Niche

The NHS will publish its 10 year Long Term Plan soon. There can rarely have been such pressure on a planning process: the NHS has been offered more money than it currently receives at a time when government is still reducing public spending. By 2023, the NHS will receive £20bn more a year than it does now, although this could be offset by reductions elsewhere, such as in the social care or Public Health budgets.

Big strategic planning processes usually follow a pattern. The more high profile and high pressure they are, the more they tend to be carried out at speed, by a small group of very clever people operating in relative secrecy. This was how many areas produced their Strategic Transformation Plans (STPs) which were the planning process local NHS management systems were immersed in for a while last year. It was why some of those plans weren’t as transformative as they needed to be.

Hundreds of groups have fed their views into the Long Term Plan over a short period. I have been feeding in the messages from the Joint VCSE Review which I chair, and which gathered views on its Action Plan earlier this year. I’ve been arguing that the Long Term Plan needs to set out a long-term investment in our communities, not just our health services. Now all of those messages are in the hands of a small group somewhere in Skipton House, who have to whittle them down to a manageable report, which will be expected to cover the big areas of political concern: cancer, mental health, waiting times and so on.

It’s easy to see how some kinds of message tend to survive this high-pressure, high-speed approach to big plans and some don’t. In particular, it’s difficult to get anything which feels too specific or small scale through all of those planning pipelines and valves. For ideas or actions to feel credible enough to survive, they need to affect lots of people, or lots of money. So there is usually only room for one or two really new ideas, and they usually have to be eye-catching and attached to a chunky spending pledge. Actions which are aimed a particular minority group are likely to seem too detailed too make it. This means that every big plan name-checks equalities, but few say anything tangible or challenging.

Another way of thinking about detail in big plans would be to recognise that if the NHS plan sets out how our public services and their partners will achieve health and wellbeing for those groups and communities currently most poorly served – including many black and minority ethnic communities for instance – this will also be a plan which will get health and care right for all of us. That’s because the Plan would have to set out exactly how the power (and responsibility) to design how healthcare works would be devolved down to communities, how those communities would get a greater share of the resources, and how all of us who want to, no matter which group we belong to, would have the opportunity to shape what happens to us when we need help to live well, or recover from illness. Those radical ideas for change would make most difference to those who currently get least, but they would be good for us all, because we are all individuals.

Conversely, when any big plan has nothing radical to say on inequalities, nearly all of us lose out.

In its last big plan, the Five Year Forward View, NHS England said something genuinely radical about working with communities. Much of that vision remained just that, a vision. But since then, NHS England has developed a programme for personalised care which was genuinely co-designed with people and the VCSE sector. The Empowering People and Communities taskforce has enabled citizens, including those who have often been marginalised or ignored, to raise equalities issues which the taskforce’s co-chairs Lord Victor Adebowale and Michelle Mitchell, have fed into NHS England’s board. It feels like the NHS is just starting to understand that equality is not a niche issue. So if ever there was a need for a Long Term Plan which makes radical change real, it’s now. Here’s hoping.

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