Horatio Holding the Bridge

NHS Operational Planning and Contracting Guidance 2017-19

This is an attempt to summarise one of the most ambitious documents I have ever read since I joined the NHS in 2003. Working in an SHA, DH’s Commercial and Contracts Unit and within Commissioners and Providers of all kinds has given me a unique overview and from this I see challenges to the capacity, capability and above all culture of the healthcare sector; especially in NHS organisations.

Horatio is the legend of a Roman Soldier who held the Etruscan Army at bay on a footbridge whilst his colleagues demolished the bridge behind him. He then swam the river in armour to escape and re-join his colleagues to fight another day. This is what NHS leaders have to do. They need to deliver the services required as their organisations are transformed into something new and ignore the sound of axes. Then they must be confident enough to take a leap.  

A strong desire to change was signalled in 2015 by the STP guidance and the 5 Year Forward view. I summarised these in earlier articles. What this document does is add a system of collective performance management and targeting summed up by the quote below.

“A genuine commitment for local leaders to run a shared, open-book process to deliver performance and improvement within the growing, but fixed, funding envelope available to that local area”.

Whilst Boards and Executives are trying to get their heads around the cultural implications there is the additional need to reduce the NHS provider deficit in 2016/17 to no more than ￡580m with a goal of ￡250m for 2016/17 and a balanced starting position for 2017/18. CCGs must achieve balance in the commissioning budget. Behind this I detect a significant, revolutionary, change. In the guidance NHS England describes using a Best Possible Value (BPV) framework and within the description this sentence stands out.

“We expect all STPs to have adopted value-based decision making processes based on the BPV framework, embedded from April 2017.”

Did you see it? The instruction talks about STPs as if they were organisations. That, combined with practical challenges that can only be overcome by collaboration, realigning and cutting resources across multiple organisations in a geographical area is to me the death knell for self-governing Trusts and even CCGs.

“Targets and Must Dos”

The Guidance identifies 10 Points and nine “must dos”. In intention these are clear and simple.

1.      Meet Financial Control Totals

2.      Implement the Five Year Forward View

3.      Each STP becomes the route map

4.      Partnership behaviours becoming the new norm

5.      New care models break down boundaries between different types of provider, and foster stronger collaboration across services

6.      Opportunity to settle the numbers earlier and for a longer duration.

7.      Certainty and stability; simplify processes and ensure they are more joined up; cut transaction costs; and support partnership and transformation.

8.      Default will be for two-year contracts

9.      The 2017-19 operational planning and contracting round will be built out from STPs.

10.  A single NHS England and NHS Improvement oversight process will provide a unified interface to ensure effective alignment of CCG and provider plans. 

Some complexity is clearly visible in these early points. First of all is the point that the STP (or agreed population/geographical area) will have a financial control total (also the sum of the individual organisational control totals). Each organisation will have to hit its own total but can, with NHS England agreement, flex to meet the overall control total. This makes each organisation, in effect, a department of the overall “STP”. This is entirely consistent with the model of Place Based Systems that the DH has been looking at from places like New Zealand. It does, however, mean that each Board has to look across at and co-operate with the other organisations; possibly massively challenged. This, from a culture that has focused boards on individual organisational performance and financial health, is a massive change. The provider sector and commissioners have, for example, long distrusted each other a one senior commissioner once described meeting with the local acute as “Looking the enemy in the eye”. The Trust’s own culture was equally dismissive of the local PCTs capability.

To overcome this culture and history must be done with breath-taking speed. The STPs must be completed by October and signed off. The 2 year contracts that will be built on them have a target deadline of 23 December 2016 for signature. Progress will therefore be contractually binding, as well as seen on trajectories.

What do we recommend organisations do?

There is a massive cultural and psychological shift needed. This needs to go beyond Boards and senior managers and permeate down. To achieve the necessary awareness and start the shift I would suggest:

1.      Urgently set up Board and senior staff workshops within their own organisations on the theory of Place Based Systems; the 5 Year Forward View and the new guidelines. Allow staff to discuss the concepts, share worries and move towards an understanding of why DH wants to make the changes it does. The outcome is to get a mind-shift towards understanding a health system led by a Virtual Body called the STP. Possibly give the STP a name; “Hertfordshire Progress”; “Devon and Cornwall Together”, anything to build consciousness of a new reality.

