We need to develop an NHS long-term plan next year.

But much more importantly we need to implement it.

Most of us now recognise that the NHS and social care can’t “go on like this and, whilst it’s true that many feel that the case for change must centre around the need for more money – to buy more of the same things, increasing numbers recognise that this approach simply will not work.

It’s not just that there is more demand, but also that it is different demand. And it’s not just that we need more from the same sources of supply. Technology and medicine demand that we need different sources,

Looking around, at any other service in our society, teaches us that if you have different demands and different supplies, you need a lot of change.

I am not suggesting that everyone agrees about what to do. As I have mentioned previously after the next election there is very likely to be a campaign launched to have a referendum on whether the NHS should continue in its current form. The campaign’s aim would be to insert a pledge in the next Conservative manifesto to hold that referendum in about 8 years’ time. By then, their argument goes, the NHS will have clearly failed millions of people and they will be ready to vote for its abolition.

Obviously, that’s a particular argument about change. I don’t think it need dominate the politics of the NHS for the next decade. But, let’s be honest, the argument for abolition will be making pretty powerful noises off.

There are many roads to changing the NHS that definitively do not lead to abolition. And whilst this blog will keep an eye on the forces that argue for its abolition, the best argument for keeping the NHS and publicly funded social care is to ensure that it can provide health and care services for everyone who needs them in a timely and human way. If there is a referendum on the future of the NHS in 8 years’ time it will be won or lost on the concrete experience of millions and millions of people. The result of any such referendum will be determined by the ability of the NHS to provide modern, timely and human services. It will be lost if the NHS fails to do so.

Many long-term NHS plans are being developed.

Most of the major think tanks are developing, or have developed, their own plans for the future of the NHS (and most with social care). The Times has its own Commission on the future of health and care. If it wins the next election the Labour Party is committed to creating a plan for the next decade in its first 100 days. And whilst the Conservatives have not yet shared their own plans, even they have a slogan in favour of “long term decisions for a better future”.

So, I think we can be pretty certain there is going to be a plan. I think we can be certain enough for me to spend the next few weeks working out what it might mean and how it might be developed.

What will it say?

This, of course, is an important question (and we will have to wait a bit for the answer).

But the main yardstick of a successful plan is not what it says, but what it does.

The problem for the NHS is not having a long-term plan. What it needs is the implementation of a long-term plan.

If I am right, and changes in demand and consequent changes in supply mean NHS structure also needs a lot of change, any plan that does not deliver it is no use at all. It just eats up time that we don’t have.

Planning change is important.  Making it happen on the ground is what matters.

The rest of this, and the next few posts, will outline how the process of making this plan will make it much more likely to have an impact (or not).

To illustrate what I mean by that statement I want to remind us of much of the last 10+ years of plans and their impact or not on implementation.

In 2010 Andrew Lansley became Secretary of State for Health – and he was “a man with a plan”. Famously he wrote his (and it was very much his) White Paper within weeks of coming to power. He then began forcing through the legislation. Within 6 months, as the legislation proceeded through Parliament, people woke up to the very radical nature of his plan for change.

Nearly everyone was very surprised by the extent of the changes proposed – including both the NHS and his boss the Prime Minister.  It was not the NHS or the Labour Party that called a halt to the process in the Spring of 2011, it was the Prime Minister. He famously called a halt to his own Secretary of State’s legislation and set up a group of NHS people to help reshape it.

Lansley’s proposals had four main themes. Creating a national commissioning body for the NHS which was clearly sperate from providers; making that an organisation that was clearly separated from the Secretary of State; putting GPs in charge of new local clinical commissioning groups (CCGs); and opening up much of the NHS to more competition.

The plan was a radical one.

So what happened?

On the first day of its life the NHS Commissioning Board (in a fit of hubris straight out of Greek tragedy) changed its name to NHS England. Given that this organisation – meant to be responsible for buying health care was run by leaders who had made their careers by of providing it, this was hardly surprising. They knew about providing health care and the fact that Lansley had set up the organisation to buy it was irrelevant. Let’s have a name that describes us as running the whole show. But it wasn’t what the plan for the NHS intended.

Next, within a very short time, the Secretary of State for Health recognised that whilst there may be a law (which he had voted for) that separated him from the day-to-day responsibilities of the NHS, the politics of his job demanded that he be in charge. Very quickly there were Monday morning meetings where the leadership of the independent quango had its independence suborned by the real politics within which the Secretary of State lived. Not what the plan intended.

Thirdly, CCGs were set up with a majority of GPs on their boards. But the crucial role in the CCGs was the Accountable Officer (AO) – accountable to the DH (and through them the Treasury) – for the money. Whoever pretended to be in control it was the AO that was the lynchpin of the national system. And within months the majority of these were not GPs. Not what was planned?

Finally, the Lansley reforms introduced an expectation of much more competition to the NHS. I remember at the time the expectation was that, in order to create new forms of integrated care, there would be new forms of providers. Where were they? Where are they?  Not what was planned.

To underline the point – much of this plan was introduced by legislation. Law usually makes things happen, but on this occasion the Plan’s intentions weren’t realised.

My main point here is not whether they were good or bad ideas. My main point here is that the way the plan was created and how it was developed involved very few people. This meant very few people were invested in it.

So very few people wanted it.

(I’m not even sure that most of the people that voted for it in the Commons actually wanted it to happen).

Under those circumstances it’s not surprising that very little happened.

It’s not just what you plan.

It’s how you plan that has an impact on what, if anything, happens next.