The 10 Year Health Plan: from words to action

 Andrew: Hello. It is September. It is political party conference season. It is Autumn, and it's also nearly three months since the government published its 10 year Plan for Health. And we are here on the Kings Fund Podcast to discuss implementation of that plan, how it's being turned from Text on a page to reality on the ground.

Today we are going to be be covering league tables. We're going to be talking about neighbourhoods and we're also going to be talking about missions and much more. You have me as your host, Andrew McCracken, assistant Director for External Affairs here at the Kings Fund. I am joined by my colleague Sarah Arnold.

Sarah: Good morning.

Andrew: And also joined by my colleague Danielle Jeffries.

Danielle: Hi Andrew.

 Andrew: Cool. So let's get into it. Since we last recorded a podcast, there's been various government announcements on health reform and health policy and how they're implementing the 10 Year Health Plan. The one I wanted to get into first is league tables, and I'm very happy that we have one of our premier league analyst in the form of Danielle here to talk us through it. What have government announced when it comes to league tables in the NHS?

Danielle: So the government have just announced a league table for trusts across the country. So they're taking various metrics, everything from finance to staff, feedback to performance across trusts, and put it into one single rank across all.

Trusts. Now that sounds like a good idea in theory, but in reality we don't know if that's particularly helpful for patients and the public and for leaders trying to understand whether hospitals are doing well or if they're performing badly. I think that's mainly because the rankings that we've got, um, they've just released are somehow.

Over simplistic, but also confusing at the same time. Brilliant. Great. Always helpful. Um, and I think that's because there are so many metrics going into these league table rankings, and that means there's a lot of uncertainty about where actually these hospital trusts rank. 'cause we know all hospitals are kind of struggling at the moment, but they're all struggling in slightly different ways.

Some are struggling with staffing, some are struggling with performance, some are struggling with finance and they don't all quite correlate in the same way. So having a single metric might not be that. Meaningful for people and, and, and what is it that you think government are looking to achieve by publishing these league tables?

What's the, what's the policy intent behind, behind this measure? Yeah, so it's all about accountability and transparency, particularly for patients. So patients do want to know how their local hospital is performing. The problem is, is. Whether actually they can do anything about these lead table rankings.

So if you see your hospital's bottom of the list on the ranking table, what does that actually mean for you? Can you go to your next local hospital? If it's two hours away, can you go private? Some people can't do that. If you call your local ambulance service and it's the bottom of the list, there's not much choice about which ambulance service you get.

So it's difficult to see what patients can do if their hospital is bottom of the ranking. To add to that, Andrew, you first referred to them in terms of the Premier League, and that's where a lot of us are familiar with League tables, but hospitals are different from football. I mean, obviously, but in particular because in football, the whole point is the competition.

It's you want winners and losers. Mm-hmm. In a hospital, you don't want that. We want all hospitals to be winners. We want the health system to be working really well for everyone, and these rankings are relative, so there's always gonna be a bottom and there's always gonna be a top. And so one. A better way to do it potentially is to look at what those hospitals should be trying to achieve and assess 'em against that rather than assessing them against each other.

And in terms of just the league tables themselves, what is the methodology like how, how does the trust end up at the top? How does the trust end up at the bottom? What is it that they're being scored against here? So what it's doing is taking lots of different measures. So things like their, uh, elective waiting list, how well they're doing against their deficit plans in terms of finances, how well their staff, uh, report back on their trust is putting those all together and giving them a single number.

The confusing thing, I think maybe in the. Current league tables is, it also gives a confidence interval. So it says there's lots of different measures. We're slightly uncertain about where some of these trusts actually rank because there's so many different measures, which means you end up with some trust, with a lot of uncertainty around them.

I think one of the things that stood out to me for it was that, uh, whether the trust is in deficit or not, uh, hinders the, the position in the league table. Um, for any of our listeners who are, are football fans, they'll, they'll get this reference. I'm an Everton fan. And have bitter experience of financial mismanagement of an organization, meaning that you get points deducted from you and you drop down the league table.

When I saw that, I thought, if this is about a patient choice measure as a patient, are you concerned whether the trust is in deficit or not? I mean, you might be as a taxpayer, but I thought that was interesting. I mean. D to put it bluntly, do, do we think this is is gonna work? Do we think this is gonna be an effective measure?