2.      There will be bafflement and even grief at the loss of status, power and influence of organisations. This needs to be managed sensitively. To build trust and understanding the initial workshops need to be followed up by cross organisational planning and discussion forums. These are not the STP structures already in place but more conceptual, problem solving and long term focused events.

3.      Within each organisation select people at all levels to become “cultural architects” for the change. Immerse them in the theory and delivery of the STPs. Ensure there are sufficient numbers to allow their influence to reach wards, support services and back office functions.

4.      The executives, leaders and cultural architects need to be visible in all areas of the Virtual STP. They should be attending staff meetings, Boards, department meetings and most of all wandering the corridors so everyone can see they are willing to understand the practical issues faced by different organisations. CG leaders in providers, providers in the CCG, MH in Acute……

Nine ‘must do’ priorities

The nine “must do” priorities are reasonably familiar with the addition of the STP milestones.

STPs

Implement agreed STP milestones, so that you are on track for full achievement by 2020/21. Achieve agreed trajectories against the STP core metrics set for 2017-19.

Finance

Deliver individual CCG and NHS provider local system financial control totals. 

Implement local STP plans to moderate demand growth and increase provider efficiencies.

·        RightCare

·        Elective care redesign

·        Urgent and emergency care reform

·        Self care and prevention

·        New care models such as multispecialty community providers (MCPs) and primary and acute care systems (PACS)

·        Medicines optimisation

·        Management of continuing healthcare processes

The list of provider efficiency measures is equally daunting

·        Pathology and back office rationalisation

·        Procurement

·        Pharmacy and estates transformation

·        Rostering systems and job planning

·        Getting It Right First Time programme

·        New models of acute service collaboration and more integrated primary/community services.

What do we recommend organisations do?

This agenda is massive and will involve multiple work-streams. Each organisation needs to look at its current situation and then sit down with its partners and agree shared priorities. Based on experience elsewhere I would look first at E-Rostering; bring clinicians together with procurement; Demand Response to use the power-plants as income generators and agreeing a list of project and programme targets for each quarter. To try to do everything at the same time is to attempt to “Boil the Ocean” and therefore doomed. Stage the implementation and put enough resource on a cross organisational programme to achieve a result and move on.

Primary care

Primary Care has its own challenging agenda.

·        Implementing the General Practice Forward View, Practice Transformational Support and the 10 high impact changes. 

·        Ensure local investment meets or exceeds minimum required levels. 

·        Hit interim milestones for increasing doctors, pharmacists, IAPT sessions and online consultation

·        Extend and improve access

·        Support large scale general practice MCPs/PACS, and enable and fund primary care to implement the forthcoming framework for improving health in care homes. 

What do we recommend organisations do?

These are highly complex targets, depending on training new staff and realigning resources. Much of this is outside the immediate control of the local NHS. What can be done however is a rapid, clinically led, exercise to identify what a model MCP/PACS would like. There are reports by the Kings Fund from the 2008 Polyclinic pilots that may help; and the 2015 Kings Fund Report on the NUKA and Canterbury system. Many out-patient appointments do not need equipment or tests exclusive to hospital.

The clinicians can explore what services need to be in hospital, what could be operated in larger centres with GPs and how they would support in-patient services using technology. They can then draw up a model and work out how the business model would work.

Urgent and emergency care

As a key target for the NHS emergency care remains a strong focus.

·        Deliver the 4-hour A&E standard, ambulance response times and the five elements of the A&E Improvement Plan. 

·        By November 2017, meet the four priority standards for 7-day hospital services for all urgent network specialist services. 

·        Implement the Urgent and Emergency Care Review, ensuring a 24/7 integrated care service by March 2020 in each STP footprint, including a clinical hub that supports NHS 111, 999 and OOH calls.

·        Reduce 999 calls that result in avoidable transportation to A&E.

·        Initiate cross-system approach to prepare for new waiting time standards for MH crisis urgent care

What do we recommend organisations do?

