The NHS continues to struggle. This is visible in terms of the comparatively poor health status of many of our citizens, comparatively poor clinical outcomes in key services such as Cancer, slow access to services, difficulty in identifying and deploying innovation, the exposure of fundamental flaws in service provision e.g. in Cardiovascular Disease, Obstetrics & Maternity and Mental Health, the sustainability of the workforce, and the struggle to deliver effective regulation. Our service is becoming increasingly unaffordable with many projecting a critical failure point in the next few years.

The NHS Ten Year Plan for England speaks to these challenges, with a strong focus on services in communities and neighbourhoods, a focus on prevention, a drive to digital, an emphasis on new service models, a regeneration of the NHS workforce and the loosening of the financial environment to support transformational change. There is also clear additional financial support e.g. for the new Health Data Research Service and to boost the capture and deployment of genomic information. There is also the opportunity to play out model change in terms of regional health innovation zones.

We are strongly supportive of this direction. But we see two key challenges it needs to address in its next steps:

i) None of these intentions is new. So to get it right this time requires a different approach. We note how so many transformation attempts have not lasted or have involved concepts and methodologies which have bounced off struggling NHS organisations. There is a risk of developing a top-down blueprint which assumes the answer without taking local context – population, services and workforce – properly into account or achieving full engagement of those that will ultimately determine whether the planned changes are successfully implemented. We think there is a risk government will be petitioned by a plethora of advice saying what the answer is. If this was definitively known, there would be no need for a Ten Year Plan. There needs to be a combination of top-down framework and local interpretation, ownership and implementation that takes account of the local context . And this will need to be properly tested for proof of concept.

ii) There is an implication in the Plan of “community good, hospital bad”. This would be unfortunate. Indeed, the evidence since 1976, with the publication of “Prevention and Health, Everybody’s Business”, is that the policy exhortation has inadvertently prompted a greater slice of the NHS budget going to hospital services. And very recent evidence suggests this continues. Meanwhile, hospitals feel under ever growing pressure in terms of Urgent & Emergency Care, Obstetrics & Maternity, Cancer, Mental Health and waiting times generally. We need a model which brings the hospital genuinely into play as a force for prevention, early intervention and integration with primary and community care and with the citizen. We also need to do this within practicable timescales so the theory becomes genuine practice.

There is plenty of evidence with which provider groups can work. This is not a research question. But it is also not a matter of applying generic wisdom from models and approaches that currently exist in the advisory world. It is about working out how the Ten Year Plan theory can be applied in a local context.