The pandemic has highlighted strengths and weaknesses in the ability of governments to respond to sudden crises. Despite the UK’s pandemic preparedness looking strong on paper, shortcomings have been identified. These include the assumptions held about the nature of the threat (planning for influenza), the political structures and processes to manage the policy response and communicate decisions to the public, and the lack of capacity in the NHS, public health, social care and other services to respond effectively. These issues and more are likely to be subjects of any future public inquiry.

The pandemic also provides a moment to look at wider questions around how we prepare for the long term. The Prime Minister stated that the government will use the crisis ‘to tackle this country’s great unresolved challenges of the last three decades’. But the task ahead is greater than fixing the challenges of the past: Government must plan for the next 30 years and beyond. This means responding to the biggest challenges and opportunities ahead, such as climate change, new technologies, and securing the wellbeing and economic security of all citizens. It also means planning and preparing for uncertainty.

This long read outlines why long-term planning is important, and why it is difficult. It gives an overview of some features of long-term planning and the approaches that may help policymakers do it better. Finally, we reflect on what this might mean for three health policy challenges facing government as it looks towards the long-term recovery from COVID-19.

The need to plan for an uncertain future seems obvious in the context of COVID-19. But there will still be some who say that the future is largely unknowable, so why not concentrate on the pressing issues of the day instead? And long-term planning takes time and resources, so why should we do more of it and what is the counterfactual?

The short answer is yes: the future is unpredictable. But we could still be better prepared to manage this uncertainty – not only to reduce risks, but also capitalise on opportunities. Broadly speaking, long-term planning is needed to prepare for shocks, respond to ‘slow burn’ issues, meet complex policy goals through sustained action, make long-term investments, and protect future generations. These categories overlap and interrelate.

Prepare for shocks

Shocks are unexpected events with destructive consequences. COVID-19 has been one of the greatest shocks for a century, but it follows many other examples including financial collapse, natural disaster and war. Some argue that unexpected shocks are  a consequence of our increasingly interconnected world, where forces can interact in unpredictable ways and unfold at speed – as seen with COVID-19.

Shock events fall broadly into two categories. There are events where the risk has been identified, even if it is not known whether or how the event will occur in practice (‘known unknowns’). Then there are events that are unpredictable, because they sit beyond the limit of current knowledge (‘unknown unknowns’ or ‘black swans’), such as the 9/11 terrorist attacks. The category an event falls into can be debatable (particularly in retrospect) – some say, for example, that signs of the 2008 financial crash were in plain sight. But while it is impossible to predict all shocks, policymakers can still plan for uncertainty, and build resilience into public services and policies to minimise risks of adverse outcomes and exploit opportunities where these occur.

Respond to slow burn risks and issues

Often referred to as slow burn or ‘creeping’, these are policy issues for which the risks are known (‘known knowns’) and can accumulate over time. The longer they are left unchecked, the greater the threat or potential impacts. They require decisive action in the near term, often incurring short-term costs (political or financial) for longer term benefits.

Ideally, policy action on known issues would be taken before a crisis appears. But policymakers are too often slow to respond to slow burn issues. Examples in public health, the NHS and social care include the failure to tackle rising obesity, to adapt care to meet the rising prevalence of chronic disease, or to reform social care in response to the crisis in the care and support of vulnerable people.

The flipside is that addressing slow burn issues can create opportunities for improving health. For example, tackling climate change has been described as the greatest global health opportunity of the 21st century, because it provides the chance to address some of the major causes of ill health such as pollution, poor diet, and physical inactivity. Another example is investing in and testing new technologies for long-term human and economic gain.

Make long-term investments

Some investments and policy decisions demand that policymakers plan for the long term, as they deliver impacts over long time horizons or lock services or systems onto particular paths. These decisions are relevant to multiple policy areas, such as planning national infrastructure (eg roads, broadband hospitals, decommissioning nuclear sites), and investment in training and skills to meet the needs of a changing economy.

Meet complex long-term policy goals

Most policy challenges are not single issues, but are complex, multifactorial and dynamic – and therefore more difficult to make progress on. Examples include reducing poverty and inequalities, tackling limp economic productivity, and securing high-quality employment in a globalised competitive environment. Meeting these challenges requires government to be agile, work across boundaries and focus on multiple interventions over time rather than searching for ‘silver bullet’ solutions. Addressing obesity is a good example, where interventions are needed across health care, food, transport, and other systems over time.