This again is a large programme of work. The integration of urgent care services harks back to the “Clinical Integration” plans of 2006/7 when NHS Direct was seen as the integrator. Bringing MH into the mix is an interesting and overdue addition. Areas to look at might be:

1.      Re-imagining crisis services in an OOH context. Holding a service modelling workshop with OOH providers how they achieve the urgent care targets and looking at how, through working in a non-secondary led MDT model, MH services could become part of an OOH service with non-clinical staff in larger numbers, supported by clinicians, responding rapidly, safely and holistically.

2.      Early discussions with Ambulance Trusts, who are struggling to hit their own targets, on how the whole system (including primary MH, Community and Care Home providers) and change the assessment and management of people to reduce exacerbations and safely utilise non-urgent resources.

3.      The Care sector is key. Social Care simply does not have the beds or staff. Funding needs to be found or reforms made to create discharge resources. Perhaps as beds shut for acute needs whole wards could be handed over to care providers; managed and funded via acute providers.

4.      Prevention will be in the hands of GPs; for example work in Hardwick on COPD pathways found that if NICE clinical guidance was followed the impact could be significant. The new Care Home framework will identify how to support the most vulnerable.

Referral to treatment times and elective care

Wait times remain a political priority.

·        More than 92% of non-emergency patients wait no more than 18 weeks from referral to treatment (RTT).

·        Deliver patient choice of first outpatient appointment, 100% of use of e-referrals by April. 

·        Streamline elective care, including outpatient redesign and avoiding unnecessary follow-ups.

·        Implement national maternity services review, “Better Births”.

What do we recommend organisations do?

Clinical leadership is vital here. The interaction between referrers and receivers can bring dividends. Safe and expert management outside hospital with support from consultants is something that prison health has been working on for many years. Looking at how electives work in countries where distance is problem is another interesting route.

Trust is a big issue. Trying to control internal referrals and follow up ratios is, whilst understandable, a sign that commissioners and providers lack trust in each other.  Building a model of pathway commissioning, even informally, may help by allowing Commissioners and Providers to control risk. If the most common pathways are agreed as x+y+y then possibly a funding mechanism can be agreed.

A good example in outpatients is sexual health services. In London CNWL consultants care for 650 HIV patients through an MDT model. The national average is 150. They worked out how to do this when commissioners slashed the budgets. Outside London the ratio is 1 consultant to 150 patients.

Mental health

The ambition for Mental Health is huge.

·        Deliver the implementation plan for the Mental Health 5-Year Forward View for all ages, including:

·        At least 19% of people with anxiety and depression access therapy treatment, with the majority of the increase integrated with primary care;

·        At least 32% of children able to access evidence-based services by April 2019; all areas part of Children and Young People Improving Access to Psychological Therapies (CYP IAPT) by 2018

·        53% of people experiencing a first episode of psychosis begin treatment with a NICE-recommended package of care within 2 weeks of referral

·        By April 2019 increase access to individual placement support for severe mental illness in secondary care services by 25% against 2017/18 baseline;

·        Commission community eating disorder teams so 95% of children and young people receive treatment 4 four weeks of referral for routine; and one week for urgent cases

·        Reduce suicide rates by 10% against the 2016/17 baseline.

·        Ensure delivery of mental health access and quality standards including 24/7 access to community crisis resolution, home treatment teams and mental health liaison services in acute hospitals. 

·        Increase baseline spend on mental health to deliver the Mental Health Investment Standard.

·        Maintain a dementia diagnosis rate of at least two thirds of estimated local prevalence, and have regard to the forthcoming NHS implementation guidance on dementia.

·        Eliminate out of area placements for non-specialist acute care by 2020/21.

What do we recommend organisations do?

This agenda takes MH into new territory. The required co-operation and integration with primary care is hugely challenging. Whilst commissioners wrestle with budgets and placements pathways and locations for care need to be transformed.

As with urgent care bringing together GPs, Psychiatrists and senior clinical staff to re-imagine what can be done and where is key. Identifying locations for care, access for young people and how technology can be applied is key.

We don’t know what is possible; MH has lagged behind in many ways however this could be a strength. There is a “catch-up” bonus in the economy that could apply. An example would be integration of MH with primary care clinical record systems. In prisons we have seen great success integrating MH, Community and Primary Care on SystmOne using its running record function. The acute sector would, strangely, need to change more to achieve this level of integration as the PAS and coding systems they use are more developed.

