Implementing a long-term plan for health: what can we learn from international examples?

Introduction

The government is developing a 10-year plan for health in England, which will be designed in partnership with the public and health care professionals. As part of this, the government has launched a national conversation about how to make the NHS ‘fit for the future’.  

This new long-term plan, and the approach taken to develop it, offer a significant opportunity to collaboratively transform the health service and improve the health of the nation.  

This is not, however, the first national strategy for the NHS, but the latest in a sequence of plans that have set out a vision for transformational change but had mixed success in practice. Indeed, while the development of the plan itself is a huge undertaking, the strategy for implementing the plan deserves equal – arguably more – attention: there is growing recognition that ‘policies do not succeed or fail on their own merits; rather their progress is dependent upon the process of implementation’.  

To support those involved in this work (and supplement the Department of Health and Social Care’s own work to review previous NHS plans), The King’s Fund has looked to some other countries for inspiration. We wanted to understand how other governments have effectively implemented new health plans and what we can learn from them. 

For this piece of work, we identified three case studies:  

• Portugal: the national health plan (2012–16 and extended to 2020) 

• The Basque Country, Spain: the strategy for tackling chronic illness (2010) and the plan for integrated care, Health: the People’s Right, Everyone's Responsibility (2013–2020) 

• Denmark: four consecutive national cancer plans (2000, 2005, 2010, 2016) 

For each case study, we reviewed the plans (in full or a summary, where available in English), literature about the implementation of the plans, and held conversations with experts (people involved in the design implementation of these or similar plans, or independent academics). See the ‘Methods’ below for more details. 

Drawing on these international examples and some of The King’s Fund’s previous work, this long read outlines six priorities those developing the 10-year health plan can focus on to support the implementation of the plan. We have created a slide deck to accompany this long read, to help those working on the 10-year plan to share these priorities and implement them within their teams.

Three case studies

Six key priorities

We identified the following six priorities to support implementation and maximise the impact of the 10-year health plan. 

1. Embed a clear vision and stick to it 

What is needed?  

At the heart of each of the plans we reviewed was a clear, long-term vision for change. This overarching vision encourages stakeholder buy-in and support for the plan, making sure that everyone is working towards the same goal. As we know from our work on collaborative leadership, a shared vision is particularly important where different organisations and sectors are coming together to deliver on plans – as will be the case for the 10-year health plan in England. The vision should be clearly communicated and visible in the plans and policies that sit underneath it, providing an overarching framework for the implementation work.  

As others have argued, continuity of purpose over time is also critical in delivering long-term change, and sticking to a direction of travel will be key when it comes to implementing the 10-year health plan. This means being able to adapt to changing circumstances without losing sight of the long-term goal. Continuity of purpose was present in all three of the case studies we reviewed, which is notably different from what we often see in policy around the English NHS (for example, when it comes to health inequalities). In Denmark, the ambition to become a world leader on cancer treatment has driven four plans over a period of more than 20 years and across multiple governments. Each plan has reflected the needs and priorities at a given point in time, while maintaining a continued sense of purpose over the long term. 

How to do it?  

Develop a shared vision. As discussed further on, engaging patients, communities and staff in the development of the vision for the 10-year health plan will help ensure that it reflects their needs (rather than just the system’s view of these) and encourages support for the plan. The King’s Fund’s previous work on international health care systems, such as the Montefiore Health System in New York, highlights that having a vision that ‘exists primarily in the heads and hearts’ of people working in the system is a defining feature of high-performing health care systems.  

Ground the vision in evidence to ensure broad-based support. Where support for a vision spans the political spectrum, it is more likely to have traction over time. To generate an overarching vision that isn’t derailed by political changes, it is important to draw on research, creating a case for change that is grounded in a strong evidence base. For example, the first Cancer Plan in Denmark was largely shaped by clinical evidence, set out by the medical community and co-ordinated by the Danish Cancer Society, on the problems with cancer care and outcomes in Denmark. The development of the procedural packages in 2007 is also a particularly good example of a wide range of stakeholders aligning behind a common goal grounded in evidence. This included cancer doctors with different specialties, hospital managers and politicians at both regional and national levels, as well as support from the influential Danish Cancer Society. 

Clearly communicate the vision to generate buy-in. Widely communicating the vision helps create a shared national narrative around a plan, an important factor in generating large-scale change. Portugal and Denmark demonstrate that top-down communication (eg, by the Prime Minister and politicians adopting the vision in their ‘political discourse’) can support the spread of this narrative. In the Basque Country, the vision for the strategy was communicated to the public and staff via succinct slogans that helped to build a collective narrative about what change was needed and how to achieve it. For example, the 2010 strategy was embodied in the slogan ‘let’s do more at home, more at the primary care setting, less at the hospital’. This slogan highlighted that the changes to how clinical staff work, not the development of a plan in and of itself, are key to creating changes in the experiences and outcomes for patients.   

