As the Sustainability and Transformation Plans (STPs) roll in they tell us something important and deeply worrying about the culture of our NHS.  That so many senior figures allow their names to be associated with works of fiction tells us they accept the top down bullying that pollutes the health service.  They have no fear of any accountability other than to those who instructed them in writing their fiction and who enforced secrecy until plans conformed to the mandated line.

And it is fiction.  Fiction now being critically and sceptically examined thanks to the ludicrous attempt at keeping things secret having backfired. In their Five Year Forward View (FYFV) the leadership of the NHS shared their estimate that there would be a £30bn funding gap by 20/21.  They said that by making efficiency gains and moving to a better system this could reduce to £8bn.  For this the NHS would recover, become sustainable and go back to meeting its targets.  The government met the £8bn.  What could go wrong?

From the very outset many pointed out that the efficiency assumptions were wildly optimistic and that there would also have to be investment in social care (to take pressure off the NHS).  There would also be large, albeit one-off, costs of transition to be met. Since the 5YFV was launched some of its assumptions have unpicked.  Its baseline was out because the NHS started from a £3bn deficit, not a balanced position. There have been cuts to Public Health funding; a further deterioration in social care; and drastic cuts to the availability of capital funding – all having detrimental impact on the Plan.  Goal posts have moved as additional requirements have been added, like 24/7 working, without any additional funding. Then there is Brexit and the inevitable inflationary pressures.

If there was now an independent (Office of Budget Responsibility- like) assessment it would show that something like an additional £20bn is required.  It would also suggest additional transitional (and capital) funding was vital and that the time scales for full achievement of transition must be a lot longer. 

The scale of this reality gap is why so many are deeply concerned about the continuing deterioration of our care system – some warning of crisis and collapse. Into this we must now factor the 44 STPs, which are the local plans to deliver the 5YFV. They were based on the same deeply flawed and unrealistic assumptions of the original 5YFV case.  Most of these plans are now published.  Most blithely forecast that the impossible will be achieved in a kind of collective cognitive dissonance.

A few plans do give a more realistic and honest assessment pointing out that even with their best efforts a major funding gap will remain.  Some just put in the projected miracle but use a risk rating approach to show miracles won’t happen.  But some plans are truly delusional.

A few STP areas will achieve great things and most will make some improvements; but they will not deliver the NHS the 5YFV describes.  We will continue to see deterioration with longer waits, further access restrictions and maybe even more charges round the margins.  The long term trend in improving outcomes will slow down and in some instances reverse.

There is or perhaps was a once- in-a-generation opportunity to change our health and social care system for the better.  It is about to be thrown away. It may just be possible to make the 5YFV and the STPs into something worthwhile, but who in the collective leadership of the NHS is going to speak out?

Richard Bourne