Another five year plan for the NHS

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b5486 (Published 17 December 2009) Cite this as: BMJ 2009;339:b5486
  1. Chris Ham, professor of health policy and management
  1. 1Policy and Management, Health Services Management Centre, University of Birmingham, Birmingham B15 2RT
  1. c.j.ham{at}bham.ac.uk

    Sets out rights for patients and security for staff, but can they be delivered?

    Mix together Patricia Hewitt’s vision of care closer to home1 and Ara Darzi’s strategy for improving quality and patient safety2; add in a large dose of financial reality to reflect the much tougher outlook for NHS spending; sprinkle over the seasoning of partnerships and integrated care; and cook on a hot stove until ready to serve. This is the recipe used to produce Andy Burnham’s Christmas dish, the latest five year plan for the English NHS.3

    Although the plan contains little that is new, it is nevertheless important in setting out the government’s stance in the lead up to the 2010 general election. Echoing Ara Darzi’s strategy, the plan argues that NHS staff themselves need to lead the implementation of reform as less reliance is placed on national targets. It is described as “the largest and most complex programme of change the NHS has ever attempted,”3 not least because it aims to continue improving performance while releasing up to £20bn (€22bn; £33bn) in efficiency savings.

    In an attempt to secure the support and commitment of staff, a deal is proposed under which pay restraint is linked to a guarantee of employment to frontline staff. Under this guarantee, the jobs of these staff would be secured in return for flexibility and mobility locally or regionally. The importance of partnership working between the Department of Health, NHS employers, and trade unions is also emphasised, heralding a return to corporatist approaches to policy making and problem solving that characterised health politics in the 1960s and 1970s.4

    The deal for patients is based on a long list of rights to services matched by far fewer responsibilities. The government’s offer follows closely Patricia Hewitt’s 2006 white paper1 and argues for prioritising prevention and the care of people with long term conditions. More of this care will be provided closer to home with people being offered care plans, support to manage their own conditions, and personalised support by a healthcare professional. The need for the NHS to work in partnership with adult social care services is emphasised—more detailed proposals are expected in the New Year—and the NHS may be given responsibility for funding of social care.

    The most original part of the plan concerns the levers and incentives that have been put in place to deliver improvements in care. Proposals here include freezing the prices paid to hospitals, linking payments to hospitals to patient satisfaction, strengthening regulation to deal with failure, and creating stronger commissioners. Whitehall watchers will be intrigued that the words “market” and “competition” are scarcely mentioned. Instead, the plan argues that more attention to integrated care could help overcome the inefficiencies that occur when patients move between services.

    Although the emphasis on integration is both welcome and overdue, the focus must be on how doctors, nurses, and other frontline staff can work together, rather than on organisational restructuring. The risk of a Gaderene rush to merge organisations is ever present in the NHS and must be resisted to avoid time and attention being diverted from the more important task of adjusting to the much tighter financial prospects that lie ahead. In working towards integration, the NHS should build on the experience of places like Torbay, which have established integrated health and social care teams to reduce the use of hospitals and provide care closer to home.5 Clinical and service integration should be the priority, with organisational change following only when really necessary.

    The scale of the challenges that lie ahead has become clearer since the announcement in the prebudget report that funding of frontline NHS services (the scope of which has not been defined) will be protected in real terms from April 2011.6 Although this is a more generous settlement than some had feared, it will be difficult to adjust to no growth in budgets after a decade of unprecedented expansion. Uncertainty also exists about the resources that will be made available to services not deemed to be at the frontline. With the funds at their disposal, NHS organisations will be expected to hold on to the gains of recent years, such as shorter waiting times for treatment, while further improving care.

    To support them in making these improvements, the government has changed the rules of the game by shifting much of the financial risk from commissioners to providers. This is most apparent in the decision that emergency admissions to hospitals in 2010-1 that exceed those recorded in 2008-9 will be paid for at only 30% of the tariff price. Whether hospitals can compensate for lost income by focusing on services outside the tariff remains to be seen. Cutting the price paid for extra emergency activity reflects the failure of commissioners to manage demand for hospital care, and the need for those running hospitals to work more closely with staff in the community to avoid inappropriate admissions.

    On an optimistic reading, the squeeze applied to emergency admissions could galvanise action to strengthen prevention; improve services for people with chronic obstructive pulmonary disease, heart failure, and other long term conditions; and develop alternatives to hospital admission. More pessimistically, it may create financial difficulties for hospitals and lead to large job losses as managers struggle to balance their budgets. If this happens, it will provide a real test of the proposed employment guarantee for staff. Paradoxically, local implementation of this guarantee, assuming it can be agreed, will be the responsibility of managers, whose numbers are set to fall by 30% under proposals to reduce management costs, and who are outside the scope of the security offered to frontline staff.

    If the proof of the pudding is in the eating, then the test of the plan will be whether it serves the government’s objectives in the election campaign and enables the NHS to build on recent achievements. The biggest challenge is undoubtedly to make a reality of policies like care closer to home that have been proposed before but have yet to be fully implemented. This requires a high level of commitment by managers and clinicians and further work to ensure that the right incentives and levers are in place to make the shift from hospitals to the community. From this perspective, the five year plan is unlikely to be the last word on how the NHS should adjust to a cold climate, and it is best read as a communiqué on the state of the NHS debate at the end of 2009, with more detail to follow in due course.


    Cite this as: BMJ 2009;339:b5486


    • Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: (1) no support for the submitted work; (2) no relationships with companies that might have an interest in the submitted work; (3) no spouse, partners, or children with financial relationships that are relevant to the submitted work; and (4) no non-financial interests that are relevant to the submitted work.

    • Provenance and peer review: Commissioned; not externally peer reviewed.