Planning guidance: the real story

Matthew: Hello, and welcome to Health on the Line from the NHS Confederation. 

The much awaited NHS planning guidance landed in inboxes just a week or so ago. But, of course, the fallout is still being examined. What does that guidance tell us about the government's ambitions for the NHS? Where does it leave NHS leaders and their teams as they face up to the most exacting efficiency targets, along with pressures to improve performance? Amid the policy detail, what does the guidance also tell us about the changing relationship between NHS England and the Department for Health and Social Care?

To explore all these issues, well, I really couldn't have anyone better to talk to than Bill Morgan. Bill Morgan was for 18 months the health policy advisor at 10 Downing Street under Rishi Sunak. Before that, he was also advisor to Andrew Lansley during the NHS reforms of the early 2010s. 

Bill, welcome to Health on the Line.

Bill Morgan: Hello. Thanks for inviting me.

Matthew Taylor: So, one of the great things about no longer being in government is that you can speak freely. And you've written some interesting things already since the election. But let's get into the planning guidance.

What did you make of it? 

Bill Morgan: I guess for me, the big thing which the planning guidance did was crystallise the decision that the government took, I think around the time of the budget last year and shortly before the Plan for Change came out, which is that their big political bet on the NHS is getting elective performance back to the 18-week standard by the end of the parliament. That is a big ask of the NHS and it requires almost everything else to be traded off against it. And I think that's what we saw in the planning guidance. We saw a lot of things essentially deprioritised. I thought that, Wes Streeting's a good communicator, saying he wants to end top-down control and the like, and that's why he's removing all these targets was neat spin. But I think essentially those things have been deprioritised. And I think UEC and primary care have also been deprioritised to the extent their performance is, like in ’25/’26, the government is targeting flat performance. But I think elective performance is really the only thing that the government is targeting improvement in, in the ’25/’26 year, with cancer performance improving almost as a symptom of improving elective performance.

And I think that's what we see come through in the planning guidance. It's an interesting decision for me. It's a sort of real distortion, if you like, of the NHS's priorities. And whether it makes operational sense is an open question and whether it makes political sense is an open question, but we'll see whether the bet pays off now, I guess.

Matthew Taylor: There's a lot unpack there Bill. 

Do you agree with the way Labour has recast that elective target? You would recognise, even when you were in government, that having chosen the overall length of the waiting list as a target was probably not the wisest call that Rishi Sunak made.

So do you think that Labour not only can try and move away from the total number, but also try to move away just from a focus on long waits in order to get that 65 per cent at 18 weeks by this time next year and then by the end of the parliament. Do you think that's a slightly better target?

Bill Morgan: I think, on the face of it, it is. I agree with you totally, the size of a waiting list is not a sensible target. And actually, in truth, it was a sort of rhetorical statement under Rishi's government, you know, like the NHS was still targeting the long waiters that was set out in the elective recovery plan.

I think it is good in theory to move away from sort of trying to tackle long waiters in these sort of almost slabs of waiting – removing the two year waiters, then the 18-month waiters, then the 52-week waiters.

They call it tail gunning. That's what we called it at the centre anyway. But it does sort of distort decision-making a bit because perhaps higher urgency patients you're not treating as you might want to do in preference to dealing with the longest waiters. 

I think though, what, that approach does give you is a bit of operational clarity. I think you know, targeting 65 per cent under 18 weeks, there's a lot of variables there. I was intrigued to reading the HSJ weeks ago, which is true actually, that you can hit that target by sort of deliberately inflating the size of a waiting list and then getting numbers under 18 weeks that way.

So with all of these approaches to dealing with like sort of waiting times are pros and cons. So I'll have to see how it plays out.

Matthew Taylor: Let's look at kind of another run on this, which is the A&E, the four-hour target, obviously. Controversy around that – is it a useful target? Should we've focused more on12 hours? And clearly quite a lot of push and shove between NHS England and the department on that. What's your kind of take on the A&E target? 

Bill Morgan: There's two things. Firstly, I think the A&E four-hour target is an excellent target for the overall health of a healthcare system. And actually it's not much to do with performance in the A&E itself. It's all about things outside of the A&E, as you know. 

So, improving admissions avoidance in the community. Sorting out flow and discharge and social care, the other side. So as a measure of whole system performance, I still don't think there's anything better than four hours, really. Which is why, of course, it was one of the things that we first did in the Sunak administration. We brought back the four-hour target and settled this argument about what the optimal measure was to use.

