Back to work: parsing the NHS 10 Year Plan

I was on holiday when the NHS 10 Year Plan came out, which meant that I got to avoid the initial frenzy of activity that was inevitably going to surround a big new government plan. After getting back I had set aside a few blocks of time to read and re-read the document in an attempt to start working out my own understanding of what it entails.

The thing about the NHS 10 Year Plan is that, as several people have pointed out, it isn’t really a plan in a traditional sense. It doesn’t have much to say about how things will be accomplished but I don’t think that this is a bad thing. The ideas and directives it contains that are related to my little part of the world involve a lot of ambiguity, but this means there is room to work out how best to deliver on the vision in a way that makes sense for our users. We now have a description of where we should be going, the question is how to get there.

The plan has many lists of product features. These all need to be catalogued and scoped and assigned owners. There are people already taking care of that, which leaves me with time to approach the plan from a different angle, namely trying to understand the policy intent that sits under the surface. Much of what is outlined in the section on digital services isn’t quite described in terms that our teams can work with because it lacks specificity on intended outcomes. We need to have a position on things like:

• How should patients’ lives be improved if we do this thing?
• How will we know if we’ve done a good job?
• How will we know if we’ve inadvertently caused problems elsewhere in the system?
• What would need to change to accomplish this?

Having a sense of how to answer those questions will get us closer to knowing how to safely deliver on the government’s ambition. For instance, the plan says:

The My Specialist tool will be where patients can make self-referrals to specialist care where clinically appropriate. From the outset, patients will be able to self-refer to mental health talking therapies, musculoskeletal (MSK) services, podiatry and audiology. This will help us transform the working lives of GPs – letting them focus on care where they provide the highest value-add. It will also be how we make sure everyone can self-refer, not just the most confident and health literate. In other cases, the tool will allow patients to leave a question for a specialist to answer without making an appointment.

That sounds logical enough, but how are we determining where this is clinically appropriate? Are we clear on what is lost, in terms of clinical judgement, if GPs no longer act as an arbiter between the patient and secondary care? If the goal is to make self-referral more readily available to people with low health literacy, how do we avoid people booking into specialist appointments when it isn’t the best route for them? What aspects of a specialist’s workflow need to change so that they can be afforded the time to answer queries from potential patients? The healthcare system is complex and we may not be able to definitively answer these questions before we start intervening, but we should at least have some sense of what we think will happen so we can adjust course later on if the results aren’t as expected.

Beyond the headlines, I’ve noticed that there are a set of themes that don’t get much fanfare even thought they are woven throughout everything:

• reducing (health) inequalities
• improving support for people with multiple long-term conditions
• shifting from a transactional to relational service design approach

These topics come up over and over again in slightly different forms. None of the keywords from those statements so much as make it into an h2, h3, or h4, and yet they are everywhere in the plan. This might be wishful thinking on my part – perhaps I am reading a superstructure onto the plan where it doesn’t exist simply because this is what I want us to be working on – but these are excellent cross-cutting themes to align work to. Being able to connect the more granular feature ideas to these overarching goals should be incredibly helpful for guiding teams toward understanding what good (and bad) looks like in delivery.

Translating between policy and delivery is hard. Each step in the translation pipeline is a place where the original intent can be misunderstood, skewed, or lost. We also need to make sure that the things teams learn on the ground when designing and delivering services can be fed back into the relevant policy holders so we can course correct together. We need to be able to fit the top-down (policy) vision with the bottom-up reality (of users), and change some part(s) of the system when things don’t line up. Right now, my main concern is how to set up a structure that helps teams do this for themselves, thus removing the middleman (i.e. me).