Because of their complexity, these issues require long-term strategies and sustained commitment – which in turn requires a clear and shared vision for how they will be addressed. This is not easy: strategies on these issues often fall short of delivering their intended goal.

Protect future generations

Intergenerational fairness is the idea that meeting current societal needs and preferences should not be at the expense of future generations. Honouring this moral responsibility requires policymakers to act in the interests of the young and unborn by safeguarding the resources essential for their wellbeing.

Intergenerational fairness is frequently invoked in arguments for environmental protections, but it also applies to economic, social and cultural resources. The Chancellor of the Exchequer, for example, said that the government has a ‘sacred responsibility to future generations to leave public finances strong’. The same argument could be made for health. A moral obligation to current generations should also incentivise long-term planning – for example when investing in the prevention of ill health.

Long-term planning is about thinking ahead to make better decisions today. This may be to mitigate threats, exploit opportunities, or maximise the likelihood of achieving preferred outcomes. Long-term planning requires long-term thinking. This means considering a range of factors affecting the future, how these might interact, and drawing on a mix of diverse perspectives. In short: thinking more and weaving the results into hard decisions today.

Broadly, long-term planning involves:

• Anticipating issues and possibilities that may occur in the future, and understanding their potential interactions and implications.
• Planning how to achieve a defined goal or mitigate a threat, with an ability to course correct in response to changing context.
• Integrating these insights into ongoing policy development, decisions and implementation.
• Investing in the resources needed to do this over time, such as people and funding, but also relationships, institutions, knowledge and technical capabilities.
• Monitoring and adjusting when assumptions are challenged, and as new issues emerge.

The time period covered by the ‘long term' will vary, and the policy question or issue will determine how far to look ahead. The objective is not necessarily to produce fixed long-term plans – though in some cases these will clearly be needed – but to embed a better process for assessing uncertainty and adapting plans in the face of change. This reflects the reality that the future is uncertain, but acknowledges it may be possible to better mitigate risks and grasp opportunities to meet long-term aims.

The rationale for long-term planning seems straightforward enough, and in many ways the UK government has significant resources to do it. For example, the Government Office for Science produces analysis on cross-cutting policy issues demanding a long view and builds capabilities in ‘futures’ thinking across the civil service. The Ministry of Defence has an ongoing programme to identify global strategic trends that the UK must respond to. In the NHS, NHS England and NHS Improvement and other arm’s-length bodies scan emerging developments and assess health-related trends.

Despite this, embedding long-term planning in government decision making remains at best uneven. Over the years, numerous parliamentary inquiries have highlighted the short-termism in central government policy (in 2007, 2012, 2014, 2015, 2019). Outside government too, many groups and civil society organisations have called for greater focus on longer term interests. And in health and social care specifically, several reports have recommended strengthening policymaking for the long term – including the House of Lords committee on the long-term sustainability of the NHS and adult social care and the Chief Medical Officer for England’s annual report in 2018.

Why is this the case? Policymakers face a combination of incentives drawing them to near-term issues and barriers to taking effective long-term decisions. There is structural short-sightedness: the public sector is characterised by year-to-year funding, and short-term time horizons shaped by electoral cycles. As a result, politicians are incentivised to prioritise current interests, delay difficult decisions, and ignore issues that are on the horizon or just beyond it. This culture also pervades public services, with long-term planning often a rare luxury.

Even when there is the motivation to develop a long-term view and use this to influence decisions, there can be a lack of good information to support decision making under complex and uncertain conditions. Policymakers may lack information on emerging issues and trends, as well as potential policy responses and their likely impact over time – including the impact of inaction and trade-offs between policy options. Thinking long term often requires incorporating incomplete data on a range of issues and considering a mix of perspectives – something too often missing from the policymaking process.

Even where the problems and solutions may be known, policymakers must have the ability to act on these insights. This includes having the permission to adapt existing policies in light of new information or a change in values. Policymakers are also constrained by external factors, including political context, the funding available and powerful groups who may stand in the way of decisions.

The prevailing ‘narrative’ in public opinion and the media on a particular policy issue also matters. One factor shaping this is to whom in society the costs or benefits are perceived to flow and when. Often short-term costs are visible to people in the present, yet longer term benefits less so, and may accrue in future. NHS England’s Chief Executive remarked in January 2021 to a committee of MPs examining lessons from the pandemic: ‘resilience requires buffer and buffer can look wasteful until the moment that it isn’t’. Policy priorities are also shaped by the preferences of the electorate, who may prefer ‘jam today’ rather than for the next generation, who if unborn or too young, cannot of course express their preferences.