Cancer

There is more continuity here; these targets are perhaps more predictable.

·        Working through Cancer Alliances and National Cancer Vanguard, implement the cancer taskforce report. 

·        Deliver the 62 day cancer standard, secure adequate diagnostic capacity, and meet NHS Constitution cancer standards.

·        Improve 1-year survival rates; improve proportion of cancers diagnosed at stage one and stage two; and reduce number of cancers diagnosed following emergency admission.

·        Ensure stratified follow up pathways for breast cancer are rolled out; readiness for other cancers

·        Ensure all elements of the Recovery Package are commissioned, including ensuring that:

o  all patients have a holistic needs assessment and care plan at the point of diagnosis;

o  a treatment summary is sent to the patient’s GP at the end of treatment; and

o  a cancer care review is completed by the GP within six months of a cancer diagnosis.

What do we recommend organisations do?

This is an area where the voice of the patient is vital. When and how people are treated will have an impact on the system. Overcoming fear will improve access to screening.

Cancer has been treated in hospital in part due to the need for kit and medicines. As the

Atwal Guwande’s work on end of life will be especially interesting for cancer patients and staf facing the end of life.

People with learning disabilities

Clear and firm targets for LD.

·        Deliver Transforming Care Partnership plans with local government, enhance community provision for learning disabilities and/or autism. 

·        Reduce inpatient bed capacity by March 2019 to 10-15 in CCG-commissioned beds per million population, and 20-25 in NHS England-commissioned beds per million population.

·        75% of people with LD on GP registers are receiving an annual health check.

·        Reduce premature mortality

What do we recommend organisations do?

People with LD need, first of all, good primary care. The co-ordination of support services and a commitment in General Practice to make the registers work will be a good starting point.

One novel approach would be to bring new eyes to LD. Traditionally LD is commissioned and delivered as a sub-set and by clinicians who understand services. Bringing in primary care and acute trained staff might act as disruptive innovation and challenge current models and pathways.

Improving quality in organisations

Amongst all the targets the focus on quality remains; including managerial approaches.

·        All organisations should implement plans to improve quality of care, particularly those in special measures.

·        Use the National Quality Board’s resources to measure and improve efficient use of staffing resources.

·        Participate in annual publication of findings from reviews of deaths, to include annual publication of avoidable death rates, and actions taken to reduce deaths in healthcare

Performance Measurement

At the system and organisational interface the impact of the changes will be felt almost immediately.

·        There will be aligned oversight frameworks for commissioner and providers: the CCG Improvement and Assessment Framework (CCG IAF) and NHS Improvement oversight framework for providers

·        NHS Improvement will use the single oversight framework to look at providers’ contribution to their STP and associated support needs, and NHS England will do likewise through the CCG IAF. 

·        Wherever appropriate we will ensure the main point of contact on implementation of STPs and support from national bodies is with the shared STP leadership for each area.

·        We will publish core baseline STP metrics in November 2016, encompassing as a minimum:

o  Finance

o  Performance against organisation-specific and system control totals

o  Quality Operational Performance

o  A&E performance

o  RTT performance

Health outcomes and care redesign

Here again the changes to reporting and governance are massive. As well as the targets listed below the approach described pushes organisations together.

·        Progress against cancer taskforce implementation plan

·        Progress against Mental Health Five Year Forward View implementation plan

·        Progress against the General Practice Forward View

·        Hospital total bed days per 1,000 population

·        Emergency hospital admissions per 1,000 population

“As part of the process for setting up new care models, NHS England will work with CCGs to ensure they have the capability and capacity to operate effectively in the changing provider landscape. This will include building on locally-led initiatives up and down the country for CCGs to work together across larger geographical footprints, for example, through joint appointments, integrated management and governance arrangements.”

 

 

 

 

 

Timetable

The timetable for changes is, in context of all the targets listed above, ambitious. As organisations morph to work together on system delivery, changing culture as they do so, they will need to implement managerial changes.

From April 2017

·        Stronger requirements on commissioners to facilitate hospital discharge and on providers to comply with recent NICE guidance

·        Mandated use of the e-Referral system (ERS);

·        Mandatory data-sharing agreements for urgent and emergency care providers

From October 2018

·        Non-payment for activity from non-ERS referrals; providers to return non-ERS referrals to GPs. 

