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HR DIRECTORS NETWORK POLICY UPDATE
21 July 2016
Siva Anandaciva Head of analysis
What we will cover
01 BREXIT AND POLITICS
02 FINANCES
03 PLANNING
04 QUALITY
05 REGULATION
06 WORKFORCE
07 NEW CARE MODELS
08 CONCLUSION
A major league hitter can time a jet plane
Johnny Bench, Cincinnati Reds
What we will cover
01 BREXIT AND POLITICS
02 FINANCES
03 PLANNING
04 QUALITY
05 REGULATION
06 WORKFORCE
07 NEW CARE MODELS
08 CONCLUSION
Brexit
No brexit budget EWTD
NHS Providers Chairs/CEOs survey, April 2016 (n = 45) • 75% see negative impact
from Brexit on NHS • 40% think positive impact
on procurement and competition
• 40% think no impact on funding NHS as a whole
• 80% see negative impact on access to funding for research and innovation, and recruitment of the health and care workforce
Source: image from The Spectator
Brexit
Impact on current and future workforce
Fall in the pound affecting procurement
prices c£900m
Delay to announcements e.g.
financial reset
Competition & procurement law
European Working Time Directive in contracts
but can revisit if not in internal market
Same SofS, same Department but
new/old priorities and new/old relationships?
All bets are off e.g. who runs NHS
Another General Election?
Wider impact on GDP and fiscal policy but first
dibs from social care
What we will cover
01 BREXIT AND POLITICS
02 FINANCES
03 PLANNING
04 QUALITY
05 REGULATION
06 WORKFORCE
07 NEW CARE MODELS
08 CONCLUSION
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 will eat new policy commitments and transformation for
breakfast
“It’s not creative accounting, it’s witchcraft”
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
And the corners of the triangle are nailed to the floor
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
20161//17 Sustainability and Transformation Funding
£5.5bn cash uplift (£3.8bn real)
£0.1bn Central policy initiatives e.g. MH, Cancer, Diabetes, IT
£0.2bn Targeted (for everyone)
£1.6bn General (for emergency care
providers)
£3.5bn commissioning budgets inc. pass through pension costs
£1.8bn Sustainability funding
• 70% released based on financial control total delivery • 30% released where operational trajectories achieved with tolerance and control total delivered
(assumed you play ball in the STP) • Better than binary pass/fail on everything, not handed back to HMT, not gummed up in system,
maintains incentive to hit your YTD even if you miss a month as you can earn missed payments • But still lots of financial uncertainty, working capital , appeals process, control total primacy,
ratcheting up of cumulative ask
2016/17 finances
89.5% of providers signed up to control totals (213 of 238
providers)
£580m deficit by end of 2016/17 under do-nothing position
£800m CCG side reserves from 1% holdback, but contingent
on considerable CCG efficiency and would not expect to see any non-recurrent investment
2016/17 finances
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 reset
Part 1 • Control outlier pay growth • Carter your pathology & back office • Consolidate elective services that
are held together by locums and have low volumes and poor outcomes
Part 2 • Capital controls • Financial special measures for
trusts • Financial special measures for CCGs • CCG interim pay control • CCG consolidation to fit STPs
Financial special measures
• Short sharp shock that is very different to quality special measures • The short shocks are sharp – removing boards, limiting autonomy, goodbye to loans,
strip assets for cash • Unclear what the objective rules are for entry e.g. a significant deficit? • Unclear how it fits tonally and structurally with new oversight framework – Box 4*? • System vs. institution unclear e.g. success regime and special measures • There are lots of reasons to not sign a control total • When everyone is potentially special, no one is special
What we will cover
01 BREXIT AND POLITICS
02 FINANCES
03 PLANNING
04 QUALITY
05 REGULATION
06 WORKFORCE
07 NEW CARE MODELS
08 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
Timelines too ambitious (we
have a vision not a plan)
Late entry of items e.g. specialised commissioning
Top-down baubles e.g. 7DS not
bottom-up wicked problems
Different patches going at different
speeds e.g. leaderless STPs
If you want to build a new
hospital, is that an STP issue?
No statutory basis, so what holds you
together?
Still regulated as institutions
System control totals and
performance proving tricky
Can not ignore the law, consultation,
judicial review
An informal initial categorisation
Good plan Addresses the key issues. Credible leadership. Credible finances. Acknowledges areas that need further work e.g. specialised commissioning
Wrong plan Does not address the wicked problems e.g. reconfiguration or service swaps, vertical integration, social care
Box 3
Do not pass go First time these people have been in a room together. A non-plan.
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
What we will cover
01 BREXIT AND POLITICS
02 FINANCES
03 PLANNING
04 QUALITY
05 REGULATION
06 WORKFORCE
07 NEW CARE MODELS
08 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
Other key new national initiatives
New Health and safety investigations branch (HSIB) • Hosted by NHS Improvement, but impartial • New chief investigator Keith Conradi from airline industry • One of the primary purposes of the investigations will be
working out where safety could be improved through greater standardisation and incorporation of human factors into clinical systems and processes
National and local “freedom to speak up” guardians • Dr. Henrietta Hughes appointed as National Guardian,
hosted by the CQC • Leads cultural change within NHS trusts and FTs so staff
feel confident and supported to raise concerns about patient care
• Learning events, training for guardians and good practice documents
Review of deaths
By April 2018 NHS will have medical experts independent review every death
Standard method developed by NHS England and Royal College of Physicians
Will cover all deaths so 300 doctors trained by April 2018 to administer
Expected to uncover more poor care that will lead to more referrals to coroners and a different caseload to what they normally see
Understood that there is variation in how coroners operate, and relationships with the NHS…
But what is the strategy?
