Sticking plaster or radical surgery: the Government says it has made its choice but will the NHS deliver?

One year after Labour won the largest majority in a generation, the NHS 10 Year Plan is published today with the Government on far shakier ground than Keir Starmer could have possibly feared when he first stood outside Downing Street.
 
With the international situation causing palpitations, the Government lagging in the polls, and Labour backbenchers forcing a rather embarrassing climbdown over welfare ‘reform’, a win on the NHS is essential, both to this Government’s purpose and its chances for re-election. The Government has bet big on the NHS at both the 2024 Budget and recent Spending Review – the 10YP now needs to deliver the goods.

The Plan itself has been widely briefed (and leaked) over recent weeks, but there is still much that the health lobby will admire in the full publication. Few will argue with the strength of articulation of the need for Wes Streeting’s three shifts – moving care from hospitals to the community, increasing the use of innovation to capture the benefits of new technologies, and delivering more prevention are all themes that have dominated health policy thinking and strategies over the last decade or more. In that light, the emphasis on neighbourhood health services will be welcomed, as will the clear willingness to drive the use of new proven technologies – including through a new health technology reimbursement pathway.

However, there are substantial headwinds facing the plan, some of the Government’s own making:

Reorganisation vs delivery

The scale of the change envisioned in the plan makes it hard to disagree with the HSJ Editor’s conclusion that the overall framework is a “mess”. In combination with the ICB Blueprint, the 10 Year Plan amounts to a radical reorganisation of almost every level of the NHS: the merger of NHS England into the Department of Health and Social Care, the reimagining of Integrated Care Boards (ICBs) as purely commissioners (meaning the removal of providers), the return of autonomy for Foundation Trusts (with the potential to manage the whole budget for populations), the establishment of neighbourhood health services and the impact on primary and community care contracts and structures.

On the face of it, the scale of this reorganisation could easily rank alongside the Lansley reforms for disruption to both NHS services and national policymakers. The legislation needed to enact these changes could become tortuous and the Government have done none of the political, media or stakeholder work to sell the need for them. As events of the past week have proven, even a large majority is no guarantee against legislation running into trouble.

Transformation vs waiting times

The Plan, rightly, emphasises the need for the NHS to “reform or die”. In the face of ever rising demographic pressures and constrained resources, “fundamental rewiring” is what is needed to ensure the NHS can both treat those in ill-health and begin to take a broader approach to improving population health. However, whilst the Plan is full of exciting ideas, the fear already is that it is not focussed enough to drive transformational change in the face of an NHS which is laser focussed on gripping both waiting list recovery and financial control (with half an eye on the winter pressures to come). Indeed, whilst the reforms in the Plan are positioned as part of delivering the Government’s promise to meet waiting time targets, they can equally be seen as a distraction from the work already under way. The Plan seems to come with very limited additional investment for technology or wider transformation – how waiting list reduction, reorganisation, financial grip and transformation can all be delivered at the same time is an open question. Come the next election, it will almost certainly be Keir Starmer’s pledge to meet the 18-week waiting list target that Labour will be judged against.

Ambition vs pragmatism

The Plan lays out a bold vision for a fundamentally reimagined NHS – one focused on prevention, community-based care and cutting-edge technology. However ambitious the plan, short term pragmatic interests may well come to dominate. Staff industrial action may rear its head as early as next week with the closing of the Resident Doctors ballot and further ballots are possible over the summer. NHS England has identified a £1.5bn financial risk this year already. In short, it is not hard to see how ambitious plans could be derailed by the messy reality of delivery. Part of the success of the Plan will be demonstrating the political will and commitment to drive through reforms, even in the face of short-term barriers.

Now it's time to deliver...

The NHS 10 Year Plan arrives at a moment of political weakness for the Government and mounting operational pressure for the NHS. The Government has bravely (or perhaps foolishly) chosen a path of structural reorganisation alongside seeking to implement a vision of significant transformation in the way the public engage with, and are treated by, the NHS. Publishing the plan – which has taken a year – is the start. But talking about performing radical surgery is somewhat easier than actually doing it (for the surgeon and the patient). As vision gives way to detail and rhetoric gives way to implementation, the risks will become clearer and the downsides of change more painful. Will the Government and the NHS stay the course? And can they take professionals, patients and the public with them? That will be a test of whether the 10 Year Plan is genuinely transformative or another sticking plaster of the kind decried by the Prime Minister.

by Kieran Lucia, Senior Director