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and service planning is undertaken by insurers which
generally aren’t linked to a specific geographical area
and have no responsibility for population health.
The UK model has already changed considerably
from the original intention of the Bill. In practice
competition is largely managed so as to prevent ma-
jor disruptions to local services – and unnecessary
duplications of service - and most recently to intro-
duce a level of planning at a higher level in the sys-
tem. The system as introduced meant that, with the
exception of highly specialised services which are
commissioned nationally, no one had responsibility
for planning across the local commissioning bounda-
ries.This meant that many important decisions about
the configuration of services across boundaries were
not taken and potential improvements in quality and
efficiency were not realised. Neither markets nor
planning were delivering the solutions that were
needed.
As a result in 2016 NHS England asked local com-
missioners to work with their neighbours, local au-
thorities (which are responsible for social care, edu-
cation, housing and other public services) and other
partners in 44 areas with an average population of
1.1 million to produce
Sustainability and Transforma-
tion Plans
“showing how local services will evolve and
become sustainable over the next five years.”[8]
Planning and reality
As the Scottish poet Robbie Burns poet puts it “The
best laid plans o’ mice an’ men gang aft agley” [9]
or, to adapt German military strategist Helmuth von
Moltke famous quotation to a civilian context, no
plans survive contact with reality. [10]
Plans, even those that are very well conceived and
designed, may not be implemented for a variety of
different reasons. Sometimes plans are unsuccessful
because of problems with the planning process itself.
They might, for example, have not been tested prop-
erly; people who are key to implementation may not
have been consulted and may not cooperate; or the
implications for support services may not have been
fully understood. There can also be external prob-
lems: politics and unexpected events can intrude
and mean plans have to be changed; key individuals
from the health minister onwards may change and
commitment to the plans can be lost; or other pri-
orities may arise that mean plans are not followed
through.
Continuity and long–term commitment are particu-
larly important in health planning where results are
often not immediate but require years of determined
work. Health care planners in every part of the world
can point to examples where these external factors
have undone months of hard work.
Similarly there are examples where consistent po-
litical will, sticking to the plan and continuity of
personnel have led to major improvements. The
enormous improvements in health in Portugal since
1974, particularly in child and maternal health, are
a testament to the importance of political will, pub-
lic support and good leadership over many years.
The improvements in the English NHS [11] and the
development of the Mexican, Brazilian and Rwan-
dan health systems are other examples where po-
litical will, sometimes going across political parties,
have been extremely important components of suc-
cess.
This discussion suggests that further thought needs
to be given to the relationship between planning and
implementation and, in particular, to understanding
how change and improvement is brought about. The
next section looks at some real life examples of ma-
jor changes which are the product of individuals tak-
ing charge of a situation and deciding to act. In some
ways they are the antithesis of any formal planning
process.
Making improvements
Some of the most impressive improvements in health care
have come about through processes which hardly seem
to involve any planning at all but, rather, depend on the
continuous testing and adapting of ideas until they achieve
the desired results.This experimental and entrepreneurial
approach is seen for example in
Parkinsonnet.orgwhich
was started in Holland by a neurologist who believed there
was a better way of dealing with the disease. From an ini-
tial start in one area
Parkinsonnet.orgnow brings together
over 2,700 health professionals into regional networks
with patients and carers to provide information and ser-
vices throughout the Netherlands and into neighbouring
countries. They are supported by a coordination centre
and academic specialists at the Radboud University Ni-
jmegen Medical Centre. [12]
Parkinson’s Disease is a generic term for a very complex
disorder which may lead to a wide range of different
problems needing attention from different carers. This
network ensures that patients are able to reach the ap-
propriate professionals and, by having access to all the
information and protocols in the network, to play a full
role in their own care.
The model breaks down all the rigidities of the tradi-
tional system with new roles for professionals and pa-
tients, home and community based care and extensive