If plans can save the NHS, then it should be just fine over the next five years. NHS England, acting on behalf of all of the health service’s many central management and regulatory bodies, issued its annual “must do” list this week.
The “must dos” come down to two big items that are always on the list and one that’s new. The two perennials are stay in budget – or, this year, sort out the horrible mess that is hospital finance – and to keep on top of the targets the public know about – like waiting times.
The new one is to try to work out how to implement the ‘Five Year Forward View’ that NHS England put out in October 2014.
The Forward View is chief executive Simon Stevens’ big plan to close a gap between the funds available to the NHS, its rising costs, and the even more rapidly rising demand being put on it by an ageing population and the growing burden of chronic disease (such as obesity).
This gap is due to reach £30 billion by 2020-21. The Conservatives promised to find £8 billion of this during last May’s general election campaign, and the Treasury duly dug up £8.4 billion in the spending review last November.
So there’s £22 billion to go, and the NHS is supposed to find it by damping down demand through health promotion and bringing in new, more efficient ways of working.
The first is a non-starter, given decades of failure in this area, the present government’s manifest reluctance to act, and public hostility.
(This week, it was revealed that 4 million people are now living with diabetes, and Public Health England’s response was an app to encourage parents to find out how many sugar cube-equivalents there are in the processed junk of their choice.)
(After which quite baffling levels of ‘nanny state’ criticism and btl outrage were tipped over the chief medical officer’s attempts to update guidance on alcohol consumption by suggesting that people should try to drink rather less than they apparently do.)
So that leaves new ways of working; which means trying to keep people out of expensive hospitals, ‘integrated’ health and social care to try and cut out the waste that occurs when they fall between the gaps between the two systems, and financial incentives for this to happen that are being trialled by ‘vanguard’ projects.
This is where the plans come in. The guidance tells the NHS’ planning and purchasing bodies, clinical commissioning groups, to come up with one year plans to tackle immediate issues and five year ‘Sustainability and Transformation Plans’ to tackle the longer-term stuff.
So, everybody is supposed to draw up one year plans that will make a start on five year plans that will eventually deliver on THE five year plan.
Heroic amounts of management effort are going to go into this Soviet-sounding regime. So is it likely to deliver the tractors? The National Audit Office, for one, gives reasons for doubt.
Just before Christmas, it put out a report noting that overspending by hospital and mental health trusts is now so bad that it is not going to be cancelled out by underspending in commissioning; pushing the NHS as a whole nearer to the point of going into the red.
Also, that this is because hospitals have run out of short-term savings, are failing to find long-term, recurring ones, and that attempts by regulators to ginger them up month on month is just disrupting any do plans they have in place.
Also, that there is “no coherent plan that shows how the gap between sources and patient needs will be closed by all parts of the NHS” and that those big, Five Year Forward View projects to change working structures and practices have yet to be tested.
Also, that past experience suggests there are reasons to think that they won’t work; and won’t save much money if they do.
The NAO ended up by calling for a “holistic and coherent” approach that would show a “clear pathway for trusts to get back to financial stability” while explaining what contribution each bit of the service would make to delivering on the Forward View.
It’s not clear that the planning guidance delivers this. There are 209 CCGs in England. If they all come up with a one year plan and a five year plan then we’ll have a lot of plans. But it doesn’t follow that we’ll have a plan that amounts to a coherent plan to deliver THAT plan.
This is why so many financial experts are worried; even as the Conservative Party continues to insist that it has stumped up the money for “the NHS’ own plan” (which, to be fair, it sort of has) and will soon be spending more on the health service than has ever been spent before (which, to be fair it is; but that’s hardly the point).
It’s also why three former health ministers came out this week to say that a cross-party commission is needed to review the future of both health and social care; with everything from the Forward View to payments for some services and tax rises on the table.
“The reality is that we either see the system effectively crash or we confront the existential crisis now,” said one of those ex-minsters, Lib Dem Norman Lamb. “This transcends party politics.” The first bit sounds right.