The health service was promised a £20 billion ‘birthday present’ for NHS70. Now, a ten-year plan is being developed to work out how to spend the money. Lyn Whitfield asks what we know so far, explores the emerging tension between stabilising hospitals and pushing ahead with transformation, and asks where new technology is likely to fit.

Back in July, as the NHS celebrated its 70th anniversary, it was promised a “birthday present” by prime minister Theresa May – an additional £20 billion a year by 2020.

Initial analysis focused on how the boost will be funded (May claimed a Brexit boost would help; but taxes look set to rise in the autumn budget).

Then, on whether the money is all it seems (it only covers NHS spending in England, doesn’t cover public health, and doesn’t extend to social care) and on how far it will stretch (the 3.4% a-year real-terms increase it represents is considerably less than the 4% think-tanks and medical bodies were lobbying for).

Now, though, attention is starting to switch to how the money will be spent. At the NHS Confederation’s annual conference in Manchester, NHS England chief executive Simon Stevens said there would be a “major conversation” with the British public on priorities.

He also seemed to suggest that this would be channelled through an NHS Assembly, made up of national and local leaders, clinicians, patient and third-party organisations, with a long-term plan emerging “between summer and mid-to-late autumn.”

However, the Health Service Journal soon established that the assembly won’t be set up until November. So it won’t have a role in drawing up the plan, although it may have a role in its implementation.

Working through workstreams

With public consultation discarded, NHS England has taken a more familiar route to developing the plan; setting up a number of workstreams, headed by senior managers, to work on different elements.

At the start of the month, the Health Service Journal reported that four workstreams had been set up to cover clinical priorities, and that another ten were in place to cover everything from workforce to targets and engagement to efficiency.

This approach has been accepted as a pragmatic response to the limited time available to draw up a plan that can be aligned with the Treasury’s Budget cycle. But it hasn’t generated much enthusiasm.

Commentators have asked how the workstream leaders were chosen, and whether they will bring new ideas to the table. Also, where the process leaves the sustainability and transformation plan footprints that were created to implement the NHS’ last big plan, the Five Year Forward View.

At Confed18, Stevens insisted that its agenda of acute reconfiguration, integrated care and, eventually, population-level planning remains “the only game in town.” But, as an HSJ reader noted, in that case “surely the STPs should have generated the foundations for the plan, instead of that being a top-down exercise.”

Big plans and operational realities

Another, increasingly pressing question is whether the approach will take providers with it. One of the problems faced by the Forward View was that it never really engaged acute trusts, as they plunged into debt and took most of its sustainability and transformation funding with them.

In her official announcement, May said the first priority for the funding boost should be to get hospitals back in the black and “back on the path to delivering agreed performance standards”. But the sheer scale of the NHS’ acute deficit and slippage on waiting time targets will make this difficult; and it could soak up most, if not all, of the new cash available.

Both May and Stevens have indicated that they don’t want this to happen, by setting out the clinical and public health priorities they want the plan to address.

In her official announcement, May said she expected the plan to transform cancer care, deliver better access to mental health services, sort out health and social care integration, and focus on the prevention of ill health. In an interview with the Health Service Journal, Stevens added cardiovascular disease, children’s services and health inequalities to the list.

But there are signs that, if these are the priorities of the ten-year plan, they won’t be the priorities for trusts. In response to Stevens’ interview, Saffron Cordery, the deputy chief executive of NHS Providers, said ideas for priorities should be “shared as a basis for discussion” and not “treated as a pre-determined agenda.”

“[Our Recovering Lost Ground report] showed the scale of the challenge facing the NHS to fill the finance and performance gaps that have opened up in recent years,” she added. “Transforming care will require additional investment, as will any commitment to focus on key clinical priorities. It is right that we debate these priorities, but we must be careful not to raise unrealistic expectations.”

Tech is out of step

A further complication is the departure of Jeremy Hunt and the arrival of Matthew Hancock as health and social care secretary in the Brexit reshuffle. In his first speech, Hancock said he had three priorities for the health and social care system: workforce, technology, and prevention.

NHS England has a ‘workforce, training and leadership’ workstream, a ‘prevention, personal responsibility and health inequalities’ workstream, and a ‘digital and technology’ strand, headed by Simon Eccles, the national chief clinical information officer, and Sarah Wilkinson, the chief executive of NHS Digital.

However, these are only three of its areas of focus; and Hancock may have his own priorities for them – although, if he does, they are not yet clear. On the tech front, the Health Service Journal recently established that Hancock met ten ‘disruptive’ IT companies ahead of his first speech; but no established suppliers to the acute and primary care markets.

Yet in a Facebook post reporting back on a night shadowing staff at the London Ambulance Service and Chelsea and Westminster NHS Foundation Trust, he indicated that his immediate priority would be “interoperable data standards” to get systems working together.

Then, digitalhealth.net obtained a copy of the prospectus for the £412 million Health System Led Investment programme that was secured by Hunt and confirmed by Hancock; and it suggests the money won’t go on apps or interoperability.

Instead, the website reports that it will be allocated to STPs, on a capitated basis, for spending on system-wide electronic patient records, capacity management, coding, information sharing, ambulances and non-acute settings, and staff-rostering.

Digitalhealth.net also reports that bids must be in by 5 October; which is not only a spectacularly tight timeframe, but one that is out of sync with the ten-year plan and any IT proposals that it might put forward to support its delivery.

Transformation: stick or twist?

Overall, reaction to the ten-year plan idea has been muted. Think-tanks and lobby groups have been united in warning that the government and the public must be realistic about what the money and the process can achieve.

The Nuffield Trust’s chief executive, Nigel Edwards, has said that with its funding announcement the government has finally recognised that “the NHS cannot adequately care for a sicker, older population if… funding is persistently lagging behind what is needed.”

But the decision to put in just 3.4% meant will leave the ten-year plan with “some extremely uncomfortable choices”. The King’s Fund has said the same.

However, pulling in the opposite direction to NHS Providers, it has also warned there are dangers in prioritising sustainability (getting hospitals back in the black and hitting targets) over transformation.

In a report, outgoing chief executive Professor Chris Ham said that in the end it is “transformation that holds the key to the long-term sustainability of the NHS” and the government should recognise this by putting prevention and the reduction of health inequalities at the heart of its thinking.

“If five years of funding increases simply restore the NHS to levels of performance last seen in 2012-13, and short up hospital-centred models that are no longer fit for purpose, a huge opportunity will have been missed,” he concluded.

“Framing the ambition around improving population health and a new deal with the public offers the best opportunity for the future.”

Big money, big plan, big risk

The ten-year plan will have to find a balance between addressing the immediate needs of the health and care service and moving it towards a new and hopefully more sustainable future. And it will have to do that while assuring the government and the public that it is making the kind of improvements that its “birthday present” were meant to provide.

It’s going to be a very tricky act to pull off; and aligning all the supporting plans and funding streams will be trickier still – as the recent announcements on technology have shown. A lot of people are going to be watching what comes out of those workstreams very carefully.

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