7 tensions at the heart of the NHS Long Term Plan

I’ve just returned from a fascinating 2 days at the HSJ Summit in Manchester. Much of the discussion naturally focused on the likely content and emphasis of the Long-Term Plan with various speakers and delegates hinting at various aspects. Having seen many such well-intentioned and ambitious plans come and often pass with less impact than their authors hoped for, I was left pondering how the following key tensions will be addressed.

1. Telling a story or setting clear targets?
We know from experience the system probably needs both but how are they blended. How can targets fit within the overall narrative and vision? Simon Sinek’s Golden Circle is really helpful in focusing us on why before what and how. So if the grand idea is around ‘channel shifts’ freeing up capacity to cope with rising demand and earlier diagnosis, enabled by integration, technology and workforce development and underpinned by prevention, the Plan needs to explain why that’s critical for a healthier nation with better outcomes, patient and colleague experience, and use of resources.

2. To prescribe or to guide?
Sir Chris Ham’s recent concerns about ICS size and shape are but one example. Can the Plan set a course which liberates and empowers local leadership? We know that emergence is a critical feature of systems behaviour. It is entirely predictable and evidence-based that any attempt to force their development by arbitrary top down diktats is likely to fail. But setting out a clear direction and guidance about key factors for local leaders to consider would help.

3. Joined up care or calling out the parts?
Parity of esteem, described again as a ‘crucial human rights issue’ must be addressed. But is Mental Health a separate chapter or woven through the Plan as an integral and integrated part? This is especially challenging given as many as 80% of physical health problems may have an emotional, psychological or mental health causal element.

4. A digital revolution or a flood of new technology?
The lessons of other industries are that it is difficult to truly embrace digital by evolution. Disruptive innovation is often bought by new players. The Secretary of State seems to grasp the key enablers and cultural shifts required. See https://www.tricordant.com/casestudy/digital-transformation-of-a-global-charity/ for a recent case study where embracing the opportunities of digital required deep thinking about organisation design.

5. The workforce – how can we move beyond just promises of more training numbers?
There have been some fundamental shifts in the attitudes of recent generations entering the workplace and a desire for much greater flexibility in careers and working patterns. How can we support employers whether GP Practices or large Trusts make employment an attractive, compelling and flexible option to entice staff back from agencies and temporary work? Just a reliance on increased training numbers, though needed in places, is not enough. Nor can professional roles stay the same – and it was encouraging to hear how professions were up for the challenge – from Regulators, Royal Colleges, Trusts and primary care. How can the Plan enable this creative exploration further?

6. Innovation or adoption?
Of course we need both but where’s the focus? The UK has traditionally been strong on the discovery and development of novel ideas, technologies and treatments. Our challenge is how do we adopt and spread these at scale across the service? How can we ensure unwarranted variation in the adoption of proven new technologies and treatments is reduced? How can we develop the capability of NHS Leadership System to absorb and adopt new technologies?

7. Coping today and transforming for tomorrow?
The challenge of ambidexterity is enduring: how do we manage ‘business as usual’ as well strategic transformation? How can leaders and colleagues across the NHS find time, resources and space to tackle transformation when the demand, financial, workforce, partnership and performance challenges are so pressing? How might the Plan and the accompanying realignments from NHSE and its national partners enable this?

Getting these tensions right feels critical. Which do you think is most critical? How would you like to see these addressed?