policy update - nhsproviders.orgnhsproviders.org/media/2087/23-june-policy-update-md-nd-v2.pdf ·...
TRANSCRIPT
Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 CONCLUSION
Pulled in different directions between the system and the institution, between local and national, between quality and finances
Asked to do perform difficult and awkward manoeuvres on financial plans, control totals, prudential accounting, performance trajectories
Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 CONCLUSION
System under sustained operational pressure 98% 92% 91% 88% 86% 83% 82% 80% 77% 75% 73% 67%
97% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%
96% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%
95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%
95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%
94% 92% 90% 87% 84% 83% 81% 79% 77% 75% 72% 63%
94% 91% 89% 87% 84% 82% 81% 79% 77% 74% 72%
94% 91% 89% 87% 84% 82% 81% 78% 77% 74% 71%
94% 91% 89% 87% 84% 82% 81% 78% 76% 74% 70%
92% 91% 89% 86% 84% 82% 80% 78% 76% 74% 69%
92% 91% 88% 86% 84% 82% 80% 77% 76% 74% 68%
92% 91% 88% 86% 84% 82% 80% 77% 76% 73% 67%
%
seen
in 4
hours
Type 1
A&Es
Q4
2015/
16
Source: NHS England
Worst A&E performance figures since the standard was introduced – 4Q 87%
Ambulance services under sustained demand and performance pressure
Elective operations cancelled
District nursing and health visiting
caseloads increasing just as contracts come up for tender
Mental health referrals increasing
Struggle through 16/17… but 2017-21 U-Bend is coming
It looks like we will just struggle through 2016/17, the
supposed year of plenty…
…but current profile of additional NHS funding, increasing activity and new policy
commitments leads to crunch period in 2017/18 – 2020/21
% in
cre
ase
in N
HS
Bu
dge
t
The chart of financial doom
Source: NHS Improvement
1. The underlying deficit is far worse once prudential accounting and underinvestment in capital are factored in
2. This makes 2016/17 incredibly difficult with additional provider stretch needed 3. Puts us off track for the 22bn 4. Financial sustainability may eat new policy commitments and transformation for
breakfast
2016/17
Source: Kings Fund QMR April 2016
2016/17 is already falling apart. We closed 2015/16 with a £50 million deficit. Our control total for this year is a £15-20 million deficit. At the end of April we are already at - £10 million. NHS FT Director
The £22 billion savings plan – how credible?
Source: Comprehensive Spending Review 2015, FYFV savings technical note May 2016
• 1% public sector pay cap to 2019/20
• Renegotiating the community pharmacy contract
• Income generation • Reducing central admin costs
• RightCare • Self care • QIPP and demand
management • New Care models
• Lord Carter • Classics CIPs
HMT worried about institutional grip
What is the calibration of ‘good’ when everyone is in deficit, and it becomes about ‘not being the biggest failure’ – do I just need
to be in the middle of the peloton?
How do you motivate staff in this environment when it feels like
you are 10-0 down at half time?
What does good look like anymore?
Source:
How are things going? Well demand is up to our eyeballs,
we are nowhere near our financial control total, and we have a Requires Improvement from the CQC. So we feel we
are upper quartile at the moment.
NHS FT NED
Conflicting views on what’s the problem and what to do
1. Individual providers responsible for provider deficit
2. Must eliminate deficits and recover performance in 2016/17 year of plenty
3. Top-down individual control totals and performance trajectories right mechanisms
4. Provider Boards must be held to hard account, up to and including removal, if they miss a quarterly milestone
1. Provider deficits are a system issue
2. Realistically no chance of financial or operational balance by 2016/17
3. Control totals must be credible and owned by provider boards
4. Support and accountability in balance are needed, recognising where factors are beyond board control due to system impact and overall context
MUST. TRY. HARDER IT’S THE SYSTEM STUPID
And pressure to be part of the solution not the problem
How will you
explain to your
neighbouring
trusts that you
have not signed
up to a control
total?
Ask not what
your STP can do
for you, ask what
you can do for
your STP
16/17 finances: best guess on what happens next
Control totals • 139 signed up in February • Further 80 signed up in May • Individual follow-up for the
rest • Post-Brexit firebreak point in
August if on track for-£500m to -£1 billion deficit
Performance trajectories Strong emphasis on back loading trajectories to Q4 to minimise Q1-3 trajectory misses Indemnity if trajectory missed due to circumstances clearly beyond control
Success is now proof of concept/capability?
