The NHS Long Term Plan: the challenge of leading the change
The publication of a major new NHS plan is always a time of high drama and anticipation, at least for the health policy community, and senior managers keen to know what is to be expected of them in coming months and years by their political masters. The recent launch of the NHS Long Term Plan was no exception, especially as its publication had been delayed amidst wider political turmoil in Westminster.
The Plan draws together a vast array of service developments and proposals to guide the NHS for the coming 10 years. It represents the other side of the deal struck by the Prime Minister with the NHS on its 70th birthday in July last year when an additional £20.3 billion was announced for the service for the five years to 2023, and then confirmed by the Treasury in the autumn Budget.
The Plan reassuringly confirms an overall direction of travel set for the NHS following the NHS Five Year Forward View: integration (of health and social care, mental and physical health care, and primary and secondary care); prevention of ill-health; improving the quality and safety of clinical care; and building up primary and community care. Refreshingly, there is also a renewed and strengthened emphasis on tackling health inequalities, and calls for a radical upgrade of digitally enhanced care.
In other respects the Plan is found to be wanting, particularly in how it addresses the significant and worsening workforce shortage in many of the health professions, and in having relatively little to say about how care for people living with multiple complex conditions will be funded, coordinated and improved, especially given the cash-starved nature of public health and social care services. A simultaneous launch of the long-awaited social care green paper would have provided some reassurance in this regard.
It is worth noting that for most frontline staff in the NHS, the Long Term Plan, like others before it, will not initially seem that significant, as they get on with their everyday jobs of caring for patients, struggling to cope with stretched resources, and enabling services to run effectively. A bold and positive vision, although important, is only a first step towards improving outcomes for people and communities. Successful implementation is the ultimate test of any plan, and we know from research and practice experience that this will depend on careful prioritisation of time and effort, along with sustained and competent leadership.
The Plan proposes new integrated care systems (ICSs) for all areas in England by 2021. These will only be effective if they have inspired and engaging models of leadership that work in a collaborative and inclusive manner, very different from the competitive and institution-focused leadership called for by the previous 2010 NHS reforms. An enabling policy environment is helpful but not sufficient for collaborative leadership in health and social care, even when legal duties are placed on organisations to promote integration. Too often evaluations of successful integrated care initiatives report that these were dependent on the individual relationships that had developed over many years – great if you have them, but we know that such stability and respect are far from the norm.
We need leaders at all levels of organisations who are willing and able to trust and share resources and responsibility with counterparts from different disciplines and sectors. In reality, collaboration is rarely purely altruistic – there is usually a value for the individual and their organisation that is being sought along with the articulated benefits for the population concerned. Addressing individual and collective aspirations is a sophisticated undertaking that requires highly developed skills of negotiation and diplomacy, personal courage and stamina, and a willingness to deal openly and constructively with associated conflicts. Leaders need support in developing such competences throughout their career, for like other areas of practice, it requires a blend of formal and informal learning enabling reflection based on research, theory and personal experience. The concept of ‘Mutual Aid’ promoted in the Plan (in which resources are exchanged across organisations for mutual benefit) is based on fine principles, but more is needed about what this will actually mean in practice. At present this appears to be limited to buddying (or take over?) by more successful organisations of their peers.
In December 2018, the University of Birmingham launched a new Centre for Health and Social Care Leadership to research, develop and support the diverse and dynamic leadership that will be needed to implement the vision that underpins the NHS Long Term Plan (and the social care green paper when it finally emerges). The themes of our new Centre – clinical, organisational, patient & community, and systems leadership – are critical to the vision and objectives of the Plan, as well as providing a challenge to those areas, such as workforce, complex frailty, person-centred care, that need further attention.
The NHS Long Term Plan is packed with important, timely and exciting service developments and proposals. The challenge for NHS, social care and patient leaders is how to prioritise and implement the content of the Plan, when with so many priorities there is a risk of everything and hence nothing being important and pressing. Having a plan is fine, but making it happen, and doing so in a collaborative, and yet effective manner, is a much bigger ask.
Professor Judith Smith & Dr Robin Miller, co-directors of the Centre for Health and Social Care Leadership, University of Birmingham.