To govern is to choose

The NHS Long Term Plan was published in January 2019 – less than two years ago – but a lifetime away in terms of the health care context. At the moment, the health service is understandably preoccupied with the short-term challenge of a surge in COVID-19 cases coinciding with winter.

Where does that leave the Long Term Plan – consigned to history or a blueprint as relevant tomorrow as it was two years ago?

At NHS HQ, attention is turning to what comes next, beyond managing a winter with COVID-19. The cross-government spending review is underway with substantial unfinished business on funding for the workforce, capital and public health. The planning guidance and financial framework for 2021/22 also needs to be mapped out and issued to the NHS at the turn of the year.

Some might think the current level of uncertainty makes any attempt at planning futile. We are certainly living with an exceptionally high level of what Donald Rumsfeld called the 'known unknowns' and 'unknown unknowns'. But failing to plan would have major consequences.

The impact of COVID-19 on the NHS will evolve and presents significant and difficult choices for the future direction of the health service.

Under pretty much any scenario, the NHS faces a growing gap between capacity and demand for several years to come. Choices and trade-offs are unavoidable. The question is whether they are addressed purposefully and actively managed, or allowed to evolve by default.

Elective care and waiting times

One of the biggest decisions will be how far to prioritise the backlog of elective care and reduce waiting times. And to what extent should the NHS redouble its efforts to deliver the vision set out in the Long Term Plan? Waiting times are increasing as the NHS struggles to tackle a growing backlog of care. More than 111,000 people have now waited more than 52 weeks for routine hospital treatment.

As we confront the choices ahead it is useful to look back and learn from history. The Long Term Plan charted a direction for the NHS to significantly improve primary, community and mental health services. From the extra £20.6bn allocated to NHS England between 2018/19 and 2023/24, over a quarter was ring-fenced to invest in these services. But when we come out of the pandemic the default pressure in the NHS will be to draw ever more resources to acute hospitals.

New analysis from the Health Foundation’s REAL Centre shows how strong the pull of acute services is within the NHS. Over the last two decades, elective care activity grew by almost 10 per cent a year but primary care by less than 1 per cent a year. Some of this was planned to tackle unacceptably long waiting times. But over the last two decades the repeated mantra of health policy has been to strengthen primary and community services.

While we often focus on pressures from increased demand for services, much of what the NHS delivers is shaped by policy and resourcing decisions. Less than a tenth of the growth in elective care over the last 20 years is the result of demographic pressures. In particular, the choices the NHS makes about the workforce have a big impact on the type of care that can and will be delivered.

Over the last 20 years the number of specialists employed in the NHS grew by 4.6 per cent a year, more than double the rate of the growth in the number of GPs. The rhetoric of a primary-care led NHS was not matched by the reality of workforce prioritisation.

Capital investment

One of the big short-term decisions with very long-term consequences is the capital allocation for the NHS in this autumn’s spending review. So far, the government has signalled its intent to invest in more than 40 major hospital schemes but without the multi-year funding allocation it agrees is necessary. Capital bids are likely to exceed Treasury willingness to pay. At the Conservative party conference Rishi Sunak committed to getting borrowing and debt under control over the medium-term and 'balancing the books'.

The trade-offs Department of Health and Social Care and the NHS make over the priorities for capital investment will lock in services for many years to come; do they put everything into hospitals or push hard to fund Sir Mike Richards’ proposals for community diagnostic hubs which are common in other countries but as HSJ reported, have a price tag running to billions? How important is the upgrade of the mental health estate set out in the Wessley review? And will there be funding for primary care capital to support the multi-professional team model within primary care networks where many deprived areas lack the estate to deliver?

There are no easy answers for policymakers coming out of COVID-19. Recovering NHS services, building resilience and delivering on the Long Term Plan are all important goals. Uncertainty is high but to govern is to choose – those choices must be made with a strong emphasis on their long-term consequences if history is not to repeat itself. We must move beyond the Groundhog Day of policy documents failing to translate to meaningful change on the frontline.

This blog was originally published in the HSJ on Thursday 15 October 2020.