The next significant step for NHS strategy and planning will be the Five Year Forward View delivery plan which NHS England say they will publish in March “setting out a shared route map for the next few years”. What is needed from this plan?
First, the plan needs to remind us all what the NHS has achieved over the last three years. The justified focus on the worsening strategic position—rapidly rising demand meets the longest and deepest financial squeeze in NHS history—has completely overshadowed what has been delivered. Even informed observers like the recently retired Treasury Permanent Secretary, Sir Nick Macpherson, currently describe the NHS as “a bottomless pit.” A phrase that risks ignoring an impressive set of achievements and under valuing the NHS staff effort that secured those achievements.
If the NHS doesn’t trumpet its own successes—record numbers of A&E patients treated, improving cancer outcomes, genuine progress on parity of esteem for mental health and regaining control of NHS trust finances—no one else will do it for us. If we are to secure support from central Government we need to clearly demonstrate that extra NHS investment delivers concrete extra benefit.
Second, the plan needs to set out what the NHS can and will deliver over the next two and a half years. We all support the future strategic direction in the Five Year Forward View which secured a better Spending Review settlement for the NHS than any other public service and, critically, ensured that extra funding was ‘front loaded’.
But the “NHS to save £22 billion” financial modelling that then followed has proved to be flawed. As the recent National Audit Office report on NHS finances laid out, there was no frontline NHS involvement in this work, it was based on a number of estimates and assumptions with limited testing and many of the savings programmes were new and untested. The financial starting point for the NHS was worse than expected, given the higher provider deficit, and the plans did not fully account for the wider cost pressures faced by local NHS organisations, particularly in social care.
Demand has risen much further and faster than the modelling expected. And the speed and scale of benefits from demand management, the Carter efficiency programme and new care models have proved far too optimistic. So the NHS now risks looking like it is failing to deliver, can’t plan properly and is, potentially, that “bottomless pit.”
The March 2017 delivery plan provides an opportunity to get off that hook. As NHS Providers has consistently argued, if the money is fixed we need to be clear what the NHS can deliver within that budget. We need a realistic number of key priorities, each with a stretching but deliverable performance trajectory. We have to stop making over optimistic assumptions that are not deliverable. Unlike the “save £22 billion” modelling, we need to under promise and over deliver, not the other way round.
To use one obvious example: the 92% referral to treatment 18 week target is now undeliverable without serious extra investment and a decent run up to recover the current gap—the March plan needs to reflect that.
A realistic plan means we can have an honest conversation about the difficult choices the NHS faces. It also means we can set frontline organisations an achievable task and stop chastising them for failing to deliver the impossible.
The third requirement for the March plan is to square the sustainability and transformation planning (STP) circle. Recently, there have been a number of voices questioning the aggregate deliverability of the draft STP plans. Are we really going to cut 6,500 nurses? Reduce A&E attendances by 1% and admissions by 4% over the next four years given recent growth rates and the known demographic pressures? Cut thousands of acute beds? Of course not.
Providers are strongly committed to the STP process. They welcome the way it has brought local health and care systems together, rapidly grown new relationships and enabled new, much needed, discussions. The March plan has to show how we build on those strengths to plot a realistic, sustainable, future for each footprint including how to change the ways in which care is delivered to people.
So whilst a March 2017 plan is, once again, an important idea, it’s vital that the plan is honest and realistic and genuinely reflects what is deliverable at the front line.
Chris Hopson is chief executive of NHS Providers, the association of NHS foundation trusts and trusts, formerly the Foundation Trust Network.