However, it is important to consider how the plan is communicated at all levels. In Portugal, despite the implementation roadmap setting out the need for a clear communications plan, disparate and low levels of communication among citizens and staff were a barrier to achieving wider buy-in. The new National Health Plan (2030) not only has a communications strategy but also two communication guides to support the implementation of national and local health plans. For the 10-year health plan to have impact over time, there will need to be a strong communications plan in place to maintain longer-term buy-in. 

2. Think beyond health care 

What is needed? 

A broad definition of health was a notable feature of the plans we reviewed. This involves understanding health not just as the absence of disease but as a state of complete physical, mental and social wellbeing. It recognises that health is influenced by a wide range of factors; clinical care accounts for only around 20% of health outcomes, while the remaining 80% is driven by social, environmental and economic factors. 

In each of the three case studies, the plans adopted an intersectoral approach to health as a means of achieving improvements in health and wellbeing through interventions involving a range of policy areas. In the context of long-term planning for the NHS, this highlights the importance of the connection between the forthcoming 10-year health plan and Labour’s health mission, with the latter bringing a strong focus to prevention and the wider determinants of health. 

Portugal’s National Health Plan was considered to be a public policy for the promotion of wellbeing, and as such highlighted the importance of it being implemented across all sectors. In the case of the cancer plans in Denmark, the approach supported a move away from the traditional siloed model of care towards the integration of services and a holistic focus on patient experience, from prevention through to end-of-life care. 

The King’s Fund’s vision for improving population health is based on action across four interconnecting pillars: 

• the wider determinants of health 

• healthy behaviours and lifestyles 

• the places and communities we live in 

• the support of an integrated health system. 

Adopting a cross-sector approach to health in this way can help to ensure that health plans are supported by a broader policy environment, enhancing their likelihood of success.  

How to do it? 

Have a coherent focus on population health. Improving population health, including for those who typically experience the worst outcomes, requires a consistent and coherent focus on population health at a local, regional and national level, as well as targeted action to support change. Portugal’s new National Health Plan (2030), which has a focus on sustainable health and reducing health inequalities, is being implemented through a ‘social pact’ at a national level, as well as formal multistakeholder commitments (between those in health and other sectors) under population-based health plans at a local level.  

Responsibility for improving population health lies with many stakeholders across multiple systems, and this can make it difficult to monitor accountability and measure impact. We know from our work exploring the Montefiore Health System in New York that measuring impact in this context requires each of the contributing systems to invest heavily in the data analytics needed to measure system-wide improvement.  

Develop a culture of collaboration. This means that the 10-year health plan will need to be backed up by policy-making in other areas, such as housing, employment and local infrastructure, with health as a common goal throughout. This will require the collective action of many in order to develop relationships and a culture of collaboration across government departments, systems, places, sectors and organisations. 

3. Engage patients, communities and health care staff in both the development and implementation of the plan

What is needed? 

In each of the case studies we reviewed, we were struck by the level of engagement with patients, communities and health care professionals, not only as the plans were developed but throughout implementation as well. This underlines what we know from other work at the King’s Fund: that meaningful engagement is an important part of developing and implementing any health plan or vision.  

Doing this well will be key to ensuring that the 10-year health plan genuinely reflects what patients, communities and health care professionals think and need, and that they can ‘see themselves’ in the plan. This is particularly important for those who will be responsible for implementing the plan; ensuring that they have a clear understanding of, and stake in, its purpose and approach will significantly aid the work of implementation. 

The government is currently running a national conversation to gather views from patients, NHS staff and other experts in order to ‘co-design’ the 10-year health plan. The government is also running focused engagement events on specific policy areas with those working in the system, such as integrated care board (ICB) executive leads and clinical leads who will have a key role in putting the plan into practice. As well as this important engagement in the development stage, it is critical that engagement is sustained throughout implementation, becoming ‘business as usual’ rather than a one-off activity.   

How to do it? 

Make use of different approaches to engage people throughout. Public and staff engagement in the development and implementation of the plan can take many forms, such as focus groups, deliberative events and surveys. For example, in the Basque Country, health care professionals were involved in working groups focused on different policy areas during the development of the 2010 strategy. In Denmark, multidisciplinary cancer groups led on the development of care or ‘procedural packages’ and then facilitated implementation by holding large meetings with hospital staff to publicise them and encourage dialogue. In Portugal, a range of approaches were used to engage people, including a website where people could submit thoughts and ideas for the plan’s development, and communication channels such as social media to raise awareness of the plan throughout implementation.  

