Plans, Views, and our policy

We now have Labour’s Ten Year Plan but also St. Stevens Vision in the 5 Year Forward View.  (It’s a bit worrying that in the run up to the general election we have policy development by the bureaucrats.)  The Tories plan for the NHS is the poorly hidden continuing privatisation of services and a move to a regulatory market without political accountability.  The LibDems may have a plan but nobody cares. UKIP have a plan centred on the return of State Enrolled Nurses and charging migrants.

Comparisons between 5 Year Forward View and Ten Year Plan [1] are superficial but nevertheless some key themes can be picked out; similarities and differences.

The major difference is that the 5 Year Forward View accepts the Health and Social Care Act whereas the Ten Year Plan starts with its repeal sending the strongest possible message that the era of markets and competition is over!  The 5 Year Forward View accepts that competition should continue to have a key transformatory role – despite the evidence that this does not work – however its nods to the reality that in general completion is being marginalised.  The Ten Year Plan makes very clear that both nationally and (increasingly) locally there should be proper political democratic accountability – the Health and Social Care Act wanted to remove the politicians and leave things to the market.

Perhaps the major weakness of the 5 Year Forward View is that it ignores politics and leaves the NHS as a bureaucracy without even restoring the key role of the Secretary of State with social care under local authority accountability.  The Ten Year Plan and the SHA wish to bring an end to the separation and fragmentation of the care system, once and for all and having the whole under proper accountability arrangements.

The 5 Year Forward View is about survival of the NHS as it is.  The Ten Year Plan is about how we move to a system delivering whole person care. The 5 Year Forward View is about integration through extending the current round of Better Care Fund initiatives.  The Ten Year Plan is more specific about moving to a single pot and a single system and about integration of commissioning.

The 5 Year Forward View says little about improving social care although it addresses this indirectly through the emphasis on integration of services.  It assumes no change in the systemic division between social and health care.  The Ten Year Plan is based entirely upon moving to a single system. The SHA position is for system integration and for investment in social care workforce to improve quality of care and for a progressive move towards free personal social care.

Similarly the 5 Year Forward View  does not directly address the systemic endemic fragmentation within the NHS whereas the Ten Year Plan  is all about moving to whole person care which removes all the barriers to personalisation of care. The SHA would like to see barriers removed between the care system and between the care system and the rest of the public services and also removing barriers within the NHS (especially between physical and mental health) exemplified especially the acute dominance.

They are both based on the NHS (or more precisely healthcare) being provided free at the point of need.  The Ten Year Plan is silent on future new charges but is assumed to be based on funding through direct taxation without further charges.  The 5 Year Forward View actually sets out some estimates of future NHS costs but the Ten Year Plan is silent on costs. Neither actually sets out where additional funding is to come from although the Ten Year Plan does explain a year one increase of £2.5bn to spend on additional staff.  The SHA would like to see a clear position on long term funding for the system, out of progressive taxation and accepts greater levels of funding are inevitable to deliver high quality care.

Both assume that there will be a continuing role for non-public providers.  Both agree that any role should be within a national policy framework but then with unfettered discretion at local commissioning level.  The Ten Year Plan brings the concept of preferred provider which means commissioners cannot outsource a (clinical?) service without having first explored a proper public solution.  The SHA position also asserts that there should also be proper ‘franchise’ arrangements for the four traditional ‘private’ services to the NHS (GPs, ophthalmology, pharmacy, dentistry).

Both assume a continuation of commissioning from providing and a continuing role for CCGs.  The major difference is that under the 5 Year Forward View the relationships between commissioners and providers are through the internal market and so through legally binding contracts.  Under the Ten Year Plan the relationships or based on collaboration and partnership and arrangements are made through NHS contracts which are not legally enforceable and are outside any competition regulations.  Obviously the SHA supports the removal of the internal market.

The 5 Year Forward View accepts that localities can vary their commissioning structures and in some cases the Health and Wellbeing Board may become the lead commissioner.  The Ten Year Plan assumes that in all localities the Health and Wellbeing Board will take on the role (over time) of the strategic commissioner of all care for the local population.

The 5 Year Forward View accepts the continuation of the tariff system developed up under Health and Social Care Act with the Section 75 Regulations intact but argues that there are already flexibilities that can be used such as year of care tariff.  Under the Ten Year Plan Section 75 is repealed along with the rest of the market architecture and many new possibilities will be permitted.

The situation around NHS providers also shows differences with the 5 Year Forward View accepting the two tier system (with Foundation Trusts and non FTs) but accepts the possibility of some convergence over regulation.  The Ten Year Plan does not address the division but instead argues for new organisational forms which are integrated provider organisations of various kinds.  The SHA position is that there should be a move to a single governance model for all public providers based on the FT model.

The 5 Year Forward View does not really say much about the move to shared decision making and more pervasive and genuine public and patient involvement. The Ten Year Plan and the move to whole person care is predicated on the need for much greater involvement across the single system although the complexity of achieving this is not yet addressed.  The 5 Year Forward View gives greater emphasis on the move to personal budgets and direct payments whereas the Ten Year Plan is more about personalisation of care through an integrated system rather than the use of budgets and payments.  The SHA accepts some role for personal budgets but is wary of the wider use of such mechanisms and would be opposed to any suggestion of imposing or even advocating the personal budget approach.

The SHA position is quite closely aligned to the Ten Year Plan but groups such as KONP and the NHS Action Party appear to argue for a greater degree of change to remove the whole of the commissioner/provider split (at least for health care) and for the complete removal of all private provision (except for the 4 established private providers as above).  This is a clear distinction and discussions over the differences might be productive if there could be more information about how greater changes could take place without major destabilisation.

[1] It is worth mentioning that neither the 5 Year Forward View nor the Ten Year Plan are actually plans in the sense of being well defined.