Source:
• 65% of sector in deficit, £2.5bn overall deficit, 11 trusts with
individual deficit > £50m
• 4 providers meeting last quarter’s A&E standard
• 68% of providers requires improvement or inadequate. 16
providers in special measures
• 80% of providers in surplus & sector in surplus
• Meeting operational standards
at aggregate national level
• Bending CQC curve
• 20% of NCM delivering, 50% of population covered
2015/16 2020/21
Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 CONCLUSION
Emerging tension between different forces
CENTRIFUGAL
CENTRIPEDAL
• Control totals for providers
• 1% hold back for CCGs • Increased CCG
assurance • STPs
• Co-commissioning of primary care and specialised care
• Devolution / Delegation
• Earned autonomy • STPs
Does the city come before the citizen?
• Our future lies in networks and health systems; not individual go-it-alone institutions - Simon Stevens.
• An emerging Aristotelian view of planning through sustainability and transformation plans (STPs)
• Strategic, multi year, place based plan to set alongside single year, institution based, operational plans
• Come together with your local place, address the wicked issues and develop a long term plan to transform care and plot a path to long term sustainability
But several tricky issues to work through
The ask 1. Timelines too ambitious 2. Too many baubles on the Christmas Tree. What is the
problem to address? 3. Did you really wake up and smell the coffee
The players 1. Different patches going at very different speeds based
on appetite, relationships and resources. Some STPs have no leaders, some have a plan ready to go, for some people the plan is still to improve as an org (e.g. special measures).
2. Relatively few LAs or clinicians are STP leads & unclear what the JD is for an STP lead. Do we have the capacity and capability?
The arena 1. STPs have no statutory basis, governance or clear
future. How are disagreements resolved? 2. Still regulated as individual organisations and that is
where a director’s legal duty lies – some significant governance and accountability issues feel parked not solved.
3. When everyone is responsible who do you hold to account when things go wrong e.g. System control totals for finance and performance
And multiple overlapping footprints
• 44 Sustainability and transformation plans
• Local education and training boards
• Academic Health Science Networks
• Ambulance services • Local Digital Roadmaps • Urgent and emergency
care networks • Maternity networks
Relationships are key but also hard
• Some STP planning meetings are turning into the conclave of the five families
• CCGs opting out from process you can not opt out of
• Little power to keep LAs at the table if they do not want to be there
And some STPs are a beautiful ship
It’s like going back to nursery school. NHS England and NHS Improvement have told us to
go an build the most beautiful ship we can. And our plan is beautiful. It’s got rigging and
masts and everything you could want.
The one thing they forgot to tell us is that the damn thing
has to float.
NHS Trust strategy director
It’s like going back to nursery school. NHS England and NHS Improvement have told us to
go an build the most beautiful ship we can. And our plan is beautiful. It’s got rigging and
masts and everything you could want.
NHS Trust strategy director
Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 CONCLUSION
NHS Provider Sector - regulation
All data correct as of June 2016
16 Trusts are in special measures
68%
Of rated trusts are rated ‘requires improvement’ or ‘inadequate’ by the Care Quality Commission (CQC)
13 Trusts are in success regime areas
Clear Jim Mackey narrative emerging
We're here to support, we're here to support, but there has to be accountability
• Trying to build headroom for leaders. In
• Interventions on the contracting round and
tendering already.
• Agency out of control sends out wrong signal. Need to get others off the pitch but we can’t do that until we prove we can handle performance and finance. Don’t put in unreasonable plans.
• As legislation intended NHSE and NHSI balancing each other.
NHSI changing the landscape
It feels like the Trust and CCG are caught in the cross-fire between NHSI and NHSE.
NHSI say we cannot sign a contract unless we can hit the control
total.
The CCG are told they MUST submit a break-even plan and the only way they can do and fund us for activity is to access the 1%
transformation fund, but NHS England will not give them permission to do that.
We are close to our control total, but do not have a realistic and
achievable plan to go that further mile. So it is getting to the point where we and the CCG either flip a coin to see where the financial
risk sits, or we ask NHSI and NHSE to slug it out and tell us what our local contract value is.