Is it actually gonna improve transparency and patient choice? I mean, I think that speaks to the duality of the purpose of the league tables. On the one hand, the for patient transparency and understanding. But on the other hand, therefore. Trust leaders and leaders in the NHS to understand how their relative organizations are ranking.

And different people obviously care about different things at different times. For a trust leader, it probably is important to know the financial deficit position of your organization. Of course, yeah. And so combining all the metrics into one single thing to be used for all these different purposes, that's part of the challenge I think.

Okay. The Secretary of State made this announcement about League Tables, uh, on the day that actually he was here at the Kings Fund to address, uh, our conference all about the 10 year plan and 10 year plan implementation. One of the other things that he announced on that day was that the 43 areas of the country selected to pilot, uh, uh, a neighborhood health approach had been, had been chosen.

They'd been announced. We've actually got a clip of what he said at the conference to, to play here. Today I'm announcing the first places selected as part of the National Neighborhood Implementation Program. We actually had 141 applications, which speaks to the huge amount of work already done to design, develop, and deploy neighborhood health services.

From those we are today naming our 43 wave one sites, covering more than 12 million patients from Cornwall to Nottingham to Sunderland. They are the ones best placed to provide immediate improvements for patients where the need is greatest. Starting in the most deprived parts of the country, vulnerable patients with multiple long-term conditions will get more joined up, services closer to home, and avoid the frustration caused by a maze of referrals that sends them from pillar to post.

In time, the sites will expand this approach to other patient groups and with GPS as the cornerstone. They will act as test beds for the new financial flows and primary care contracts we described in the 10 year plan. So that's what Secretary of State said here at the Kingsland about these neighborhood health areas.

We know that the shift from hospital to community was one of the three big shifts set out in, uh, government health policy and in particular in their 10 year health plan. Um, but what does it actually mean for these 43 areas that have been selected? What's gonna be different for them, Sarah? Um, well, so the 10 year plan put neighborhood health front and center, and the idea was to move beyond hospital by default, but there wasn't necessarily a huge amount of clarity on what that might actually mean From next year.

The idea is to introduce two new neighborhood provider contracts, which would formalize things and make things a bit clearer. But in the meantime, the plan is to kind of go ahead and select local sites to almost kind of trial it out and have a go. Um, so for the 43 locations selected, the idea is for them to develop their local neighborhood health services.

It comes with a very small amount of additional money, so 10 million pounds total across the 43 organizations. That might sound like it's obviously not a negligible amount of money, but that means each site is getting 230,000 pounds. Mm-hmm. Which isn't too much money in the, in the scale of how much it costs to run healthcare organizations.

That idea will be to help appoint people to lead those neighborhood health teams. There are a range of different neighborhood health models across the country already, or models of people delivering coordinated care at place level somes hosted by trust. Some are hosted by primary care providers. Other others are alliances, and it's not exactly clear how things are gonna be set up in different places.

The idea is to let different places develop them and decide for themselves, although with the commonality that. They'll be convene professionals across a range of areas, including gps, nurses, social care, local government, voluntary, and community sectors. I think mainly the thing is that there's quite a lot of variety.

I heard Claire Fuller speak at the Health and Social Care select committee recently, and she said the reason neighborhood health might be confusing is because it means different things to different people at different times, and I think that's a very accurate summary of where things are. But I would think we might want to get to the position of starting to move towards further clarity.

Hopefully the approach of learning by doing will work out. I got you. And that's Claire Fuller who leads on primary care for NH Single England as it is currently. I mean, do we have a sense of, you know, I, I noticed both of you, Danielle and Sarah, uh, noted down there what Secretary of State said about GPS being at the cornerstone of neighborhood health.

Who, who is actually gonna be in charge of these new neighborhood health approaches? How's that actually gonna function on the ground? Who's, which organization is making this actually happen? I think it depends. Again, as I said, it'll be different in different places. In most cases, the applications appear to have come from.

A range of organizations coming together. The people who got written to to apply included local government, included trusts, included ICBs, included gps, so theoretically anyone could apply for these things. It's quite unclear and quite hard to tell though exactly who's leading in different places because the places that were announced were just the list of geographical locations rather than the organizations that are, um, doing it.

