The Forward View into Action - Planning for 2015/16
Original document: The Forward View into Action: Planning for 2015/16
LMC Commentary, December 2014
This document comes with many logos on the back cover. NHSE, The Trust Development Agency, Monitor, Public Health England, Health Education England and the CQC. But this is not enough because at least one other agency is promised within its pages.
Once again, considering the crisis facing the NHS it is startling to read that this document is about the approach for NHS bodies to "make a start...towards fulfilling the vision...in the Five Year Forward View." However anyone hoping for any sense of retrenchment and concentrating on what really matters will be disappointed to read that NHSE's bureaucratic, CQC-based definition of "high quality, timely care" that England expects will not be compromised. "Planning for tomorrow and delivering for today go hand -in-hand. Next year will not see a relaxation in the NHS Constitution standards...or the requirement set by taxpayers (sic) and Parliament that the NHS lives within its means." That said the "new" £1.98bn for "front line services" is much vaunted and it is stated that this includes winter pressures money for next year by making these emergency officially "recurrent" presumably instead of just happening every year anyway. There will be £200m investment fund for new care models and £250m further investment in primary care. It is, of course, always important to recall how these sums compare with, say, the annual budget of a medium sized hospital trust or the drug budget of a single county.
NHSE promises a "differentiated national approach" in order to make rapid progress on new models of care and these will emphatically not be imposed from the top down. Nevertheless, NHSE, Monitor and the TDA will act in concert to design a "success regime" for challenged health economies and, it will come as no surprise to discover, there will be strict conditions applied to more happy organisations before they get the go ahead. "Local and national partner organisations" are issued an "open invitation" to put themselves forward by the end of January 2015 to work alongside NHSE in designing prototypes so, as ever, it will pay to be in at the beginning.
To start with all NHS bodies are asked to refresh their operational plans "for 2015/16 only" in the light of the demand that mental and physical health achieve parity by 2020. Each CCG is hereby expected to increase its allocation to mental health services in 2015/16 and growth should be by at least as much as its total allocation increase.
Furthermore providers and commissioners are expected to submit aligned, realistic activity and financial assumptions and to work with HEE to make sure that workforce plan are not only right for transformation but also affordable. Why these plans should be any different to the previous and presumably unaligned, unrealistic ones is not stated. All this from a department still making sure that capital spending programs are still often skewed towards PFI contracts ("MD" Private Eye passim).
To return to the theme of making haste slowly we must now "get serious about prevention." Intriguingly CCGs should work with local government partners to set and share "quantifiable levels of ambition" to reduce local inequalities in outcomes and health care supported by agreed actions. An example is specifying behavioural interventions for patients and staff concerning alcohol, smoking and obesity. As reported in the news media during the quiet Christmas period the first national diabetes prevention policy is proposed, linked to the NHS health check. More plans are to be announced in March and a new National Prevention Board will be set up. This is not to be confused with the new, broad-based task force summoned up to achieve a healthier NHS workforce. Sensibly there are also outline proposals to help keep people in work, thus saving the DWP money, and to reward employers who provide NICE recommended workplace health programmes for their workers.
Empowering patients rather disappointingly refers mostly to expanding personal health budgets, including extending these across social care, and including people with learning difficulties. As well as this "policy-based evidence" field we also read about the continuing importance of choice and commissioners and providers should work together with patient groups to "understand current delivery" in order to make "significant strides" to honour patients' entitlement to choose. The previous simple unified model where anyone could go anywhere within the NHS is clearly thought to outré to be considered. A particular priority will be for CCGs to work with GPs to make sure patients are aware of their rights and are offered a choice of mental health service provider, "making well-informed and meaningful choices at appropriate points along the pathway." It will be interesting to see how this works in Somerset.
As trailed in the news report before Christmas it will be made easier for groups of midwives to set up their own NHS-funded services and pregnant ladies will be advised on how to make a choice about where to give birth.
Community engagement stresses the importance that CCGs must place on meeting their statutory duties on consultation and also how they must work with local government to support unpaid carers. All NHS employers will also have to review flexible working arrangements to support staff who are carers. To energise volunteering it will be made easier for voluntary groups to obtain NHS funding by means other than "burdensome contracts." NHS employers must also lead the way in being progressive, making sure their boards better represent the diversity of the areas which they serve. April will see an NHS workforce equality standard. The NHS Equality & Diversity Council will be supplemented by a new joint taskforce to challenge and support better and faster progress. Doubtless hard pressed acute trusts will welcome this new requirement.
New models of care will be co-created and the four types (multispecialty community providers [MCPs], integrated primary & acute care systems [PACS], viable smaller hospitals and enhanced health models for nursing homes) will be "prototyped" in a small number of sites. In each one a structured model of support will be co-designed and there will be a new national New Models of Care Board. Those wishing to join the vanguard will of course have to demonstrate ambition, tangible progress and a credible plan with funding in place, effective management, strong, diverse and active "delivery partners" and positive local relationships. They will also have to be keen to engage intensively with other sites across the country as well as sharing their pearls of wisdom with national bodies using richer standardised data that will enable real time monitoring. GPs who match these criteria will be able to bid for some of the £250m improvement fund and this sum will be made to recurring over the next four years to allow for longer term planning. They will have until February 2nd to make up their minds.
The early widespread adoption of these new models of care cannot be forced onto CCGs but they will all be expected to review their medium term plans with a view to fitting them to MSPs rather than stand alone bodies when considering reprocurement.
A new deal for primary care is foreshadowed in three whole paragraphs, one of which reminds us that primary care is not just about general practice. It is of course central to the new population-based healthcare set out the in Five Year Forward View. However the document recognises the pressure and recruitment problems being encountered saying that NHSE is working with HEE, the RCGP and GPC to encourage trainees into, make better use of the workforce in, help retention of and encourage the return of clinicians to general practice. Co-commissioning CCGs will also have additional flexibilities and some of the prime minister’s challenge fund will be made available. It was with some sadness then that your reviewer heard today that an early version of this plan was reported in the Daily Mail as promising £20 000 "golden hellos" to GPs who would then go on to "have salaries of up to £110 000" (sic). There will be details next month about how some of the £1b fund (made available in the Autumn statement over four years) will be used to improve premises. In other news, 80% of GP referrals are expected to be made electronically by March 2016 in line with the 2016/16 GMS contract.
All of this requires prioritisation to make sure that quality and outcomes are improved for society, individuals and the taxpayer. A revitalised National Quality Board will provide collective leadership to make sure that current standards, as assessed by the CQC, are reviewed and barriers to change removed. It is disappointing that such a flawed and failing organisation should still receive such prominence in national planning as "the only game in town." The concept that "quality can be inspected into a system" seems inviolable. Francis and compassionate care, sepsis and acute kidney injury (there will be CQUINs on these), multiple antibiotic resistance and antibiotic prescribing policies (a new quality premium measure for the CQC) and service and delivery improvement plans (SDIPs) agreed between commissioners and providers will all feature in this field.
This is a strange document, by turns pessimistic and then Pollyanna-ishly unrealistic, with a surprising reliance on the same central control that has served the NHS so badly over the decades. Anyone hoping to just be allowed to "get on with the job" as a means of serving the public will be disappointed. There is too much money and political kudos at stake.
Dr Barry Moyse
Deputy Medical Director