included maximum waits of 6 months. That was the problem that politicians had heard members of the public going on and on about so they framed the NHS’s problems in that way.

The NHS did not like this. For the most part they couldn’t understand what the problem was – because for much of the NHS it wasn’t their problem – and they didn’t believe that it was possible to do anything about it.

(I must admit that one of my best moments of medical politics in 2019 so far has been seeing how 18 years later medical organisations are saying how vital maximum waiting times are ….)

Understandably the NHS was worried that it was being set up to fail. The timetable was unreasonable and politicians were setting public expectations in a way that could not be achieved.

So what could politics and politicians do?

First they had to have a political narrative explaining why they were insisting on this as a goal. This wasn’t difficult since it had come from the public as a need, but it needed framing in such a way as it could be achieved.

We know that waiting times have been too long, and it will take some time to bring them down. That why we have interim goals for reducing the maximum waiting times. We are sorry you have to wait 7 months – which is too long – but it’s only fair we deal with the people waiting 15 months first.

This narrative was at the core of every speech from the Secretary of State.

Thank you very much for asking me to talk to the Midland branch of the Royal College of x We know that waiting times have been too long…

Once every couple of months the Prime Minister would make a speech on the NHS, and it would contain the narrative.

But the engine were the ministers, on a weekly basis, going on visits to health centres, hospitals, ambulance headquarters etc. etc. And this did not just involve the ministerial car swanning up for a quick 30 mins around the institutions. A ministerial visit did not count as such unless there was a meeting and Q and A with staff, an interview with local regional TV, 30 minutes of answering questions on drive time radio and if possible lunch or tea with the editor of the regional newspaper.

Each of these visits would have local stats and local examples of the impact of long waits and how short waits were important in that location.
(You will note, dear reader, that this was in pre-social media days – now it would involve a range of very different social media interventions as well).

This meant we were taking the narrative to the staff and the public. Over a year nearly 200 visits were made where on many occasions this narrative was heard for the first time. But over a year this aim and the struggle to get there would be heard again and again.

Two points then…

First the NHS should not be in a position to frame its own problems. They are different from the public’s.

Second the form of remorseless story telling that politicians can provide is unsuited to being carried out by NHS managers.

NHS managers don’t see it as their job (and it probably isn’t). But if the NHS plan is going to work, it’s vital that it is done.

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