And a lot of them were joint applications and how it's actually gonna work in practice is gonna be worked out over time. And if we take it away from the sort of world of systems and structures and finances and policy. What sort of difference is it gonna make, do we think, for, for people in those areas?

What are they gonna notice that's different? I think hopefully it will feel like more of a community, neighborhood health rather than these big system type health we've had in the last few years. Especially as, uh, those integrated care systems and regions are all getting bigger. They're all merging, they're all moving further away from the local system that, so hopefully these neighborhood systems will.

Bring it back to where the people actually live and actually moving the care closer to where people are. So more local services, more integrated services, more person centered services. Hopefully what we'll get out of these. Okay. And as I said, that was, so that was Secretary of State, making that announcement here at an event at the Kings Fund.

That was all about the tenure health plan and how it's implemented. We actually spoke to some of our attendees at that conference, uh, about implementation of the 10 year health plan. We've got a, a couple of clips, uh, from them here. So I think for the sector that that I work for, so I work within the drug and alcohol sector, so we're a charity.

There's nothing clear at the moment in terms of how substance use is being sort of built into this plan. And I know that's been raised a couple of times now, so still really. Keen to hear where that's being included and how that will be implemented at a local level. Nobody's gonna argue the three shifts.

I think they're sensible and that's exactly what needs to happen. The challenge of that is also what underpins the priorities and the, and the needs to deliver the tenure plan. It's very much about the culture of organizations, the culture of system, and how it connects to community. And that requires a different, a paradigm shift in how we think about people and communities, how they connect and make sense of our system and our organization, but also how they define health on their own terms.

One of the things that stands out for me in terms of the challenges is. How do we realize some of the workforce ambitions? And I know people might say, well, that's not necessarily, um, various service issues, your residents, um, centered, but without the colleagues who do the work and whether it be in a health setting, social care setting, volunteering, community, social enterprise, without those colleagues feeling good about themselves and what they do, then that's always gonna become challenging.

So a flavor there of what was going on for some of our health and care leaders attending our recent conference, a a few themes came out of that for me. A sense of confusion from our first contributor there, but then also something about the cultural shift needed to to really change how we think about health and care services.

And then finally. About how the, the workforce is in place to actually deliver this change. I actually wanted to come to you first, Sarah, 'cause our first contributor there, uh, worked at Drug and Alcohol Charity and spoke about the, the confusion that they're experiencing. And, um, I assume that is both on the side of changes happening with health services, but perhaps also what's going on in local government.

I think that really highlights how a lot of our health, and we know this is not created through the NHS, it's created in our communities and local government has a really important role to play in that there's currently, alongside the 10 year plan reform, there's also a lot of reform going on in local government right now.

And I think it was maybe five days or a week after the 10 year plan was announced, a devolution bill started going through Parliament, and that's gonna be quite a. Major shake up for local government. The idea is to create a new tier of local government called strategic authorities. They'll have a duty to consider how to improve the health of their populations and reduce health inequalities, and most will also, or many will also have a mayor, theoretically anyway with additional powers.

And so at the same time that ICBs are being. We organized to harness economies of scale. We're also seeing local government being reorganized and there's theoretically anyway gonna be quite a major interplay between them. So we know that ICB boundaries currently that are being reorganized, they're currently being organized into clusters in many cases, rather than being merged officially right now.

And the reason for that is because they want to where possible, line up the areas of strategic authorities and line up ICBs. Although elections, the new elections for mayors won't happen until at least May, 2026. So that kind of highlights the additional uncertainty. So I think there's a lot of ambition to align local government and the NHSA lot more closely so they can work more closely together.

And things like drug and alcohol services that are currently mostly within the remit of local government won't fall through the gaps as much or will still be. Will happen in a coordinated way, but I think there's still a bit of time before that's gonna happen. And as well as the sort of like structures that Devolution Bill is putting in place and the boundaries of them.

Is there any, within that, is there any shifting of responsibilities between what used to be with the health service and what might be with local government? Or is this more purely about how current responsibilities are organized? I think it's mostly about how. Current responsibilities are organized. I heard Jim Mackey speak about this fairly recently, and he was saying one option could have been to completely throw everything up in the air and reorganize, um, the responsibilities between local government and the health system, to which he probably heard chorus of people saying, please, no, not a major reorganization.