From November 2017

·        The four priority standards for 7-day hospital services for all urgent network specialist services;

·        Compliance with new data security standards (April 2017)

·        New conflicts of interest guidance (June 2017)

·        New interoperability requirements for clinical IT systems (January 2019).

·        Roll out of Carter Review Recommendations in Community and MH Autumn 2016

There is a change in how NHS England is organising itself. It will begin to use the Best Possible Value (BPV) framework to make investment decisions. The BPV framework is “a structured approach to assessing the value of a particular project. It uses logic models and success hypotheses to estimate both quality benefits as well as financial return on investment and provide a robust mechanism for tracking the delivery of these benefits”.

For 2017/18 and 2018/19, the BPV framework will be used to assess most applications for transformation investments. The DH expect all STPs to have adopted value-based decision making processes based on the BPV framework from April 2017.

What do we recommend organisations do?

We have treated the areas above as one; in these areas the transformation of culture and of systems needs to harmonise. The big problem in achieving this however will be finding and empowering resourcs. It is for this reason a radical approach will be needed.

1.      Currently there are a lot of staff producing board papers and reports. They need to be re-assigned to programme work as rapidly as possible.

2.      A single performance framework should be serviceable by a single provider team and a single commissioner team; possibly even one integrated STP Performance body. An STP Information Warehouse could be transformative and application of Big Data and Statistical expertise allow effective projections and risk based decisions to be enacted. This should enable the ambitions of the BPV Framework, possibly even exceed them

3.      A single report will also be most effective if Board intervals are increased to the maximum possible. Controls must not be loosened however and leadership teams will need to ensure that, as all these changes occur, thy can quickly see clinical and financial performance.

4.      In a recent assignment we saw a million-pound deficit go unchallenged for over 2 years. We picked it up in 3 minutes. Such things should not be possible and simplifying reporting, with clear delegated responsibility to team and department leaders, will enable grip.

5.      The performance staff released need to be trained as rapidly as possible in simple project management and support the delivery of improvement projects. During the days of the Modernisation Agency there was widespread training in simple techniques. Perhaps this is something to look at.

Summary

The STP process could be seen as simply one more initiative that is doomed to fail. To take this view would be a mistake. When the DH set up the performance framework based on the STP infrastructure and created a “jointly and severally liable” approach across a geography they turned a paper exercise into a major transformation.

The challenges are, without doubt, huge. Currently all my work in the NHS suggests that an understanding of the STP process is confined to staff at the top of organisations. The discuss and evolution of a new, “Place Based”, Organisational Consciousness, cannot take place in the board room alone. All the experience I have tell me that the common beliefs and perceptions based on the last 20 years or more run contrary to the intentions of the STP process. What the sanctions on staff and organisations will be is still unclear however, at a macro level, this approach seems to be a last gasp to save the NHS as a tax funded system of care. Perhaps the ultimate sanction will be to belong to the generation of leaders who failed to save the system?

The timescales are frightening. In Canterbury and Alaska the emergence of the place based systems took a decade of evolution. The NHS is giving itself less than 5. That does not mean it is impossible but what is required is staff engagement on a scale hitherto unseen. At this point the visibility of the leadership at NHS England needs to increase. Staff will need to find leaders to believe in; and the best way for this belief to be transmitted is visible commitment.

What does this mean for interims and consultants in healthcare? The skills we have are, right now, needed but outside the traditional boxes. Facilitation, service modelling, innovation and challenge are all needed. We can say what internal staff may fear to utter aloud, focus on the bigger picture and ignore perceived risks to status and career.

All the experience we have gained across organisations, tendering, planning and modelling, needs to be brought to bear. CIPs, new models of care, costing and modelling have a central place.

I will not be pessimistic about the guidelines. Some will see un-achievable goals designed to wreck the NHS. I don’t see that. I think these changes were flagged last year and the complexity of their implementation shows frustration in the designers of transformation. Unable to work through Trusts and across the commissioning/provider divide they now seek to bypass them.

The battle to save the NHS has truly begun. “Cry Havoc…”