Making the NHS plan work.

  1. We’re missing the politics (and the politicians).

In reading through the NHS long-term plan I am impressed by how many bases it touches and by the amount of serious thought its authors have given to implementation. All of the different issues have been worked through to give it a good chance of having the necessary impact.

But when I put it down I still had this nagging feeling of something important being missing. And I have now discovered what it is – it’s politics and politicians.

Of course  the NHS has always said that it doesn’t want politicians to be that involved so this is a gap that the NHS has always sought, but when reading the plan you can see that it has been worked through by the best of NHS leadership and framed in their words and feelings. It is then sent out to persuade the world of what it has in mind.

It’s the NHS talking strongly to itself in its own ways of thinking and working. And I, and most people that read it, will do so within that same framework..

The argument for the NHS frames itself.

It is however about issues that are much bigger than the NHS. The ageing population, the move to digital, the need for much greater efficiency – all of these are not exclusively NHS issues, but are major historical changes that will blow the NHS this way and that – as they will nearly all aspects of society.

And therein lies the problem. The issues that will dominate the NHS over the next decade – that will SHAPE it – are bigger than it is. It follows then that if the NHS frames its own plan, solely within its own frame of reference  (which of course institutions want to do), given the scale of the issues, it will be wrong.

It is of course is one of the objectives of the Lansley reforms – a set of institutions where the NHS – in the shape of NHS England – was in control of itself. Where ‘politics’ were taken out of the NHS.  But given that the plan has come about because the NHS had been asking the Treasury for a lot more money and that money had been achieved through politics, it does rather suggest that the NHS cannot be in charge of itself.

Over the years many generations of NHS leaders and staff have said “Why don’t they just let us get on with it?” Being in charge of its own destiny is what everyone organisation and individual wants.

But as we see, every minute of every day, in the Brexit debate – we as individuals and organisations cannot frame our own lives and futures – they are framed by others.

In current political context – we can’t take back control because we need a wide range of resources over which we don’t have control.

What does this mean for the NHS plan?

It was launched by the Prime Minister so wasn’t it obvious that politics were in charge? But not really – one speech, a press release and then it’s over to the NHS itself to make the case.  And for the rest of the week, month and decade that is what the NHS will do.

But since the plan was conceived within the NHS framework – that case will be made, without politicians, by the NHS.

I know Brexit is dominating every political fibre at the moment, but even if it wasn’t the idea should have been that every Minister and Government MP would have had a series of speeches this weekend to make the case for the plan. This hasn’t happened because the NHS framed the plan itself.

But the fact that this doesn’t happen at all – the fact that politics doesn’t frame the plan – will have consequences.

One of the most important aims of the plan is to increase the proportion of expenditure spent on primary and community services. This means that the proportion of spend on hospitals will not be as great. NOT that there will be less money for hospitals but that that section of NHS spend will grow more slowly.

This is an important boast of the plan – and indeed if it doesn’t happen the plan will not work.

But actually this is and will be contentious. This is NOT technical. There will be a series of rows. There will be, as the years unfold, arguments about this change in the proportion of spend and those arguments will involve the public. If next winter (2019/20) is a bit hard, it will be difficult for hospitals. They may well make their case for a bigger slice of the cake (as they have always done before). They make that case to MPs and the public. They will say that the NHS is in crisis today and that crisis is in the hospital sector. Let’s put this shift of resources to primary and community off for another year.

This will then be a political battle- the NHS leadership will say BUT we all agreed we had a plan that said we would not do that.

But what will the public, parliament (and the government) say?

For the plan to work it needs the public to be really persuaded by the changes.

For the public to be persuaded it needs something outside of the NHS to do this persuasive work – and that’s  what politics does,

Tomorrow I’ll explain how.