Editorial Tuesday 1 July 2014: What if everything you planned turned out to be wrong?
Stephen Dorrell's thoughtful speech to the Reform conference on integration today invites the policy sphere to think about the health and care continuum in a different way.
It follows on from the NHS England imperative for providers and commissioners to send in their longer-term plans over a two-year and five-year timescale.
If you want to make God laugh, tell her your plans
In an ideal world, those plans would all cohere and add up neatly to a system capable and willing to transform itself to deliver the quantity and quality of care that people need within the financial envelope that's likely to be available. Job done.
Call me a dreadful old pessimist, but I have a sneaking suspicion that this may not pan out in practice.
I suspect that more than a few of the plans will involve heroic assumptions about commissioners able to delay or divert prospective need for acute care, freeing up resources to enable care closer to home. Who knows: maybe CCGs will infer the resources can be freed up to permit them to set their GP providers a four-hour access target?
I also imagine it is not impossible that on the provider side, there will be many assumptions about being the 'last man standing'. As a senior provider once memorably expressed it, "we've done the projections, and we're fucked ... but every other provider's more fucked than we are, so we'll be okay".
This version of the future has an almost-heroic level of chutzpah, but once again, it seems unlikely that it'll be greatly welcome for communities, staff and local and national politicians to witness a Darwinian thinning-out of the provider market.
So what's the answer? Is it ever-bigger squirts of lubricating cash from the Electoral Resilience Fund, the Prime Minister's Panic Fund, the Pothole Care Fund et al?
I rather doubt it.
Only Simon Stevens can save us now?
So does Simon Stevens have a plan of miraculous dexterity and ne plus ultra ingenuity to fix everything? Simon deserves to be held in very high regard, but expectations of an 'and with one bound, Jack was free' escape route seem likely to over-invest hope in the power of magical thinking.
Wooly thinking may be comforting when worn next to the skin, but this isn't quite the weather for it.
Simon is, however, surely right in his repeated emphasis that a one-size-fits-all model is not going to address the challenges facing the health and care system.
The NHS has done brilliantly well doing more with less, but while most healthcare remains delivered by humans, at some point there is a Law Of Diminishing Returns effect on quality and access. Or a massive deficit.
Only we can save us now
I suspect that Simon Stevens did give a massive clue in his speeches that he wanted providers to be involved in commissioners' plans.
The smarter health economies have recognised that in an era of flat growth at best, the whole of the public sector - and others - will need to work together to make the money go as far as it can. I'm particularly fond of the 'Leeds pound' approach taken across that city's entire public sector, including housing, emergency services: they want to see how far they can make public spending go to improve all public services across the city.
That will, I think, be necessary but not sufficient. The leaders of health and care economies are going to have to engage with their local populations, to explain why and how things need to change - and crucially, to frame it always and everywhere in terms of improving services and delivering the best quality, safest and most timely care in the right settings.
There is little point in a cuts-and-closures-based dialogue (or as it tends to be, monologue), when a) the implicity-required significant extra forthcoming shroud-waving-inspired funding may not be tremendously likely and b) that also risks perpetuating services which may frankly not be as safe as they should or on the right scale.
This won't be a reassuring message, but it looks very much as if we're going to have to do this to ourselves.