Lessons on long term planning from challenged health economies

long term planning

This report from Monitor, the TDA (Trust Development Authority) and NHS England, aims to share some learning from the Intensive Planning Support Programme (IPSP), which was delivered to 11 “challenged” health economies to support their 5 year strategic plans.

Although the report is obviously focused on England, many of the challenges identified and lessons will be relevant to other health systems.


Health economies who fared well tended to demonstrate:

  • shared understanding and ownership of the challenges faced locally, based on open and honest communication, leading to a shared vision and clearly articulated case for change
  • extensive engagement with patients, public, stakeholders and staff
  • clinicians in leading roles within change programmes
  • shared governance to support decision making
  • robust implementation planning, aligning commissioner and provider plans
  • workforce planning to ensure the capability and capacity needed is in place
  • encouraging the leadership behaviours to enable effective sustainable change
economy wide planning

Economy-wide planning can help build the strong working relationships between multiple organisations to tackle long-standing and complex issues but does depend on trust

One of the key challenges  facing health economies is to maintain momentum for improvement – the report recommends harnessing skills and efforts of all involved.  The need for system leadership is acknowledged alongside the need for support mechanisms.

The IPSP has been expanded to provide further support and there are plans to continue support via regional teams.  It’s not clear from the report how health economies have been supported to develop the capacity and capability to continue without the intensive support.  The solutions being explored are shared at a very high level but it’s not clear how these are distributed across the 11 health economies and how these have been prioritised.


Risks to delivering the plans include public and political pressure; lack of consensus; misalignment; culture and behaviour.

Lessons learned are shared but at a very high level (listed below) – although it has no doubt been worthwhile to capture these, as they stand, I don’t feel they’re useable or portable to other health economies.  I would have liked more insight into how processes and practices should be changed to reflect learning or what skills gaps exist and how they should be addressed.

Long term planning: what went well

  • More cohesion, coherence and collaboration across the health economy
  • Extensive clinical engagement in the design of the future solutions
  • A new governance structure that brought the LHE together
  • Joint national partner support helped leaders prioritise the issues and secure alignment
  • Resources for facilitation to enable problem-solving between partners
  • Rapid pace helped buy-in: “you needed to be there so as not to miss anything!”
  • ‘Honest broker’ external support helped shift perspectives and build momentum
  • The creation of ‘one version of the truth’ to define the scale of the challenge has been a key catalyst for change

Long term planning: what could be improved

  • Commissioner and provider plans less well aligned than expected
  • Earlier engagement of other LHEs with linked service reconfigurations
  • Information was less willingly shared due to tendering processes
  • Split responsibilities between national partners for project management caused complexity
  • Greater transparency of outputs by national partners would have built more trust
  • Clearer communication with local teams at the start would clarify the approach


There is a sense that the IPSP was intended to “springboard” challenged health economies and there is mention of sustaining change but there isn’t as much detail as I’d hoped about how leaders will be supported – the report skates over the very real retention issues facing the health service.  There’s clearly a need for ongoing support and I wasn’t clear how the IPSP was supporting health economies to develop the skills, behaviours and knowledge to function effectively in future.  It felt to me that a joined-up effort involving change specialists e.g. NHS IQ could have provided more practical learning and incorporated the existing evidence base e.g. the NHS Change Model.

shared vision

One of the keys to success is the alignment of commissioner and provider plans, based on shared understanding and ownership of the system-wide challenges and vision.

There are some assumptions about the ability of some interventions and initiatives e.g. BCF to deliver savings and improvements – the report references the need for expanded roles in primary care and social care but doesn’t seem to acknowledge the capacity issues.  I also questioned the assumption around that innovation is the answer – perhaps it is more innovative ways of working (e.g. co-production) which are needed.  Recent evidence suggests that for service integration to succeed, there is a need for strong relationships and trust, which take time to develop.  The current turnover, particularly at senior level, is a real risk.  Engagement is recognised as important although the overall feel was a little NHS-centric and seemed to me to miss an opportunity to encourage involvement of patients and third sector organisations.

The report is a relatively quick read and it is heartening that learning is being shared and to be fair, those involved will have been under significant time pressures.  Commissioners may wish to scan through the appendices to check how well their 5 year strategic plans stand up to the risks and lessons identified.


Monitor, TDA and NHS England, Making local health economies work better for patients, Monitor, 2014.

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