Luke Evans: Something crucial is missing from the new NHS plan – delivery

Dr Luke Evans MP is Shadow Minister for Health and Social Care.

There was a lot last week to surprise Westminster, yet amid the tears, welfare u-turns and market tremors, one thing that didn’t come as much of a surprise was the new Ten-Year NHS Plan.

Possibly the biggest surprise that day was Rachel Reeves’ somewhat impromptu appearance at the Plan’s unveiling. The sight of a beaming Chancellor, stating she “is up for the job”, left a somewhat sidelined Health Secretary standing awkwardly next to his big moment.

Now that a few days have passed, it’s time for a little reflection. What does this much-trailed vision of the NHS really offer?

There is, to be fair, much to commend. Across the House, we can likely agree on many of its aims: shifting care into the community, strengthening digital services, and putting more emphasis on prevention. These are goals that the public, clinicians and policymakers alike can all align behind.

But as you turn the pages, a troubling realisation sets in: something crucial is missing: where is the chapter on delivery?

There’s no manual for implementation. No roadmap for execution. It risks becoming the placebo plan – promising transformation without the means to achieve it.

As a doctor, I have a lot of respect for the power of placebo. Placebo researcher Irving Kirsch points out that “The placebo effect is the clearest example of how expectation alone can lead to real physiological outcomes.” I hope this is true for the NHS on an organisational level.

But we also know a placebo is no substitute for evidence-based treatment. The mind can only get you so far.

Likewise, much of the NHS relies on goodwill and positivity. The same goodwill that took us through the pandemic, runs up against the reality of ever-growing workload and burnout. A glossy plan which is light on delivery may not be the answer.

The King’s Fund was among the first to raise concerns:

“There are more than 150 pages of a vision of how things could be different in the NHS by 2035, but nowhere near enough detail about how it will be implemented… Without this detail, it is hard to judge how the ambitions written on the page will make a difference to the reality of the care we receive.”

They’re right. Across governments of all stripes, NHS reform has often stumbled not over the “what”, but over the “how”. The longest-serving Health Secretary, Sir Jeremy Hunt, admitted:

“There is much to welcome in today’s plan, particularly the proposal to bring back family doctors, which I tried to do but frankly did not succeed in doing when I was Secretary of State.” 

It was spoken with the humility of a man who knows more than most about the challenge of turning ideas into NHS reality.

Thomas Edison once said that “vision without execution is hallucination.” Time will tell which this plan proves to be. But while some ideas do jump off the page, they can’t be judged in isolation from history.

Much of the Labour Government’s health strategy has been based on the Darzi Report; this is the same Lord Darzi who was brought in as Labour health minister by Gordon Brown in 2007. He rightly identified three shifts that need to take place: analogue to digital, a move to the community and more emphasis on prevention.

These are sound principles. But Darzi’s review – fortunately for the Government – starts from 2010, ignoring what came before. And that oversight matters.

You might expect this criticism from a Conservative shadow health minister. This isn’t political point-scoring, however, but much more about context which is crucial when it comes to understanding the roots of our current challenges. NHS culture wasn’t shaped over the last decade, but at least the last three.

The Mid-Staffordshire scandal from the mid-noughties has rightly seen stringent patient safety policies brought in, but with it a deluge of paperwork. During that same period, the UK saw rampant MRSA infections and a drastic fight for infection control. A raft of testing, measures and treatments saw rates fall by 86 per cent a decade later in 2012 – yet this triggered a tidal wave of further bureaucracy.

Then there was the fiasco around Modernising Medical Careers (i.e. bringing in MTAS – the Medical Training Application Service) which saw thousands of doctors’ careers thrown into jeopardy, leading to the resignations of the national directors of the scheme, and a formal apology on the floor of the House from then-Health Secretary Patricia Hewitt.

And perhaps most notoriously, the National Programme for IT (NPfIT), launched in 2002 and officially dismantled in 2011, became one of the costliest public sector tech failures in British history. In 2013, the Public Accounts Committee reported that the cost of the botched programme was over £10bn, with the taxpayer footing the bill.

Why raise these now? Because if we want to fix today’s NHS, we need to learn from the full sweep of experience: Labour, Coalition, Conservative, and see the Ten-Year Plan through that lens.

There are two areas for reform currently being lauded by the Government – on social care and NHS England – where questions about delivery are overarching.

On the very day the Health Secretary launched his Plan, not one but two -arliamentary receptions were being hosted by leaders from the social care sector. Their question was as immediate as it was obvious: where is the plan for social care?

With between 15 per cent and 30 per cent of hospital beds occupied by patients medically fit for discharge, the NHS cannot move forward while the back door remains jammed. The response from the Government, once focused on cross-party talks, has now morphed into an independent commission, with initial results not expected until 2028.

That is little comfort to those facing challenges today. And it raises the spectre of another Dilnot-style political impasse, which we should all work to avoid.

One thing the Plan did start to do is change the fog to mist when it comes to what the post-NHS England landscape might look like, and the future role of Integrated Care Boards (ICBs).

It’s worth noting the irony: Labour, in opposition, castigated the last government for its “top-down reorganisation” of the NHS. Yet earlier this year – largely without announcement – this Government embarked on the biggest top-down reorganisation in over a decade.

Many NHS leaders accept the need to streamline: duplication and bureaucracy have long plagued the system. But recentralising leadership under the Department of Health carries real risks, particularly the re-politicisation of health service decision-making.

And then there’s the cost. Repeated parliamentary questions – oral and written – have yielded vague answers: “There will be some upfront cost in the millions, but savings in the future.”

However, independent estimates put the bill at over £1 billion. In the middle of the toughest financial squeeze in years, and with the Chancellor having lost all remaining headroom, this lack of clarity should set sirens wailing for anyone trying to run a budget – let alone an entire health system.

There is a lot in this 160-page plan to work through over the next few weeks, particularly in light of resident doctors’ vote to strike once again, but the ambition in this plan is not in doubt. The delivery is – and when it comes to the NHS, history has taught us that getting the structure wrong, or failing to see the system as a whole, means the best ideas can collapse under their own weight.

The patients, the taxpayer and the workforce need more than a placebo; they need evidence-based treatment. They need a plan that works and works together.