Councils committed in NHS England’s new blueprint

The main thing to note about the much-vaunted Ten-year-plan for the NHS in England is that it confirms an existing direction of travel rather than striking out towards a different strategy. Thank goodness. Regular changes of approach just cause confusion and delay achievements.

If you study the reaction of informed organisations, several of whom gave evidence to the Health Select Committee earlier this week, what is noticeable is not any disagreement with what the NHS wants to do, but anxiety about its capacity to deliver such change. Listening to the experts form The Kings Fund, the NHS confederation, the Nuffield Trust and the Health Foundation, and one senses that the will might just be there – but the means might not be enough!

Workforce is a major issue, especially in the light of BREXIT. But so also is the cumbersome organisation bequeathed by the Lansley Act in 2012. To migrate STPs to becoming Integrated Care Systems ideally requires a raft of legislative changes, but whether Parliamentarians will relish this task remains to be seen. One important decision seems to have been taken – not to disturb the well-established but difficult-to-manage statutory requirements to involve and consult patients and the public on changes to the NHS. Managers making heavy weather of service reconfigurations have often argued for a relaxation of the rules, but The Long Term Plan rightly leaves well alone. It recognises that success will be seriously jeopardised if local communities cannot be given a sensible role in the process; effective consultation is a great safeguard against management mistakes or unforeseen consequences.

Indeed, the Plan boasts a commendable amount of dialogue leading to its publication. It quotes 200 distinct engagement events and 2,500 responses to engagement questions from a large number of organisations – including the Patients Association and Healthwatch England. It promises an NHS Assembly in early 2019. All this is good, but it is one thing to consult on a national plan, but quite another to consult on local implementation. It is at that community-level coal-face that service change can be most challenging and where quality-assured processes can give Managers and politicians greater confidence that all is being done properly.

Implementing this Plan depends crucially on managing many different moving parts. The Plan promises to fix the issues raised by the recent Carter Report on operating the Ambulance service and it cleverly ties in local authorities in the ‘clear expectation that they will wish to participate’ in Integrated Care Partnership Boards. Commentators have noticed that NHS England boss, Simon Stevens has made it clear that:

 “when agreeing the NHS’ funding settlement the government… committed to ensure that adult social care funding is such that it does not impose any additional pressure on the NHS over the coming five years.”

What this means is that the NHS is resolutely unwilling to pick up the pieces if the Government’s stringent parsimony with Councils creates problems in children and adult social care. You sense that cost-shunting still happens, and this Plan clearly signals that the NHS will not be a fall-guy if there is any further catastrophic mismanagement of Social care. It is sad that this is necessary, but as witnesses at this week’s session pointed out, it is contradictory for the NHS Long Term Plan to base part of its reduced hospital bed requirements on tackling smoking and obesity, when the public health funding to do so via local authorities suffers a significant reduction.

The great benefit of meaningful public and patient involvement is that organisational nonsenses like this are often clearer to local people than to centralised policy-makers. What reads well in a comprehensive document like the Long Term Plan can look somewhat different when applied in a context of difficult local budgeting, failed initiatives, poor morale and unaddressed health inequalities. Have sympathy for Managers struggling to meet top-down deadlines for change and savings. But at the same time, find ways to help them by using consultation to search for positive new ideas rather than negative opposition to any change in the status quo.

Having a plan helps explain to people how it can make sense to change some things. Without effective machinery for dialogue, however, messages remain uncommunicated and important conversations do not happen. If the Government – not just in England, for the same holds true in the devolved administrations – wishes to implement it successfully, it has to invest in that engagement machinery, pay for its development and maintenance, train those who run them – and provide encouragement to all those participating. It is perfectly do-able, and in one sense, is a great mission statement for the Institute’s work on Health and Social care in the coming years.

Also see my previous piece on Councils, the NHS and Consultations.