But I think perhaps that felt like perhaps biting off more than they could chew it. It felt like the idea was not to have completely reorganized the responsibilities, but kind of make the most of what you have and instead clarify the roles and responsibilities so it works better. So some of the other themes we heard there from, from our delegates were around the sort of cultural shift about how a health service, I guess, relates to the people it serves.

And linked to that perhaps also that we have the right workforce in place to, to serve those needs. To what extent are government thinking about that and have plans in place to, to make that cultural shift and the workforce to, uh, to, to staff the new health service that they, they've set out. So I think that cultural shift.

Point is really important. Um, I think if we just talked about league tables and they are very secondary care focused. They're very focused on acutes. They're not focused on that shift to community. Um, so they're missing out primary care, neighborhood health. Um, so there's still a question about how are we going to.

Create accountability, create transparency. How are we gonna know if neighborhood health is working, if all of the measures and accountability are focused on secondary care providers and trusts? So I think when in terms of implementation, there's still a question about how is the government going to do a lot of work more towards care in the community and measure what communities are interested.

Like we heard in the clip, the communities might not be interested in how their local hospital is performing, but they might be interested in how their local social prescribing services are performing. So I think there's still a lot of work the government needs to do to change that shift of where they're measuring what they're doing.

And on the workforce side of things, it felt to me like a few years ago there was a lot of, uh, organizations, including the Kings weren't. Calling for greater planning when it came to the workforce that actually, uh, a lack of staff was more of a hindrance in the NHS and in social care than sometimes, uh, finances were.

But in recent months and over the last year, it feels like that narrative has shifted slightly and a lot more people saying, well, hang on. The NHS has got a lot more staff, but we're not seeing the productivity at the, the, the other end. What were we expecting from government when it comes to, uh, future plans around the workforce to deliver this 10 year health plan?

Well, I still think planning's really important. It's not that we don't think planning is a bad idea and there shouldn't be any plans. It's more instead of like thinking about how to get more and more staff in, it's about thinking how can they be deployed most effectively to work with each other? What's the right mix of skills to kind of meet.

Population needs. So we've been talking about the need to shift care into the community. That means rather than hiring a lot more hospital doctors, thinking about hiring the staffing communities to deliver services. Also, we saw a workforce plan in 2023 that was very much about increasing numbers. We're expecting another workforce plan.

Hopefully by the end of this year that should set out. The workforce that is needed to provide the 10 year plan and kind of its wider ambitions and that will focus on skills that will focus on retention. We're expecting there to be projections of less numbers needed than had been in the 2023 plan, so hopefully that will then align and will make more sense in terms of how that workforce needs to deliver the plan.

So you mentioned there that we're expecting a workforce plan out of government, uh, to follow on from what we've already seen in the 10 year plan. What else are we expecting in terms of the implementation of the plan and next steps? Are there any major milestones on the, on the horizon that we need to be looking out for?

What we're hoping to see very soon is planning guidance. So normally that is published every year, although often quite late in the year, and that sets out the metrics and financial guidelines for trusts and local organizations that. That they're meant, meant to meet over the next year. This year they're taking a new approach and doing a three year approach so organizations can take a little bit more of a long-term view.

Hopefully we'll get that. I think I saw recently the, at the NHSC board by the end of September, although we're now quite late in September or sometime in the beginning of October. It's not many days at the point that we're recording this podcast. Exactly. So I think we'll see that, which should. Be very helpful.

Originally, there was also potentially a view that there might be an implementation plan that might set out really in one broad sway everything, which obviously sounds like a massive undertaking. I think the plan now is not so much to do that and instead to kind of look in bits at kind of planning guidance and then the workforce plan.

We'll also be seeing a cancer plan, which should set out, I guess in some ways, one of the first tests of the 10 year plan to see how the approach will work in reality on a particular. And cancer is quite well resourced and, um, quite well researched compared to some other areas. And so it'll be interesting to see if things work in cancer.

If things can't work in cancer, then I don't have a huge amount of hope for other areas, to be honest. I think the main thing is that we're. What we saw in the 10 year plan is a very broad plan. Um, it was focused around the three shifts rather than those specific conditions or specific areas like inequalities or cancer or CVD or those big topics.

So I think what we're gonna see over the next few months is hopefully some more specific details for those different areas. So things like. Substance, uh, misuse that we heard about in the clip. We will hopefully hear some more detail about those specific topics. Okay. I'm gonna move us on to another topic now.