So that's the first one. The second thing, of course, there was this obvious bit of argy bargy between, I guess, the government and NHS England in setting the 78 per cent target of a planning guidance. And it spilled out of NHS England were trying to seek a lower target and ministers were firm at it had to be 78 per cent.

Planning guidance is always a negotiation. So NHS England’s open to negotiation, if you like, knowing that will have to be bid up by ministers; ministers will put them under pressure. So I can understand why NHS England opened the negotiation slightly low. But course, if you open the negotiation at a performance level lower than the last government was targeting, I understand why that's provocative to ministers. So it's just a particularly fraught aspect of a planning guidance negotiation, I think, which ended up spilling out into the public domain.

Matthew Taylor: We've talked a bit about kind of reduction in targets. We talked about electives, A&E. Another element of this is just the financial side of it. I've spoken to two or three leaders since the planning guidance was published. A not untypical assessment from the Q leader was that we got 4 per cent efficiency target, but if you add in the non-recurrent cost we've got from the things we've done this year to break even, you add that in, we're probably talking about a kind of CIP, a cost-improvement programme, of kind of like 8 per cent. 

I mean, that's not going to be achieved through efficiency, is it? That's going to have to be achieved through making some pretty difficult choices and some service cuts and probably some kind of accepting different kinds of risk, isn't it?

Bill Morgan: Totally. And I think this was sort of manifest at large in the planning guidance itself. If you're going to bet the farm on elective recovery, then everything else has to go hang. So we'll see how that plays out through the planning process and when the rubber hits the road, when we get into the next year. But yeah, there are going to be very tough decisions. 

And I think actually some decisions might be taken on which impacts on the operational health of the NHS overall. Again, the focus on elective recovery in isolation doesn't make much operational sense to me. Because it's quite a discrete part of NHS activity and it does mean that frankly, things like the three shifts feel somewhat dead at the moment. If you're channelling a lot of money into acutes to deal with the waiting list, you're not going to shift care from hospital to the community, from treatment to prevention and so on. 

So it's quite interesting. I think sort of government policy as it is, is moving in a slightly different direction to where the government rhetoric is.

Matthew Taylor: Now, it's interesting you should say that. The defence that I hear, and for which I have a certain amount of sympathy, is that the public are pissed off about just about everything, and got to try to get something, where they'll say, okay, that has improved, because otherwise… and they're not going to talk about left shifts or prevention or anything else.

I heard Tom Ridden, you talk about this at an event we organised last week on neighbourhoods. I think he was going to say, we understand there's always a pressure between the short-term retail offer and the kind of longer-term shift but we are trying as far as we can to talk about that short-term retail offer in ways which at least don't contradict ideas like the leftward shift. 

Is that too pan glossy a view?

Bill Morgan: No, I think the thing with focusing on electives is, if you were serious about doing those things, admission avoidance and more investment in the community and stuff, and that's what you'd prioritise in a way through the planning guidance, your plans, local NHS plans need to put resource into community settings.

And then with what resources left over you then, the amount of elective activity you do is almost a balancing item. But of course, it's all well and good saying we are trying to do these things, but if you've fixed and geared all your resource into electives, and it does leave very little scope to seriously move resources into community settings.

I do feel for them. You're right. They need to show delivery, they need to show improvement in the NHS. I just think whether it might be more advisable to target more modest improvement across the board, A&E, primary care, electives, and then say at the time of the next election, look, we're halfway there, and it'll take another term to finish the job.

Because as it is, you know, if you, if actually achieve this, then elective performance will look pretty good at the time of the next election, but UEC and primary care performance still won't be that great. 

And I don't think the electorate says we're bothered about waiting times. I think the electorates really bothered about waiting; waiting for everything, GP, ambulances, A&Es, elective in the round. So think that's where, again, the political judgment seems to slightly awry. They're focusing on a very discreet aspect of NHS activity.

Matthew Taylor: I guess they would say in the planning guidance there are clear targets in relation to A&E and ambulance waits, dentistry, primary care access. Even though they've taken away lots of other stuff. But I think you're right. I think you've got to remember is all of this is being done in the context of incredibly limited financial and also on social care, which is still in a very kind of powerless state and will be for some time yet to come.

Bill Morgan: Yeah. I mean, the other thing about finances, of course, is the demographic headwinds are really beginning to blow very fiercely now as the sort of baby boomers reach their seventies, eighties. And that dynamic, those headwinds get stronger. Every year now for the next sort of ten years.