Overcoming any one of these challenges is unlikely to be sufficient on its own. But when a combination of factors and incentives align – when policy issues gain sufficient attention and public support, feasible solutions are identified, and policymakers have both the will and the power to implement them – a window of opportunity can open for major policy change to happen. The pandemic may create space for longer term thinking on key policy issues affecting the nation’s health and care.

So, what might make long-term planning easier? A mix of approaches can be used encourage policymakers to take a long-term view. The examples below are presented under two broad categories: methods and approaches and institutions and structures (Table 1).

Different approaches attempt to overcome different barriers to long-term planning. Some support information gathering or policy measurement, while others try to shift the context and incentives for decision makers. Approaches vary widely in their ease of implementation (from low-cost planning exercises to establishing new legislation or agencies), as well as the strength of their influence over policymakers. And no one approach is a silver bullet: overcoming short-termism is likely to require a combination of approaches, applied systematically across government, which together can affect the culture of decision making. They also require a supportive context among key decision makers who ‘get it’.

Many of these approaches are already used in UK government, but their impact has been mixed. Stronger mechanisms that hold policymakers to account more firmly for long-term actions, more systematically applied, and integrated with decision-making processes are likely to be needed to address the most difficult or urgent policy challenges facing health.

Table 1: Approaches to support better long-term planning

Methods and processes

The future is inherently uncertain. ‘Futures’ or ‘foresight’ approaches can help policymakers to make sense of this uncertainty. They draw on methods such as horizon scanning, forecasting, trend analysis, and scenario planning to increase understanding of future possibilities, identify threats and opportunities, and plot courses of action that maximise the chance of achieving a goal. These methods are used across government and public bodies, supported by the government Futures Toolkit.

The frameworks and measures used to assess government policy help shape the context for decision making. New measures can shape new thinking. Moving beyond economic measures of progress, such as GDP, to include measures of wellbeing, sustainability, and planetary health, for example, could incentivise policymakers to prioritise for the longer term. Alternative metrics can help expose the true costs and benefits of decisions, as well as holding policymakers to account for broader outcomes over the long term. Example measures include the Office for National Statistics’ health index and the sustainable development index. Government policy frameworks include New Zealand’s Wellbeing Budget and Wales’ Future Generations Framework.

Long-term planning requires a vision for the future that commands public support. Vision is necessary to guide decision making, but raises the question: whose vision for the future should policymakers aim for, and how should they develop it? Involving the public is an important part of a long-term planning process that is inclusive and reflective of citizens’ values and preferences. In Wales, the Wellbeing of Future Generations Act 2015 established a single vision for Wales, informed by the national conversation called ‘Wales We Want’. In Scotland, the parliamentary think tank Future Forum ran a programme of events exploring the question: what kind of country do we want Scotland to be in 2030 and beyond?

Long-term planning can require difficult choices – especially when short-term costs are incurred, and benefits are uncertain. Engaging the public meaningfully on complex issues and potential trade-offs can help to build consensus and political will for action. Citizens assemblies, for example, have become a popular method for unblocking difficult long-term policy issues, including responding to climate change at national and local government level.

Institutions and structures

Long-term planning requires resources: capacity, capability, expertise, and more. Institutions and structures (such as teams, organisations, legal obligations) play an important role in designating resources to long-term planning and protecting these from the pull of day-to-day pressures. Longstanding institutions also allow expertise, capabilities, and relationships to develop over time. For example, in the NHS and social care, the Sustainable Development Unit (now Greener NHS) has provided analysis and policy for environmental sustainability since 2013.

Establishing independent institutions, free from political interests, can help remove some of the barriers to tackling difficult long-term policy issues. For example, the independent Committee on Climate Change has statutory duties to provide analysis and advice to government on addressing climate change, as well as holding government to account for progress made. But strong political leadership is still needed to meet the UK’s targets.

Institutions can be established with a specific mandate for protecting future interests. For example, Wales’ 2015 Act  established a Future Generations Commissioner, whose role is to act as a guardian for future generations, encourage public bodies to take account of their long-term impact, and monitor their performance in doing so.

One challenge in setting up independent institutions is to make sure that they are not too remote from policymaking. If this is the case then their analyses may become irrelevant to day-to-day decisions, and miss windows of opportunity to shape emerging policy.

Finally, policymaking is guided by the promises made in legislation, manifesto commitments, policies and targets that – to varying degrees – hold policymakers to account for following a particular course of action. These mechanisms are a form of what Jonathan Boston terms ‘commitment devices’ and are used widely in government, including in health and social care.

