The Ten-Year Plan revives the ideas of `earned autonomy’ and `patient choice.’ Both have a heritage from reforms in the 2000s which the Plan does not seem to acknowledge.
Earned autonomy is the idea that better performing organisations are granted more decision-making freedom. This was the basis of granting Foundation Trust status in the 2000s. Earned autonomy would supposedly allow better performing organisation to have more freedom from central control and oversight and in turn, more incentive to innovate. Some might argue that is `liberates’ NHS Trusts from burdensome bureaucracy whilst others might say that it creates an uneven playing field across the country, threatening the `national’ dimension of the NHS. However, evidence from Foundation Trusts showed that few took (full) advantage of their `freedom’ because of the higher risks they faced, the limited organisational capacity/capability, and subtle forms of (on-going) centralisation: they were able to act more autonomously but often were unwilling.
The second retrospective aspect of the Plan relates to Patient Choice. It plans to “allow patients to search and choose providers based on quality data” and to “use patient reported outcome measures and patient reported experience measures to help patients when choosing their provider on the NHS App” (p.13). There is a good amount of evidence about the exercise and impact of choice. Victor et al (2012) concluded that “comparative information seems to have a relatively limited influence on the choices made by many patients”, not least because they made decisions on a variety of factors, not just outcomes. Moreover, given the diversity of patient demographics and conditions, it is possible that patient choice might exacerbate inequalities in access to care. Choice is based on the publication of performance measure and yet whilst greater transparency is a worthy objective, “it is not clear that public reporting will necessarily be as effective as its proponents intended”.
The Plan extends the incentive to keep the receipts of the sale of land assets in much the same way that the Lansley 2013 reforms introduced the `49% rule’ (to allow trusts to earn up to half their revenue from non-NHS sources). Whilst the average across England, some trusts have exploited these `commercial’ opportunities in terms of income from joint ventures, clinical trials and retail outlets.
While there are many positive aspects of the Plan, it appears that little has been learnt from (research) evidence about previous NHS reforms.
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