Cowper’s Cut 383: The specious hallucination of the NHS Ten-Year Plan

If as a government, you wanted to substantially lower expectations for your NHS Ten-Year Plan, then you might arrange for your disability welfare reforms to be crashed by backbench rebels in the Commons and withdrawn, and for your Chancellor to be in tears in the Commons chamber during Prime Minister’s Questions.

If that were not enough, then you’d get the Department For Health But Social Care to preview your plan to make the NHS digital-first using a promotional film of copies of the Plan being printed onto good old analogue paper.

To really hammer its impertinence home, you would then publish the full document online only as a PDF, and without the expected chapter on delivery, making it the Yodel of NHS plans. (It’s a shame that there doesn’t seem to be an option to have the Ten-Year Plan faxed to you.)

Health Service Journal has summarised the key points, highlighting where it varies from the briefings, leaks and trails, and there is no point in my duplicating their careful work.

In my last column, I suggested a list of questions that I suspect remain a useful framing device as you read the Plan.

Many of them, unfortunately, were about delivery: the Ten-Year Plan does not have any content about that.

This makes a mockery of the PM’s claims in the introduction that “this is a time for radical change – major surgery, not sticking plasters. The measures in this Plan are radical and urgent”. The executive summary asserts that the Plan will “reimagine the NHS through transformational change that will guarantee its sustainability for generations to come”.

So radical and urgent, so reimaginatory and transformational that the Plan features nothing on delivery?

One must have a heart of stone not to laugh.

NHS interim chief executive Sir James Mackey told HSJ that The Plan was about creating “energy and enthusiasm”, which has not hitherto been anyone’s narrative about it. It seems improbable that this will be its impact.

To track any meaningful NHS change, you always have to follow the money: the Plan says merely that it will “shift the pattern of health spending. Over the course of this Plan, the share of expenditure on hospital care will fall, with proportionally greater investment in out-of-hospital care”. No quantum, no timeline: just assertion.

This was meant to be the NHS Ten-Year Plan: what has been delivered is the NHS Ten-Year Intention. It is embarrassing that the many people involved in finalising this document either do not know or do not care about the difference.

The Plan also pledges to create, sorry, ‘reimagine’ “a patient-controlled system, in place of today’s centralised state bureaucracy, and one where frontline staff are empowered to reshape services”. Sure, there’s copious waffle about the NHS App, and how it will pick up your shopping, walk your dog and mow your lawn (I exaggerate, but only slightly): what is lacking is any meaningful articulation of how the NHS will become patient-controlled. This is an intriguing, and highly consumerist concept: if this is indeed where we are going, then it should be possible to articulate how it will happen. The Plan doesn’t.

Nor (beyond good intentions) do we get one shred of detail on how front-line staff will become empowered to reshape services (something last common in acute hospitals during the pandemic).

Polyclinics in Portacabins?

Polyclinics, AKA Darzi Centres, AKA walk-in centres, are to be reborn as ‘Neighbourhood Health Centres’, which will in a naturally-unspecified period of time be open 12 hours a day, six days a week. This will be stiff competition for hospital A&Es, which are open 24 hours a day, seven days a week.

Nor is there any evident capital plan for these: I am told there is £10 million in new capital for this. Let’s do the maths: if we charitably assume just five neighbourhood centres per ICS, then that is 42 x 5. 210: so that’s £48,000 per centre.

Good luck with that. Might buy a Portacabin.

The Plan is incurious about why these failed last time round, which Monitor analysed succinctly here.

Indeed, it evidences zero curiosity why previous plans to move to a more preventative model of health service did not work. In the absence of meaningfully understanding that, those behind this plan are putting all their bets on the ‘and then, A Miracle happens!’ school of policymaking. Which is courageous of them.

Retreads gonna retread

The return of Darzi centres is not the only bit of Noughties nostalgia here. New Labour retreads gonna retread: we get personal health budgets; a concordat with the private sector (including the frankly hilarious notion that private providers will be persuaded to set up in poor communities); FTs again; league tables again (ignoring utterly the conclusions of the Francis Public Inquiry into Mid-Staffs) … I could go on and on and on. They have: this is 168 pages, not one of which is practically useful.

 With no discernible irony, the Plan’s ratatouille of writers state that “it is now self-evident that more money alone has not always led to better care”. Ahem, ahem. If not ‘bullshit’.

The workforce section pledges to “give leaders and managers new freedoms, including the power to undertake meaningful performance appraisals, to reward high performing staff, and to act decisively where they identify underperformance”. Leaders and managers already have every single one of these powers. The Plan is silent on why they are (barring Clinical Excellence Awards) rarely or never used.

A vision of the future is a necessary starting point for a strategy or a plan.

But if your vision is delivered without timescales, resource plans and shifts and most importantly of all, a proper and serious description of how the changes will be made, then your vision is a bit like an AI hallucination: you can understand how it’s happened, but it’s neither use nor ornament.

Rhetorical inflation

I’m a big fan of tremendously bogus language in policy documents, and this does not disappoint. As well as ‘re-imagineering’, we get the fabulous pledge that the DHBSC will “launch a moonshot to end the obesity epidemic”. Was there some informal prize for the most extravagantly mixed metaphor?

Chapter Six, on transparency and quality of care is wildly confused. One moment, it lists scandals since the 1990s, claiming that “the failures that underpin each are consistent: incompetent leadership, toxic culture, rampant blame, workplace bullying, and a failure to learn from mistakes. There is also a fundamental lack of transparency, which means low quality or neglectful care does not come to light quickly; that the response is not fast or decisive enough; and that patient, staff and public attempts to sound the alarm go unheard”. Nowhere does it mention lack of adequate resourcing, which was definitely a big factor in many of the scandals listed.

It then says that “direct patient feedback will be core to our new approach to quality”, and within a few pages that “we will revitalise the National Quality Board (NQB) and task it with developing a new quality strategy by March 2026. Whereas today the quality landscape has become crowded and unclear, the NQB will provide a single and authoritative determination of quality”. Right. So patients and the National Quality Board will have a shoot-out over whose word is final about service quality?

The workforce chapter strikes me as not particularly engaging and inspiring, which given the scale of known staff disillusionment, feels like a problem. The finance chapter (like the document overall) is largely a list of intentions, shorn of granular detail. Its section on capital and infrastructure is particularly underpowered. The assertions that community and digital care will be much cheaper are un-evidenced.

In his ‘Afterword’, Health But Social Care Secretary Wes Streeting writes, “this Plan is a call to action”. And it is a call to action, albeit of a pretty diffuse sort. But the irony is mordant: a call to action is not a Ten-Year Plan.

If we are meant to judge this as a call to action, then this is serviceable - if verbose. If we are meant to judge it as a plan, then this is ineffective, imprecise and specious. It is a waste of time.

Let the recriminatory briefings among those involved in its production begin.

Recommended and required reading

The Financial Times’ Sarah Neville on East Birmingham’s successful shift of care into community settings.

Again, Sarah with a decent long read on the future of the NHS.

The People’s Partridge has once again distinguished himself with his appearance at the Covid19 Public Inquiry.

The private provider sector is cross about NHS commissioning for minimum waiting times.