The NHS, for example, has committed to delivering its NHS long term plan, containing targets for reducing health inequalities, air pollution and carbon emissions, among others. However, accountability for meeting commitments and targets varies widely. While some targets are enshrined in law, such as the carbon reduction targets under the Climate Change Act 2008, others are looser commitments that can be easily ignored or adapted.

If more long-term planning is needed, what policy areas should be targeted? The short-term challenges facing policymakers during the pandemic are enormous. Health and social care services are under extreme pressure, the NHS is racing to vaccinate the population, and politicians face hard choices about the mix of policies to control the spread of the virus. But COVID-19 has clearly exposed longer term policy issues that require decisive action from government. Here are three examples.

First is the need to strengthen health care capacity and resilience to shocks. The NHS entered the pandemic with fewer doctors, nurses, hospital beds, and equipment than most comparable countries. The NHS responded quickly to COVID-19 with a range of measures to redesign services, recruit additional staff, and increase hospital capacity. But pressures on services are extreme and disruption caused by pandemic has left a backlog of unmet health care need.

A plan for increasing NHS capacity over the long term is now clearly needed. The basic contours are obvious: the NHS needs more staff and physical capacity. But exactly how much depends on detailed analysis of future health needs, potential shocks to the system, and choices about the ‘right’ level and type of capacity to meet them. How to identify, test and spread promising technological innovations better and more quickly will also be critical.

Becoming more resilient also means strengthening the system’s ability to identify threats, collaborate between sectors, and learn and adapt in response to new data. It also means strengthening capacity in other services the NHS interacts with, such as adult social care.

Second is the need for a long-term strategy to address England’s widening health inequalities. Life expectancy has stalled over the past decade – even declined for people living in some of the most deprived areas – while health inequalities have widened. COVID-19 has amplified these inequalities in the immediate term, as well as causing long-term damage to the social and economic conditions that shape health. Unlike previous governments, there is currently no national strategy to reduce health inequalities in England. As the nation’s largest ‘industry’, the NHS’s role in economic and social development beyond its health care remit is also part of this agenda.

Recovering from the pandemic in a way that prioritises health will require sustained policy intervention over the long term – backed by extra investment. As a start, a cross-government strategy is needed to set out long-term goals for reducing health inequalities in England, priority areas for intervention, and how progress will be measured and reported. Areas for immediate investment include the public health grant to local authorities, early years services such as Sure Start, and policies to address child and in-work poverty. Wales’ Future Generations Act and New Zealand’s Wellbeing Budget –which redesigned the budget process around a set of wellbeing priorities – are two mechanisms that could help government prioritise long-term interests as part of this strategy.

And third is the need for fundamental reform of social care funding in England. The current system is a threadbare safety net – with publicly funded care only available to people with the highest needs and lowest means. The pandemic has taken a heavy toll on people using and providing social care, and national policy action to protect and strengthen social care services during COVID-19 has been too slow and too limited. But long-term problems have made things worse: the failure of successive governments to reform social care has been laid bare. The system is widely thought to be unfair, unsustainable, and in need of reform.

Government is not lacking analysis of the problems in adult social care in England (which are well known) or potential policy solutions to address them (explored by five independent commissions, among many others – and even enshrined in legislation). The case for reform has been clearly amplified by COVID-19. But, ultimately, long-term reform requires political will and leadership. If it chooses to, the government can afford to provide fairer and more generous support for vulnerable people in society. If it does not, the government will be choosing to prolong one of the biggest policy failures of our generation.

Governments often struggle to plan for the long term. COVID-19 has exposed gaps in the UK’s pandemic planning and preparedness for shocks. But recovering from the pandemic in a way that promotes and protects health will require long-term thinking across a range of policy areas. This includes sustained action across public services to narrow health inequalities, strengthen the capacity of the health care system to meet future care needs, and more.

A mix of mechanisms and approaches should be explored to support policymakers to take a longer term view. But political will, leadership, and a cultural shift away from short-termism will ultimately be needed to make progress – along with stronger mechanisms to hold decision makers to account for the long-term impacts of today’s policy decisions.

The Health Foundation will be expanding on these issues later this year as part of its Shaping Health Futures programme and the work of the REAL Centre (research and economic analysis for the long term). 

Jennifer Dixon recently discussed the issues raised in this long read with the trustees of the Foundation for Democracy and Sustainable Development (FDSD) Peter Davies, John Lotherington, Graham Smith, and Andrea Westall. FDSD published a blog drawing on this conversation.