Uh, and that is the prevention shift. This is the government's ambition to be less focused on treating sickness and more on preventing that illness in the first place. Um, and we've had a question coming from one of our listeners, uh, Anisha Mayer. Uh, now I'm gonna paraphrase your question here, Anisha, but essentially we know.

What moves the dial when it comes to improving the health of the nation and that a lot of that is outside the control of the Department of Health and Social Care. It's things like access to green space, active transport, a thriving voluntary sector, supporting people in their communities, a thriving life sciences sector, um, developing new ways to keep people healthy.

So her question was. To what extent are other government departments, transport environment, others, all pulling in the same direction of the Department of Health and Social Care when it comes to that health focus and wanting to improve the health of the nation. So that was the question. Now, there was actually a couple of relevant statements from the Secretary of State when he was here speaking at the King's Fund on this.

So I just, I just wanna play you one of those clips. Now, the King's Fund and Health Foundation have highlighted the excessive influence that the food, alcohol and tobacco lobbies have. On public health policy. We know we've got some great allies in our food and drink industry, including some of the biggest supermarkets, brands and suppliers who really do care about our nation's health.

But we also know in those industries, particularly in tobacco, there are powerful vested interests who too often have got away with calling the shots. I will continue taking on these vested interests where they work against the health of our people and the interests of our nation, and I will need your support to do it.

So I actually welcome the scrutiny I'm getting from the Kings Fund and the other think tanks and the challenges the wider health sector is putting in front of me. That's exactly why I'm here today. So that was Secretary of State responding to something, uh, a joint piece of work that, uh, chief Executive of the Kings Fund, Sarah Willow did with Chief Exec of the Health Foundation, Jennifer Dixon.

Talking about the government needing to do more on prevention. The particularly interesting thing I thought was what Secretary of State said at the end there about welcoming that scrutiny and welcoming that pressure. He, he went on in the question and answer session to talk about how the fact that some external pressure and some publicity around the need for more action on prevention helped him to have arguments when necessary across.

Government, which I thought was really telling. So back to Anisha's question, that idea that other government departments are all singing from the same hymn sheet, um, it sounded like from Secretary of State there, that sometimes he needs a little bit of extra help to apply pressure to his cabinet colleagues.

Um, but thankfully. Labor have a plan for this to get all of government working hand in glove, and that was their mission led approach to government. Do one of you wanna just give us a quick prey of what that mission led approach was, and then we can talk about the latest developments when it came to mission led government?

Yeah. So, uh, a mission led government was designed to, as you say, Andrew bring all departments together to focus on five things. And one of them was health, not just within individual departments, but all departments were. In theory supposed to be working towards improving health, um, which is really important, as you say, for prevention.

We've had that for the last sort of year or so, but recently we've seen, um, maybe some wobbles around whether or not we are having a mission delivered government. I, I think the phrase we use as has the mission gone missing? Yes. And it's relevant to the, the, the reshuffle that happened recently. I dunno if Sarah wants to give us a quick update on how that reshuffle relates to the health mission.

Well, alongside the cabinet reshuffle a couple of weeks ago, a slightly less widely reported change occurred and the mission delivery unit, which was set up within the cabinet office to deliver the five um, government missions instead got moved to the cabinet office from the cabinet office into number 10, um, led by Darren Jones in a newly created chief Secretary to the Prime Minister role.

Alongside that, the mission seemed to have been streamlined into three priorities instead of five missions, one of which is still improving the NHS. So there is still health in there, but it's much more narrow focused on the NHS in particular and not wider health. And we know that health so much more than the NHS.

So it feels like the original vision for a really wide health mission that also included prevention, halving the. Gap in life expectancy between the richest and poorest areas has been significantly narrowed. And whilst kind of having that focus in number 10 means there might be a strong focus from the pm, it does feel like what might be lost is the sense of collective ownership and cross-government working as alongside the wider ambition of the mission.

Okay. And if, if we step away from that mission led approach, just more generally looking at attempts in the past and where we are today, to what extent has there been success in getting all the government behind a. A health agenda. I mean, there's certainly been some success, I wouldn't necessarily say in terms of all of government, but there's been some really major kind of public health initiatives that have been really, maybe not so popular at the time, but have been really widely celebrated once.