Deliberative events with the public and health care professionals will play a big part in the government’s national engagement exercise and could be used at different points as the plan moves to implementation and specific policy interventions are designed. A deliberative approach to engagement involves supporting participants to consider various sources of information, discuss views with others and make decisions about what plans or policies should be prioritised.  

Engage a range of people throughout. Crucially, engagement in the development and implementation of the 10-year plan needs to include a broad range of people, including clinical staff, local authorities, voluntary, community and social enterprise organisations, and importantly, citizens. In Portugal, a range of networks involving stakeholders across different organisations, sectors and regions were set up to support the implementation of the plan. These, as well as citizen networks to engage members of the public in the progress of the plan, supported engagement not only during the development but also the implementation of the plan. In the design of engagement activities with patients and communities, those leading the exercises need to consider carefully how to reach people who are typically under-represented.  

When engaging health care professionals and other stakeholders, seeking the views of those perceived to be in opposition to plans is an important step. Being genuinely curious about the arguments for and against doing something differently will help bridge the gap between polarised parties. For example, if a plan aims to support the shift of care away from hospitals and into the community, it will be important to engage meaningfully with secondary care staff and get their ‘buy-in’.  

4. Ensure implementation is a key focus from the outset

What is needed? 

Implementing national health plans involves translating strategic aims into actionable steps that can be executed at national, regional and local levels. While it may seem logical to begin implementation after a plan has been published, a notable element of all three case studies was that implementation was considered from the outset of plan development. Denmark and the Basque Country had sections within their health plans dedicated to implementation and Portugal published a ‘roadmap for implementation’ alongside the main plan. 

Whether the approach to implementation is embedded within the 10-year health plan itself or set out separately, it is important that it provides detailed information clarifying what is needed to move from strategy to practice. This includes stakeholders’ responsibilities and the accountability mechanisms necessary to guide them in achieving the plan’s goals.   

Plans for implementation should also consider elements such as budget and resource allocation, strategies for engaging and communicating with key implementers (see priority 3), the balance between central direction and local flexibility (see priority 5), and targets to assess progress (see priority 6). 

How to do it? 

Define and engage those responsible for implementation. Plans for implementation should specify who will be involved in the activities required, and the government’s current national conversation must engage these people – for example ICB leads – as the 10-year plan is developed (see priority 3). In Denmark, involving regional representatives in working groups to develop the new standardised procedural packages (introduced by the second Cancer Plan) significantly helped their roll out.  

Clarify priorities within the plan. The plan should also provide the order of priority for the specific goals or actions set out under an overarching vision (see priority 1). This will help those responsible for implementation make necessary decisions, for example about where to focus resources. Being transparent about trade-offs during engagement exercises and ensuring the plan is not a ‘shopping list’ of requests (see priority 3) will also help encourage buy-in (including from those losing out) and build confidence in the deliverability of the plan. 

Identify policy levers that will support delivery. Identifying policy levers (the tools government can use to influence outcomes such as funding, incentives, guidance, laws and regulation) to support implementation early on means they can be built into the plans. Contractual or legislative measures can ensure specific aspects of the plan are enacted (such as Denmark’s legal mandate on waiting times or Portugal’s legal responsibility for plan evaluation), and financial incentives can motivate compliance and progress.  

Ensure strong central support for implementation. Effective implementation requires strong central support to guide and oversee implementation activities across different regions and local areas; however, this requires dedicated resource and staff time. In Portugal, they noted the importance of human and financial resources for the co-ordination and management of implementation, and cited a lack of these resources as a key barrier to implementation. Those implementing the 10-year health plan should ensure sufficient time and resource are directed to managing the plan’s implementation. 

Establish networks for wider support. Implementation also benefits from the support and input of a wider range of stakeholders, enabled in all three case studies by the set-up of implementation groups, networks, committees or councils. For example, in Portugal, advisory groups and consulting boards (with experts and representatives from public and private bodies), and inter-regional and intersectoral networks helped facilitate the regional and local implementation and support the ‘health in all policies’ approach. Additionally, networks with members of the public and representatives from patients’ associations were formed to gather diverse perspectives on implementation and improve support for the plan.  

5. Allow plans to be adapted locally

What is needed? 

Our case study areas covered populations of different sizes (and none were of the scale of England). However, they each provided some insight into the interplay between national and regional levels (or regional and place level in the Basque Country) when it comes to implementing transformative health plans.  