NHS FT Finance Director
A new oversight framework
QUALITY CQC rating, patient
& staff surveys
MONEY Old metrics
Use of resources Carter
OPERATIONAL PERFORMANCE
Small set of constitutional
standards
LEADERSHIP Well led framework
Organisational health
STRATEGIC CHANGE
In progress, likely to include STPs & NCM
Earned autonomy
More autonomy
Limited autonomy
Essentially special
measures
• Local decision making free of constraints
• Fewer data and monitoring requirements
• Simpler processes for transactions
• Recognition and opportunity to spread success
A new single oversight framework for FTs and Trusts, which establishes a single definition of success and a new relationship between the regulator and the regulated
Ten initial thoughts on new NHSI oversight framework
Danger of two competing CQC /
NHSI ratings
Individual institutional vs
system accountability
Relative or absolute standards
in current environment?
Developing leadership and
strategic change domains
What, when, how and why moving
through segments
How practical will benefits of full
earned autonomy be?
FT pipeline and FT status
Clarity on voluntary support
& intervention incl. mandation
Legal base
Overall narrative and relationship to
current strategic context
CQC new strategy to 2020
Encourage improvement, innovation and sustainability in care • More flexible registration e.g.
NCMs • Assessing use of resources • Views of quality across
populations and local areas
Intelligence-based approach • Development of CQC Insight • Targeted and risk-based
inspection where comprehensive inspection is exception to the norm
Promote a singly shared view of quality • Alignment with NHSI oversight
framework
Improve CQC efficiency • Focus on CQC VfM and changes
to fees
Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 CONCLUSION
What do we want?
Happy staff who find joy in work
Working in new settings
Working with new partners
Working across 7 days
Involved in the business
Coping with more demand
Taking a role in chains, turnaround, commissioning
Staff under pressure
NHS Staff sickness
absences is 27% higher than any
other public sector
organisation average, and
46% higher than
the average for all other sectors
Source: Nuffield Trust
Though some movement on junior doctor contract
Provisional agreement on new contract but needs to be ratified by referendum with results on 6 July
Additional costs to providers including additional employer pension contributions – needs close tracking
Significant additional duties for monitoring safe working hours and breaks and rotas
Need to track impact on wobbly existing rotas
Still significant trust and morale issues
Source: Junior Doctor Blog
Is this contract safe? On paper yes – the new safeguards reduce runs of shifts and provide a system that could
both address individual overworked doctors and collect data on understaffed rotas for the first time.
But in practice? In practice there has been no
groundwork laid for the expanded roles of educational supervisors, no realistic investment in the Guardian role in many trusts, and the financial pressures on hospitals right now are mounting. I simply cannot see hospitals
having the will, the manpower or investing the resources to make this work.
The old banding system was difficult enough- some
trusts actively hid hours monitoring data, and flat out refused to sort out rotas that breached safe working. But
where it did function, speaking from personal experience, it worked very well and effectively.
What is our offer?
Source: Roy Lilley, NHS Managers
…flexible rotas; child friendly (a crèche); a culture that is kind, creative and fun;
whole person training and development; dump bully-bosses and staff who behave
badly; listen to people; realise your people have a life outside work; find out what inspires people and do more of it; show people what good looks like and help them achieve it; accept pay is a
'national thing' but figure out what you can do locally with access and discounts
to become the local employer of preference...
Consultant contract
Radical contract reform
All change is painful, so change in one go
Put forward joint position from as least worst option
available through negotiation
Less radical reform Negotiate a package that
achieves delivery of 7DS but at a cost
Defer reform
Avoid strike of juniors and consultants at same time
Scale back 7DS ambitions
Supply of staff
• Significant variation in vacancy rates from 15% in London to 3% in parts of the North
• Expectation that by 2019/20 ‘we will have it right’ in terms of supply and demand for nurses and that in the meantime, agency staff and overseas recruitment must plugged the gap
Agency and locum caps
Source: HSJ, Liaison
• Zero-sum game • Unintended
consequences e.g. therapists
• Additional levels of management sign-off on bookings
• Review of job planning • Sharing capacity across
wards • E-rostering • New posts e.g. physician
associates, associate nurses
So a workforce squeeze regardless of the contract
Pressure on rotas and
performance and CQC
requirements
20% vacancies in specialties even
in some attractive deaneries
Exiting training Locum & Agency
caps
New limits on consecutive long
days
“ We need more nurses and junior doctors than we have at present to run these rotas. The posts we need are not being allocated, and even if they were allocated in sufficient numbers we do not have enough people in the right parts of the country and the right specialties to fill the posts. ” NHS Foundation Trust CEO
Some other workforce developments
HEE accepts Shape of Caring Review
recommendations
Nurses to remain on the shortage occupation list
Consultation on “nursing associate”
role
Consultation on reform of
healthcare education funding
Safe staffing guidance
Lord Carter and clinical productivity
Lack of a national workforce strategy
Given the size of the NHS, workforce planning
will never be an exact science, but we think it clearly could be better
than it is.