So the fiscal position, the fiscal headroom, certainly for the NHS, just sort of the outlook keeps getting worse in a way. So it is very challenging.

Matthew Taylor: Let’s talk about a bit more about some of the other kind of political dimensions of this bill.

First, I think people will be intrigued. When you were in Number 10, how do politicians perceive NHS leaders? Were they sceptical or did they recognise the challenges that they face?

Bill Morgan: It's an interesting question for me because of course I was there between 2010 and 2012 and again, between 2022 and 2024. And I missed out the ten years in between. I was doing other stuff. And I do think there's been a change in how ministers perceive NHS England in that time. And it was obvious to me, cause I was comparing two different periods, one after the other almost. I think for me, the thing which has changed is that in the sort of 2020, early 2010s, there was a clear, trust from the central government that what the NHS said it deliver, it would deliver.

Then that builds an environment of trust in which the treasury can say, well, if we give you a bit more money, what can you deliver then? And then the answer comes back. And then you can plan decisions on that basis. 

I do worry a bit, a lot actually, but now that trust simply isn't there. And what the NHS says it's able to do in any given year, it ends up falling short, and there are lots of exogenous variables – strikes, which offer good reason for why the NHS might have fallen short, but it does undermine trust in the NHS's ability to deliver what, what it says it can, and therefore the sort of budget negotiations you have with the NHS. So I think that has been, definitely a worsening in that respect. And I think as a sort of almost minimum thing to do we've got to get back to well quite quickly where the NHS is delivering what it says it can deliver, and that's the sort of default because unless you get that trust back, it becomes very problematic.

Matthew Taylor: I absolutely hear that. And you've got to do that without reverting to kind of creative ways of reporting and accounting, which make it look as though you're doing it when…

Bill Morgan: Yeah, and in fairness, I think that whole relationship and the challenges are now replicated at the local level, at the regional level, at the national level, and then between NHS England and government. I think there's probably people in NHS England who might agree plans with local leaders and then the local plans aren't delivered and so I think the breakdown of trust and the confidence in delivery might be a feature of a whole system at the moment.

So there does need to be a sort of reset of realism.

Matthew Taylor: I hear that, but, and there's lots of elements. One of the things that I consistently say to ministers, official  NHSE folk is that it does feel as though very often when we read about the arguments between the department, NHS England, it's a kind of conversation about how much can the centre can demand from the service. There doesn't seem to be nearly as much conversation about what does the service need from the centre? 

You were part of the centre. Do you can share that view that, whether it's kind of Number 10, NHS department, treasury, there needs to be a slightly more self-critical conversation at the centre about how it is the centre supports leaders to do what they need to do.

Bill Morgan: I think actually the periods of greatest improvement in the NHS have come from when Number 10, Treasury and the Department are all, and NHS HQ are all sort of singing from the same hymn sheet. When they're sort of having an argument, it doesn't help delivery.

I actually think the tendency to harangue the NHS for more delivery than it can offer, I think that is in part a function of this institutional split between NHS England and the department of health. I think there was a slightly healthier relationship. I mean, again, I experienced this in 2010 to 2012, there was a slightly healthier relationship when the NHS was inside the department of health. It had a separate identity. There was an NHS bit of a building and a department of health bit of the building, but it did seem to work a lot better.

Matthew Taylor: But let's just talk a bit about the role of Number 10, because it seems to be much less kind of active at least in the health policy space than you were. Is that something you've, picked up on? And what do you think should be the role of the health lead in Number 10?

Bill Morgan: Number 10 is not absent. So, I think the prioritisation of the electives that's been determined by Number 10 political strategy. So, they are taking big decisions. I think having said that, you're right, I don't think this Number 10 is driving sort of health reform in quite the same way other Number 10s have done.

But Number 10s are creatures of the boss, aren't they? You know, if the boss is happy to delegate. The Number 10 is happy to delegate if your boss has got forensic attention to detail, Number 10 need to have forensic attention to detail. So you sort of take your lead from the boss in that respect.

I don't think there's a right or wrong way of how Number 10 should operate. Each way of operating has strengths and weaknesses. 

Matthew Taylor: I disagree with that Bill. Let me suggest a proposition to you, which is I think the kind of triumvirate within Whitehall, if it works well, is really effective. 