National health plans offer a country-wide agenda for change and aim to provide some level of consistency across different regions. Although a national mandate can help to facilitate change, consideration must be given to regional and/or local variation, both in terms of population demographics and the resources available to different systems to deliver improvement plans. In Denmark, policy implementation tends to follow ‘parallel tracks’, with legislation and guidance being provided nationally while the day-to-day work of implementation is led locally. In the case of Denmark’s Cancer Plan II, the plan made clear that it was to be operationalised and adapted by county hospital authorities, for example on the question of the level of diagnosis and treatment capacity required. 

Local adaptability refers to the ability to tailor national health plans to meet the specific needs of different places and populations. Building flexibility into a national health plan helps ensure that implementation will be effective across a diversity of systems and places.  

How to do it? 

Build flexibility into the plan. An effective national health plan strikes a balance between setting out an overall vision (see priority 1) and directing top-down approaches for improvement and providing enough space for systems and places to be innovative and responsive to local needs.   

In the Basque Country, the 2010 strategy explicitly acknowledged that plans for transformation required a combination of uniform elements (to promote a fair and consistent approach to improvement) and sufficient flexibility and support for local teams to be innovative and adapt plans to meet local needs. See the case study below for more detail. 

Provide support at a national level to enable local action: as our recent research on integrated care systems shows, national government has an important role to play in creating an environment that allows local areas to succeed in delivering on their own plans and objectives.  

Successful implementation of the 10-year health plan will require national bodies to provide systems and places with sufficient support and guidance on how to translate plans into action and achieve the desired outcomes, while at the same time avoiding overwhelming local areas with national asks and being clear about which actions need to be prioritised. 

6. Measure implementation and evaluate the plan’s success 

What is needed? 

Monitoring and evaluation are crucial for tracking the progress and impact of health plans. Both activities should be conducted at all levels of implementation – local, regional and national – and can offer insights about how implementation may be off track, help guide resource allocation and strengthen accountability. Monitoring and evaluation plans were set out by our three case studies from the outset, and the 10-year health plan should do the same, detailing the methods that will be used, the required resources and budget (and where these will come from), and who will carry out the work.  

Learning from the achievements and failings of previous health plans is also important, and we understand that the Department of Health and Social Care is undertaking work to identify key lessons from previous NHS plans. For example, the evaluation of Denmark’s first National Cancer Plan highlighted the need for the centralisation of cancer surgery at fewer centres, which was subsequently followed up on and in progress by the time of the Cancer Plan II. Additionally, Portugal’s 2012–21 health plan was based around learnings from the previous 2004–10 plan, and the current plan (running to 2030) has benefited from the implementation evaluation of previous national and subnational health planning processes.  

How to do it? 

Define who is responsible for monitoring and evaluation. Evaluation teams should be separate from those implementing the plan and need to be established as early as possible so that monitoring and evaluation can begin straight away. In Denmark, the multidisciplinary cancer groups were responsible for continuous monitoring of key indicators such as waiting times and access measures, process indicators such as surgical patient volume per doctor, and outcomes such as one-year and five-year survival rates.  

An evaluation of the first Cancer Plan was undertaken by the Danish Centre for Evaluation and Health Technology Assessment (which sat under the National Board of Health). In Portugal, the responsibility for the evaluation was given to a national health institute called INSA and was formalised through a legal decree to ensure that evaluations would be carried out.  

Develop targets and indicators of success with key stakeholders. The indicators included within the 10-year health plan must be suitable for monitoring implementation in all places and local areas to enhance buy-in and compliance with monitoring efforts. To identify the most appropriate monitoring indicators, it can be beneficial to determine these by working with health professionals and key stakeholders in local areas. 

However, rather than fixing all targets and metrics at the beginning, it may be more appropriate to define indicators and metrics as the plan develops. Developing indicators with those who will be implementing the 10-year health plan would assist the monitoring and evaluation of the plan. 

Conclusion 

The development of a new 10-year plan for health in England offers a genuine opportunity to make meaningful and sustained improvements to the nation’s health. While getting the content of the plan right will be crucial, success in bringing about real change will depend on how it is implemented. Our research on international health plans demonstrated what we know to be true in the NHS: identifying a broad set of ambitions for improving health is relatively straightforward compared with the work of navigating systems, ways of working and varying interests and priorities in order to put those ideas into practice. 

In this long read, we have outlined six aspects of implementation that offer learnings on the factors that can help (or hinder) implementation. All six will be important for those implementing the 10-year health plan to prioritise. However, fundamentally they demonstrate the importance of two cross-cutting themes. First, the critical importance of placing a specific focus on implementation – doing this early and ensuring that implementation plans are well integrated with the overall approach. And second, the value of meaningfully engaging the right people at the right time.  

Prioritising implementation now is key to ensuring that the vision set out in the 10-year health plan becomes a reality.