The current shortage of nurses is largely of the
health, care and independent sectors’
own making
Workforce is a relatively neglected area of policy which is often pursued
as an afterthought
Regional planning to solve the insolvable
NHS England, NHS Improvement, HEE, CQC, PHE, NICE new regional structure based on four areas
Create Local Workforce Action Boards. Aligned to STPs (albeit < 44). Lead on local workforce issues. Jointly chaired by HEE and local CEO
Baseline health & social care workforce and identify issues. Develop a high-level workforce strategy to meet STP ambitions and an action plan for required investment in workforce
Providers not standing still
• Ask patients what extended hours they would value
• Use evidence to target services and particular periods to extend service
• Listen to concerns of patients over impact on staff
• Then start conversation with clinicians and support staff
• Get details right e.g. canteen
Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 CONCLUSION
5YFV New Care Models growing
Two further new care models proposed
Reinvention of the acute medical model in small district general hospitals
Differs from Acute Care Collaboration (ACC) vanguards by specific focus on small district general hospitals, and
interest in care pathways and clinical workforce, rather than organisational
forms and operating models
Tertiary mental health services
Secondary MH providers taking on tertiary MH services such as secure MH and forensic services, perinatal mental health, Tier 4 CAMHS, CAMHS eating disorders, Tier 4 personality disorder
services
x14
x9
x6
x8
x13
Five vanguards
losing funding in 2016/17
as risk appetite grows (or shrinks)
And new care models are like marriages
• They look wonderful from the outside
• They have tax implications
• But they take a lot of work
• They cost a lot of money up front
• It’s the little things that count
• And they don’t magically solve a dysfunctional relationship
It’s easy to be cynical but 5YFV KPIs matter
1 Brave CCGs where the council will become the strategic commissioner, the operational commissioning will move to the provider, and the CCG remains as a shell for statutory purposes
2
Fundamental changes to how we do things. PACs that may not have outpatients in the future. Move from a position where high DNA rate in geriatric outpatients (booked 6 weeks out) due to confusion or admitted already, to an open access outpatient slot tomorrow, telehealth and primary care access
3 Emergency department consultants after telehealth support to care homes launched: fewer patients come to our department to die. They die where they chose to.
Greater respect for localism
The whole culture of Waterstones, which he says had become too top-down, is now in flux. Local managers must make choices to suit local custom. They have abandoned uniforms, they can choose their own sales items to prioritise, and stock more non-book goods such as stationery. In other words they must curate, much as the staff in Daunt Books do, helping shoppers find interesting titles and avoid the obvious. James Daunt
Source: Management today
Including development of healthy new towns
Nye Bevan was Minister of health and housing. Now back
to integrating health, home and environment.
10 pioneers areas building
dementia-friendly communities, new residential
care facilities, having fast-food-free zones near schools, walkable neighbourhoods etc.
But needs considerable commercial partnership
working
Source: Anna Kovecses
Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 CONCLUSION
Things that have changed since we last met
2015/16 closes with a £2.45bn / £3.3bn deficit and 65% of
providers in deficit; 2016/17 control
total exercise round two; £22bn plan
“unveiled”
Second cut of place-based STPs being
developed & a new strategic framework
for specialised services
Government and junior doctors
committee reach initial agreement on
contract with growing questions
over implementation
impact
New care models sees large funding cuts for vanguards
and new programmes for maternity, U&EC, cancer and MH,
diabetes
New CQC strategy unveiled and NHSI
oversight framework to
shortly be unveiled
A lot going on across a range of different fronts
Final thought: Welcome to Croydon
• ED rebuild with CAMHS paeds area
• Frailty Unit reducing length of stay and medical outliers
• Accountable care partnership • 10 year capitated
outcomes based contract
• Under/over 65 incentives
• Age UK a key member • One member one vote
THANK YOU • Sivakumar Anandaciva • Head of Analysis | NHS Providers • One Birdcage Walk | London | SW1H 9JJ
• DDI: 020 7304 6819 • [email protected]
Q&A
Images from Googleimages & HSJ