But the triumvirate should be, in my view, Number 10 that thinks about the political strategy as a whole and thinks about cross-governmental issues, not many of them, but core cross-governmental objectives. The Treasury that obviously thinks about the money, the numbers, is kind of critical in its kind of perspective on things. And then you've got the Department, which understands the policy in detail, understands the stakeholders, the people out there delivering it, and if it works well, that's a good triumvirate actually.

So I do think it is important that Number 10 is a big part of that conversation. What do you think of that, Bill?

Bill Morgan: I think in respect of NHS reform, if you're reforming the NHS, and you're provoking controversy – which is, let's face it, if they’re serious reforms, they will be controversial – you really, really need to have Number 10 totally across that, and driving it, perhaps, but at the least, Number 10 needs to make sure it's briefed the PM about what he or she might be getting into.

Because it's so electorally salient, the NHS, if reforms run into trouble, and the PM feels exposed or unsighted, then Number 10 will distance themselves from the NHS reform process. And Number 10, that's Number 10 job, they're trying to protect the PM here, but it does, it does then mean that the reform effort is sort of killed off. I say this with the experience of the sort of Lansley era, I guess. 

And heading into a ten-year plan at the back of my mind, and one of the concerns I'd have if I was in the Department of Health or, frankly, in Number 10 is, is the PM across what will be happening in the ten-year plan? Is the PM fully sighted on the arguments we might be getting into? Is he happy with the arguments we might be getting into? Is he willing to defend them for the next 18 months, two years, as we go through what might be controversial reforms. 

I think for any reforms to be successful in the NHS, do need to have the PM engaged and I worry a bit that the current Number 10’s appetite for delegating stuff might not be conducive to success there.

The other thing, of course, is that health reform takes time and might take more than the tenure of a health secretary, and PMs tend to last longer than ministers do in their post, so the good thing about Blair driving the reform process is that it didn't really matter who was health secretary because there was a coherency, a long-term coherency to reform. So if a PM doesn't have much of interest, then you can get wild changes in the reform destination, depending on who the health secretary is.

Matthew Taylor: That's really interesting. And of course, I have had this conversation with others and some people say, because you've got to remember that, there's no one that the PM trusts more than Wes Streeting, so maybe part of the reason they don't micro engage with it is because Starmer knows one of his best lieutenants is working the part.

Look, Bill, this has been a fascinating conversation. I want you to come on again after the ten-year plan is published. And when you do come on off the ten-year plan is published, I will remind you of your answer to this, my last question, which is what do you think is the critical thing that that ten-year plan should be trying to achieve? 

Bill Morgan: So I don't want to be too cynical in observing that these ten-year plans don't often last much more than two years before focus tends to shift to a new plan. And of course there's a bit of mythology about the NHS plan of 2000, that it was set out the path for the next ten years, which was never followed because two years later we had delivering the NHS plan, which, basically repudiated the NHS plan’s philosophy. And then two years after that was when we had the NHS improvement plan, which was when 18 weeks became a thing. So, people recollect that slightly differently.

So I think, even if it only lasts two years, there's some things that do need to be answered in this ten-year plan. We do need to know why CVs are going to do in future. We need to know whether trusts are meant to compete or collaborate with each other. 

There’s fairly important first order questions, which it needs to answer, which I don't think the answers are clear to yet. I think if I was saying, okay, if it’s genuinely set a path for the next ten years, which would stick and succeed, there are some things in healthcare which genuinely have an impact over that timeframe. You need ten years to move the dial. I think taking action on public health is important. So I'd like to see that being a strong theme of a ten-year health plan.

I think fixing the capital regime is vital. We talked about that when I was in Number 10, Matthew, I mean it doesn't at almost every level, the current capital regime does not work and fixing that… 

Matthew Taylor: We've got a paper on that published today as we, we speak. Uh, So I'd encourage people to check out the NHS Confed website to look at that about how we can bring more private investment in, but sorry… 

Bill Morgan: … and it, and, private, like what role of private finances is one of those unanswered questions, which we do need an answer to for the next ten years. Workforce reform is the other aspect – if we can train a more flexible workforce for the future, then; it takes, ten, 15 years to train a consultant. You need to really start now. 

If you want to have an impact in ten years now, that's something that the government can't lead by itself as to do in conjunction with the professions. But the ten-year plan is a good place to signal that direction. 

Public health, capital and workforce reform, I think the three pillars of genuinely successful, ten-year plan.

Matthew Taylor: That is where I will start my next interview with you. Thank you so much for joining me. I knew it would be a brilliant conversation.

