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THE repeated postponement of the 10-year “long-term plan for the NHS” called for during the summer by Theresa May is partly a product of the fixation on Brexit — but partly a reflection of the cleft stick in which NHS England is trapped.
The NHS is saddled with a massive staff shortage exacerbated by eight years of real-terms pay cuts for staff and the increased pressures on front-line staff, and a wholly inadequate budget which we now know is set to continue falling behind increased costs for another five years.
But it is also lumbered with a fragmented structure and legislation (Andrew Lansley’s 2012 Health and Social Care Act) that squanders resources on carving up services and contracting, and blocks any effective strategic planning or collaboration.
Unless this vicious combination can be broken, any new long-term plan will be as hopeless and empty as the last attempt has proved to be.
Next year will mark the fifth anniversary of the Five Year Forward View (FYFV), effectively Simon Stevens’s manifesto as the incoming chief executive of NHS England.
It was uncritically embraced at the time by all the main political parties as a visionary effort to modernise the NHS and to bridge the rapidly growing gap between the pressures and demands on the NHS and the post-2010 NHS budget.
On the other extreme a handful of conspiracy theorists laboured gamely through the largely abstract and waffle-strewn document to prove it was all coded messages pointing to the privatisation of the whole NHS, led by Stevens’s former bosses in the US health corporations.
Both these views hold up badly now. Looking back at the 44-page FYFV is like stepping into a museum: most of the key commitments have long ago been sidelined or reduced to token gestures.
For example, the insistence that “the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”
While the concept of improving public health to reduce demand on the NHS is a good one to which nobody could object, it was hardly new at the time.
But since 2014 we have seen year after year of cuts to public health budgets which are supposed to fund schemes to help tackle obesity and reduce consumption of alcohol, drugs and tobacco.
Worse still, public health is now run by councils whose core funding has been more than halved since 2010, and which are unable to invest or act in any serious way to address any of the social determinants of ill-health — such as poverty, poor housing, poor environment and poor diet.
Many more FYFV ideas have also remained little more than words on a page. For instance, patients were to be given control over shared budgets for health and social care: Stevens in a July speech in 2014 even suggested “north of five million” such personal budgets might be operational by 2018, sharing £5 billion between them.
This sounds ambitious and generous until you do the sums and realise it would result in average payments of just £1,000 per year, £20 per week — well short of the amount required to secure any meaningful care package for any but the most minor health needs, even if the services required were available and the patient/client was confident enough and able to sort out their own care.
The latest figures show that the vision was unrealistic on almost every level: the number of personal health budgets has apparently been rising each year since they launched in 2014, but there were fewer than 23,000 people receiving one in the first nine months of 2017/18 — a long way short of five million.
Carers, too, were promised new support by the FYFV (not for the first time, and no doubt not for the last): yet the plight of carers remains desperate, with increased misery for many of them hit by the succession of welfare cuts and the nightmare of universal credit.
Also, according to the FYFV, barriers between GPs and hospitals, physical and mental health and health and social care were going to be broken down: there was going to be a “Forward View” for GPs and a shift of investment from secondary care into primary care (how many times have governments proposed that since the 1980s?); and there were bold promises to invest in more staff and improved services for mental health.
Predictably none of these things have happened. Barriers are still intact. Overworked, understaffed GPs face ever-increasing demands, with no sign of the promised increase in numbers or resources. In mental health there are thousands fewer mental health nursing staff than there were in 2010, and the performance on almost every measure is as bad or worse than 2014.
The FYFV also looked to technology and new apps as a way to improve the monitoring of the conditions of some patients with long-term conditions — a proposal echoed more recently by Matt “The App” Hancock, the current Health Secretary, but five years later the idea that apps could actually replace the need for staff or healthcare in more than a few cases is still desperately short of evidence.
The FYFV promised that: “different local health communities will … be supported by the NHS national leadership to choose from among a small number of radical new care delivery options, and then given the resources and support to implement them where that makes sense.”
This was the basis on which — almost exactly three years ago — NHS England issued its edict on December 23 2015 that led to the drawn-out process of redividing the NHS into 44 “footprints” each of which was to draw up a Sustainability and Transformation Plan (STP).
The chaotic and secretive process that this unleashed during 2016 meant that by the time the half-baked and inadequate “plans” were published at the end of the year the very term STP had become toxic.
Since then, many, if not a majority, of the STP proposals for reductions in bed numbers have been abandoned, along with some reconfiguration plans for hospital services, because they were not only unpopular but unworkable.
This attempt to circumvent the fragmentation of the 2012 Act and force NHS (and even local government) bodies to work together has run alongside a repeated criticism by Stevens of the “purchaser provider split” imposed on the NHS since Thatcher’s “internal market” was introduced in 1990.
But despite the efforts to get round or ignore it, the law has remained unchanged: NHS England has now been invited to suggest changes — but the government is poorly placed to deliver them.
As the STPs became more discredited and irrelevant, the focus shifted to another concept from the FYFV, “accountable care,” likened to “accountable care organisations that are emerging in Spain, the United States, Singapore, and a number of other countries.”
Within months this terminology, soon linked in the public mind with the disastrous US health system, had also become toxified, and since then the language has focused on “integration” — of health services but also of health and social care.
This only sounds good in the abstract: in practice the idea of linking up the tax-funded, free at point of use and largely publicly provided NHS with the council tax-funded, means-tested and largely privatised and dysfunctional social care system has never been an easy one to sell. Even local government is increasingly cagey about being drawn into an NHS-led “partnership.”
The latest notion of “integrated care provider” contracts in the NHS effectively tries to rebrand the concept of “accountable care” — except it does not even offer the verbal promise of accountability let alone any actual accountability to local communities, while still carrying the potential danger of privatisation, despite top-level denials that this is intended.
After such a comprehensive failure to deliver almost any significant element of the FYFV, the likelihood of making a 10-year plan any more than a wish list or a pious declaration seems to be vanishingly small.
Five years after promising implausibly high levels of productivity increase and performance based on reducing the pressures on the NHS, a new 10-year plan needs to address chronic debts, deficits and rising pressures; lack of capacity to meet key performance targets; soaring levels of occupancy and inadequate numbers of hospital beds; legislation that militates against rational and strategic planning; the chaos of Brexit and the Brexodus of EU nationals further massively compounding staff shortages alongside a complete absence of serious workforce planning; a dysfunctional and chaotic social care system leaving vulnerable people without support, and a government obsessed by its own internal party splits that has shown it will not properly fund the NHS in the short or the longer term.
The full list is longer still: but it’s already clear the NHS England plan, when it emerges, can deal with few if any of these questions properly.
In my next article I will look at the type of long-term plan we need, and the issues campaigners need to address in 2019.
Meanwhile please have a happy and peaceful festive season and do what you can to support another year’s work by Health Campaigns Together www.healthcampaignstogether.com.
John Lister is editor of Health Campaigns Together.
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