Uh, in hindsight, things like the Clean Air Act, a lot to do with kind of cleaning up a water, that kind of thing. And more recently the tobacco and vape spill that is kind of going through. So I think this is something that the government can do. It has done in the past, but there needs to be, hopefully still the focus needs to remain despite things moving on.

And on a note of positivity, you mentioned earlier one of the things that contributes to health is life sciences. Hmm. That is somewhere that I think the government is making a lot of progress on. It's clearly an important area of focus life sciences, with both a very important part of the 10 year plan.

And then immediately afterwards, a life sciences sector plan was published that has, um, a lot of very clear priorities and goals. And objectives, and it's gonna be reported on every year and that it's gonna be a really big focus. So that is something that is a real priority for the government, both meeting its economic and health.

Goals at the same time. And so bringing it back to what we saw in that reshuffle and the, the sort of, uh, changes to mission led governments and to what extent that still exists or it doesn't exist, should we read a lot into that? Or is that, is this just sort of Westminster intrigue type stuff and it actually, you know, whether you call it mission or you call it something else, it doesn't actually matter.

The government's cracking on with prevention. What's your. Both of your take on, uh, to what extent this will make a meaningful difference to the whole, uh, sickness to prevention shift? So I think it is a bit worrying that we are losing some of the mission focused government, and I think a lot of the rhetoric from government at the moment is very, uh, single issue focused, particularly when it comes to health.

Mm. It's very much focused on the 18 week target. League tables acute care. So you're sort of missing that angle of this is a whole government approach to health, and without that mission, you sort of miss some of that broader, wider determinants of health that can go across departments like education, housing, department of work, and work and pensions.

And whether you call it a mission or whether you call it something else, I think it is that cross government working that Danielle's talking about is really important. We've seen it in other countries. Who have chosen to prioritize health, where, for example, instead of just reporting on the economic impact of policies and the cost, they also have to show how policies will impact health.

That's the kind of really cross government approach that could make a real difference, but that feels like is not gonna happen if we're gonna kind of focus back on single issue areas. Okay. Thank you. Um, there was one other topic I wanted to just very briefly mention at the end of this podcast, and that is social care reform.

Previous listeners to the podcast will know we've discussed, um, the Casey Commission, uh, that Barrons, Louise Casey is leading for the government looking at social care reform. That commission had its first cross party talks recently that brought together representatives from the five main Westminster political parties to, to begin a process of trying to develop.

Uh, political consensus around social care reform. I, I did think it was telling one thing that Secretary of State said when he was at that Kings Fund conference recently about social care reform, and that was the. While the Casey Commission will publish its first report in 2026 with some recommendations, what government needs to do now, the main report is to come in 2028 and he, uh, explicitly said that his ambition through that report coming out in 2028 is that we'll go into the next general election expected in 2029 and with all political parties having to answer the question of how they would reform social care.

So I think that was the first time I'd heard him say explicitly that. Part of the plan there with the KC Commission is to create the political impetus for all parties to have credible plans for social care going into the next election. So lots for us to follow in future podcasts, future blogs, future events at the King's Fund when it comes to that.

But that is all we have time for today and for this month's podcast. Not only is it the end of this episode, it's also the end of our, uh, three part mini series on the 10 year plan and implementation. So if you do want more from the Kings Fund on some of the. Themes we've discussed here. You can go to the King's Fund website to see a blog from our very own Danielle around Trust League tables, what they mean and how they can work.

There is also on there, the piece that I mentioned from the King's Fund and the Health Foundation calling on government to do more when it comes to prevention. And if you want even more health policy updates, you can join us in person at the Kings Fund for our annual conference in November this year.

We've got, um, some pretty good speakers this year. We've got Jim Mackey from. NHS England. We've also got Chris Boardman, former cyclist Chair of Sport England, Henry Dimbleby, who wrote the government's food strategy, and Kevin Fung, who some listeners may know from Radio four, also an NHS doctor. If you do have any feedback for us on the podcast, that is very much welcomed.

You can get in touch with us via [email protected], or you can drop us a message on X LinkedIn or Blue Sky. But for now. Thank you to Danielle. Thanks Andrew. Thank you to Sarah. Thank you. Thank you to our producer Sarah Murphy, and thank you to you all for listening.