Bill Morgan: Thank you. 

Matthew Taylor: Now, before we leave you, it's time for another Leader in Six, this time with Andrew Moore, group chair of University Hospitals of Leicester, University Hospitals of Northampton.

One of the questions I ask in those short interviews is, tell us something exciting about you that's nothing to do with the health service. I have to tell you, Andrew Moore gave the best answer, so listen out for that. 

So first question. What's the number one issue that you're wrestling with right now? 

Andrew Moore: Finance. A real challenge for both hospitals. Significant deficit and from my business experience, I just keep coming back to the fact that we can't do anything that we need to do and want to do in terms of investing for patients unless we get to grips with our financial challenges.

Matthew Taylor: Second question, what innovation is there in the trust that most excites you? 

Andrew Moore: The innovation that excites me would be our relationship and development with nerve centre on systems and data.

I think it's a game changer for large organisations such as the NHS and the work that we're doing in terms of, for example, the electronic patient records system will transform, not just digitising systems and documents, we would change the way we provide care for patients.

And I think that is really exciting. 

Matthew Taylor: Great. If you were king of the NHS for a day, what's the one thing you would do? 

Andrew Moore: I would really focus on culture. I think we are a large organisation, one of the biggest employers; the biggest employer in Europe, one of the biggest employers in the world.

And I think for an organisation of this size and scale, we need strong and healthy culture. I think there are areas where we can evidence that, but there are areas where we can't. And I think that needs to really address areas such as racism and discrimination and things that none of us would be proud of.

I think really investing in culture and education programs around culture would be where I would start. 

Matthew Taylor: Which leader across your career, and you've been in health service for a relatively short period of time, which leader have you most admired that you've worked with?

Andrew Moore: Well, I admire disruptors because they initiate change and significant change. And we're living in a world of disruption now. I think we've probably got more disruptors now than we've ever had. But I'm probably going to go back a few years and an older disruptor that I've had quite a lot of experience with sadly didn't work with him. But know a lot about him and I've been able to witness firsthand The impact that he had and that was Sam Walton who back in the early sixties created a small shop organisation called Walmart. And today is the biggest retailer in the world. 

Matthew Taylor: Great. Tell us something about yourself, Andrew.

This should be easy for you. I mainly interview people who've been working in the health service all their lives. You're a newcomer, but tell us something interesting or surprising about yourself, which has nothing to do with your role as chair here. 

Andrew Moore: So this is probably topical. But my claim to fame is that I'm the person who introduced Black Friday to the UK.

I introduced it, I think it was back in 2012. Nobody in the UK had any understanding of what Black Friday was all about. Amazon were dabbling with it, but nothing serious. So because of the fact that I worked for Walmart at the time, I knew how major it was for Walmart.

And I managed to convince people under great secrecy to introduce it into the UK. It was very tightly controlled programme. Only a few people knew about it. We didn't even tell our stores until the last moment and then we unleashed it and it was a riotous success. 

And I remember going on to Sky television and the interviewers were like well, no that won't work. Nobody knows anything about it. What Black Friday, Thanksgiving has had nothing to do with the UK. 

How wrong they were. It changed retail forever. 

Matthew Taylor: Interesting story. I wonder what the Black Friday equivalent for the NHS might be. And then finally, Andrew, recommend something that you've watched or listened to recently, or read recently, that you think other people might appreciate.

Andrew Moore: TV programme, think it's on BBC2, Corridors of Power. It’s fantastic. The premise is really around the role of the US and being the policemen of the world. And what it does is it goes back to the sixties and the Kennedy era and goes through every president since then on the wars the US has been involved in and how they went about it. And really it's a programme about decision-making, but it's right in the White House and they've got fantastic people talking about it. The people that were there in the room explaining what happened, the pressure that they were under, the life or death decisions that they had to take.

Fantastic. And I kind of think, my God, we've got some tough decisions to make in the NHS, but these guys probably just trumped us. 

Matthew Taylor: Fascinating. And I just read a piece this morning about Trump, which basically said, Trump will be no different to other American presidents, it's just that he won't dress it up as virtue. Andrew, thanks very much for talking to us.

Andrew Moore: Pleasure. Thank you 

Matthew Taylor: Well, thanks so much again to Andrew Moore and to Bill Morgan for joining me.

We'll be back in a couple of weeks. But in the meantime, please, please, please do make sure to subscribe or follow us wherever you get your podcasts or leave a generous review.

It really does help. See you next time.