The Ten Year Backward Plan - a clear commitment to continued gobbledygook

by David Gilbert

January 7, 2019

I was going to avoid Twitter and blogs for a while. But this is too important. I’m also recovering from a gut bug, and should be resting... hey-ho.

If you’re looking for signs that the ten year forward plan will foster patient leadership, co-production or meaningful engagement with patients/users, carers, communities or citizens, then, er, don’t.

Gone is any pretence at ‘harnessing the community’s resources’ or any remaining pledge to work with patients and the public as equal partners in decision making – whether in improvement work, governance at local level (for example in integrated care organisations) or at policy level, let alone in the workings of the (allegedly non-merging) NHS Improvement/NHS England.

Power in the system remains entrenched in the hands of the professional elite – clinical, managerial and policy makers.

Empowering People (ho-ho)

A small section on ‘empowering people’ is focused solely on individual patients/carers gaining access to digital and online tools, like apps to manage their conditions, or accessing their own records (something that was to have been done years ago) or making sure (ho-ho) that there will be interoperability of shared records to ensure integration for people with long-term conditions.

And there I was thinking we had shifted a little in our perceptions that patients can be leaders – that the five new Patient Director-like posts in the NHS and the emergence of hundreds of patients/user leaders working as entrepreneurs, strategic advisers and the like might have created a ripple in the institutional pond of arrogance that besets a NHS that thinks culture change happens through resilience training and reshuffling the deck chairs at a structural level.

A section on leadership and talent management shows we are still a million miles from a mindset that acknowledges patient leadership or any sort of co-production in improvement, governance and policy work. “Great quality care needs great leadership at all levels. Evidence shows that the quality of care and organisational performance are directly affected by the quality of leadership and the improvement cultures leaders create”. Er, yes. Hello? Patients here? We can help?

But no: There will be a new ‘NHS Leadership Code’ that “will set out the cultural values and leadership behaviours of the NHS and will be used to underpin everything from our recruitment practices to development programmes”. Ah, some values and principles for existing system leaders (that’s not us by the way). That should do it.

Meanwhile: “We will also do more to nurture the next generation of leaders by more systematically identifying, developing and supporting those with the capability and ambition to reach the most senior levels of the service”. Will this include patient and carer leaders? Don’t hold your breath.

But the NHS just loves its volunteers (but not enough to provide some sort of opportunities, skills and career ladder). Here’s a commitment: “We will encourage NHS organisations to give greater access for younger volunteers through programmes such as #iWill and an increased focus on programmes in deprived areas, and for those with mental health issues, learning disabilities and autism. And we will back the Helpforce programme with at least £2.3 million of NHS England funding to scale successful volunteering programmes across the country, part of our work to double the number of NHS volunteers over the next three years”. Hmmm.

Might there be a mention of building on the amazing community development work or peer support in the section on ‘Improving population health’? No, it’s all focus on the integrated care services (please don’t mention STPs, ACOs, etc – that’s old hat). These amazing integrated organisations will “shine a light” (bless) on health inequalities.

Collaboration (but not with us)

The plan makes a values-based and meaningless plea for more collaboration at national level (this is where the plan is a bit surreal – the authors, based in NHS England presumably talking to themselves) – but it is collaboration between the same old elites who have got us into the problems we have in the first place. “As local health systems work more closely together, the same needs to happen at national level. NHS England and NHS Improvement will implement a new shared operating model designed to support delivery of the Long Term Plan” Ah, an ‘operating model’ whatever that means.

And at local level, there is a clear commitment to continued gobbledygook: “As ICSs take hold, we will support organisations to take on greater collaborative responsibility. There will be a clear expectation that strong, successful organisations not only provide high-quality care and financial stewardship from an institutional perspective, but also take on responsibility, with system providers, for wider objectives in relation to the use of NHS resources and population health. This will mean that neither trusts nor CCGs will pursue actions which, whilst potentially improving their institutional financial position, would result in a worse position for the system overall. This will be supported by a system oversight approach which reviews organisational and system objectives alongside the performance of individual organisations, whereby our regions seek to understand the drivers of challenges facing organisations and ensure that solutions reflect the wider system changes required”.

