The best laid plans: making the NHS Long Term Plan a reality

Recently, national NHS bodies published the Implementation Framework for the NHS Long Term Plan. The document outlines the process for developing yet more NHS plans – first by local NHS organisations and their partners, then (again) by national NHS bodies – to show how the NHS will deliver the commitments it made in its Long Term plan earlier this year. (So: the Implementation Framework is a plan for the plans to deliver the plan… Clear?)

The timelines for developing the plans are tight. Sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) – both geographically-based groupings of NHS organisations and local authorities in England – have been tasked with writing five-year plans by September 2019, describing how they will improve local services by 2023/24. Final plans are to be agreed by November 2019 (and, we are told, published soon after). A national version will then be produced by the end of the year.

What should the plans cover? The short answer is – unsurprisingly – everything in the NHS Long Term Plan. This includes strengthening primary and community services, improvements in mental health and other service areas, reductions in health inequalities, and more. But there is some flexibility: local organisations must outline how they will deliver a set of ‘foundational commitments’ (such as developing primary care networks) against agreed national targets, but will have more freedom in planning how and when (within the period covered by the NHS Long Term Plan) they will achieve ‘wider service transformations’ (such as action on prevention).

Readers may have more than a slight sense of déjà vu. Back in 2016, NHS organisations in 44 parts of the country were instructed to write sustainability and transformation plans (also called STPs – before the ‘P’ became partnerships), focused on improving services and reducing financial deficits in the NHS to 2020/21. A similar process also took place in 2013.

Developing STPs in 2016 proved a major challenge for NHS leaders – and the process produced mixed results. To give the latest round of system-wide planning a better chance of success, at least three lessons are worth remembering from the experience last time around.

First, the right people need to be involved in developing the plans. The new Implementation Framework calls for plans to be ‘clinically-led’, ‘locally owned’, and ‘developed in conjunction with local authorities’. But the NHS has not always found this easy. The 2016 STP process was criticised for weak engagement with front-line staff, local government, and patients and the public. Given the focus on prevention and improving equity in the NHS Long Term Plan, poor collaboration with local government (again) will set the plans up for failure.

Second, the assumptions underpinning the plans need to be realistic. Some projections in the 2016 STPs – for example, related to reductions in hospital activity and bed use – were wildly ambitious. Assumptions in the new plans must be based on a clear-eyed assessment of the evidence. Good intentions to develop more integrated models of care, for instance, are susceptible to magical thinking about the effects these new care models will have on demand for care and its costs. While more coordinated care can improve patient satisfaction, evidence of impact on service use and health care costs is less clear. The challenge is that – as our recent analysis suggests – the NHS will need to moderate demand in growth for hospital care over the coming years or make difficult trade-offs in how additional investment is allocated.

And third, NHS leaders must consider the support needed to implement the plans once they’ve been written. Developing and spreading new care models takes time and resources – both of which are often underestimated. Front-line staff need to be given the skills and space to improve services. This includes support to adopt new digital technologies – a key part of the NHS Long Term Plan – where success depends as much on people and context as on clever new innovations. The phasing of NHS England’s funding settlement will make implementation more difficult, as the ‘backloading’ of additional funding (with the biggest increases coming in 2023/24) runs counter to the need for up-front investment in developing new services.

Learning from the experience of the first round of STPs may help improve this summer’s planning process. But, ultimately, the delivery of the NHS Long Term Plan depends on national policy decisions about the wider budget for the Department of Health and Social Care, as well as long-term funding plans for social care and other public services. Without greater investment in current staff and training of new staff, the NHS’s chronic workforce shortages – currently at around 100,000 – will worsen. Without adequate capital investment (for buildings, equipment, and IT) – for example, by increasing our spending to match the OECD average – the NHS will struggle to deliver modern and efficient services. Without additional spending on public health and wider local authority services, the NHS and its partners will struggle to deliver shared ambitions to boost prevention and reduce inequalities. Cuts to the public health grant have equated to reductions in spending of a about a quarter (23%) per person between 2014/15 and 2019/20. And without additional funding for social care, people will continue to suffer unnecessarily, placing additional pressure on the NHS.

If inaction from national policymakers in these areas continues, local systems will be writing their plans for the future with one hand tied behind their backs.

Hugh Alderwick (@hughalderwick) is Assistant Director of Strategy and Policy at the Health Foundation.

This article was originally published in the HSJ on 4 July 2019.