That’s all clear then, isn’t it? Who writes this tosh?

But of course we will be “deeply interconnected, leaders in all parts of the NHS will be encouraged to support one another across and beyond their organisations. This will be especially the case for thriving, successful organisations which will increasingly be asked to support their neighbours develop capabilities and build resilience. This will form part of a ‘duty to collaborate’ for providers and clinical commissioning groups alike.” But don’t expect collaboration or true partnership to be a focal point. There is nothing here about duties to plan and make decisions with partners outside the golden glow of the professional elite.

The Most Paternalistic NHS Plan Ever

In short, this is the most paternalistic, system-centric, professionally dominated NHS plan I have seen in my entire 30 year working life. It fails even the most basic tests.

It ends with a sop – a thank you to all the thousands of patients and the public ‘engaged’ and ‘listened to’ in developing the plan (no evidence produced for this claim) and a climactic page 115 (if you’re not asleep by then) announcing the launch of an NHS Assembly in early 2019 (p.s. what happened to the £2million pound a year NHS England Citizens Assembly?).

This will bring together “a range of organisations and individuals at regular intervals, to advise the boards of NHS England and NHS Improvement as part of the ‘guiding coalition’ to implement this Long Term Plan”. That’s clear on purpose and scope then.

I am not equipped to give a view of much of the content of the plan, though I am with Andy Cowper, from the HSJ who aimed a distinct ‘meh’ at the likelihood of this plan being much better than previous ones.

I am however well-equipped to have a say on patient and public engagement, co-production and leadership. And, I am honestly appalled at this paper. Angry.

Not only does it fail to build any systemic case for more influence and partnership with patients/users, carers, communities and citizens; not only does it fail to build on the Five Year Forward View’s arguments for working with communities; not only does it fail to weave in any commitment to a true change in culture through real collaboration…

It takes a step back in time. It is almost as if all our work to build co-production, patient and public engagement, patient leadership and new roles in healthcare are simply ignored. It is an insult added to the long term injury of lack of voice.

Whoever wrote this – whoever ‘leads’ this piece of work – should be ashamed. They won’t be. We have to make them so. Onwards and upwards.

By the way, if you want to glimpse the future of true ‘patient-led’ healthcare, have a read of this:
© 2018 David Gilbert

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3 comments on “The Ten Year Backward Plan - a clear commitment to continued gobbledygook”

  1. Dear David "Happy" New year! It doesn't look like it, does it?  Thanks for your run down of the "new" NHS. Could it be that Health Department has gone back to the Stalinist imperial way of thinking ie we know best and no amount of training of volunteers etc will be able to help us or come anywhere near having the wit and wisdom to be able to contribute? It's interesting to note that there is not one person in the Treasury that was working there or anywhere nearby in 2008. That's probably the same in Dept of Health. So much for the mega meeting that Olivia got together last year in Wembley: how much did that cost? And have we heard anything since?What about the mega bucks they found for PPV training last year?  Oh well, don't be too downhearted, it could be worse. Couldn't it?

    Keep up the good work 'cos there's lots of us who agree with you so we can all shout it out. Best wishes Anne  Our aim is to see an active and effective Patient Participation Group in every GP practice and that each group is based on the mutual interests of the Primary Care Team and Patients of the practice.NHS Constitution for England - GOV.UK

  2. Hi David
    You have highlighted glaring omission in the (not so) new NHS Plan. This is particularly depressing as I've been trying to support our Head of Patient Involvement to move us further here in the direction of co-production and increasing the capacity and capability of our patient leaders. I hoped this plan would enable me to leverage more resources but this sadly isn't going to help

    Still, we will keep trying!

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