Responsibility for quality is too diffusely distributed across the national leadership,
making pursuit of a common agenda difficult
Compounded by inconsistencies in local
accountability that lose something in translation from national level
Between June 2011 and the end of 2015
there were 179 quality-related policy measures announced by government.
Nearly one a week.
Control and improvement are out of balance
What we will cover
01 BREXIT AND POLITICS
02 FINANCES
03 PLANNING
04 QUALITY
05 REGULATION
06 WORKFORCE
07 NEW CARE MODELS
08 CONCLUSION
NHS Provider Sector - regulation
All data correct as of June 2016
16 Trusts are in quality
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
6ish Trusts are in financial
special measures
Frimley (27) Salford (15)
West Sussex () Northumbria (18)
Newcastle (39)
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.
• Interventions on the contracting round (CCGs
but not LAs) 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
Some issues with the NHSI oversight framework
• One approach for an FT and trust provider sector facing similar challenges
• Potential to align far better with CQC • CQC rating slots into NHSI quality
rating • NHSI develops use of resources
methodology to slot into CQC rating
• Takes some relativity into account
through performance trajectories
• Provides some implicit clarity on the FT pipeline, authorisation process and sequence with earned autonomy
• Familiar first three domains
• Subjectivity of leadership and strategic change
• Alignment with special measures
• Institution vs system not resolved
• Overlap between CQC and NHSI rather than one framework e.g. CQC rating is not the only thing that determines NHSI quality rating
• No substantive move to outcome indicators or whole system metrics
• No explicit recognition of trajectory and there is a difference
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
Improve CQC efficiency • Focus on CQC VfM and changes
to fees
1. Horizontal integration at
national level i.e. NHSE, NHSI, CQC
agree on what good quality care looks like
2. Vertical integration
e.g. boards and CQC can speak in same
currencies (e.g. Frimley and Barking) and CCGs on same
page
But how long will we continue this approach?
Source: Don Berwick
The goal
The reality
What we will cover
01 BREXIT AND POLITICS
02 FINANCES
03 PLANNING
04 QUALITY
05 REGULATION
06 WORKFORCE
07 NEW CARE MODELS
08 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 (six pilots with S.Firn)
x14
x9
x6
x8
x13
Five vanguards
losing funding in 2016/17
as risk appetite grows (or shrinks)
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
What we will cover
01 BREXIT AND POLITICS
02 FINANCES
03 PLANNING
04 QUALITY
05 REGULATION
06 WORKFORCE
07 NEW CARE MODELS
08 CONCLUSION
Things that have changed since we last met
2015/16 deficit,
2016/17 off track and a
reset
STPs submitted and a new spec comm framework
Junior docs agreement
rejected and new
safe staffing guidance
NCM funding, Estates review
New CQC strategy and
NHSI oversight
framework
Brexit, a new Prime Minister, a
new Cabinet
A lot going on across a range of different fronts
NHS Improvement 2020 objectives
Shared planning guidance must dos
Develop a high quality and agreed STP
Return the system to aggregate financial
balance
Sort out general practice
Deliver A&E and ambulance targets
Deliver RTT Deliver cancer
standards
Achieve and maintain the two new mental
health access standards
Deliver actions set out in local plans to
transform care for people with learning
disabilities
Improve quality, particularly for
organisations in special measures
And also deliver paperless NHS and seven day services and prevention
So what is the signal and what is the noise?
1. What do you get sacked for? A&E (or your equivalent) and finances
2. Safe and sustainable staffing – comply or explain. But explain proactively to CQC, NHSI, Healthwatch, MPs, everyone.
3. STP play nice but don’t forget the law and what you get sacked for
4. Is FT status the pot of gold at the end of the earned autonomy rainbow, not the rainbow that leads to the earned autonomy pot of gold
Welcome to Frimley
Wexham Park (our Prime Minister’s local hospital)
Oct 2015 Feb 2014
Clinical processes, management time, enthusing staff are all important. The hard and soft basics matter e.g. theatre utilisation
time, humility, cakes on the bus, long service awards
Welcome to Road House
• Guys, our core business is to run a hospital, and we’re not very good at it.
• Section 28 coroner referrals on preventing future deaths. You need to not just burn their house, but key their car and insult their partner to get one. They are that bad. We had 5 on the books.
• Serious incident lead and clinical audit lead in same room but not on the same planet
• Clinical director prep for CQC – what are your five key risks? Absolutely right. Now look at your risk registers which are three years old and don’t match what you just told me
• Flush out the bad apples. Managers and clinicians who have been cute and stayed below the radar being harmfully incompetent
NHS Trust Strategy Director
Welcome to Oxford
DTOC is an issue we will never solve. We are the worst in the country.
Perhaps the STP will solve it….Then new CEO said let’s buy capacity – we
can afford it, and we can’t afford not to. 60 care support workers directly
employed from career fairs aimed outside health & social care sector, who
provide social care in people’s homes after discharge from hospital. Bought
intermediate care beds. Reduced DTOC significantly.
Let’s find our 300 keenest people and ask for a 2 minute smartphone selfie
video on what their improvement idea is. 600 minutes of improvement. Lots
of popcorn.
Welcome to Croydon
• Not all good news
• 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
and one member one vote
THANK YOU • Sivakumar Anandaciva • Head of analysis | NHS Providers • One Birdcage Walk | London | SW1H 9JJ
• DDI: 020 7304 6819 • siva.anandaciva@nhsproviders.org
Q&A
Images from Googleimages & HSJ
What we will cover
01 BREXIT AND POLITICS
02 FINANCES
03 PLANNING
04 QUALITY
05 REGULATION
06 WORKFORCE
07 NEW CARE MODELS
08 CONCLUSION
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
• Open to over-supply planning
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 contracts
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
• Still a question of how it will be implemented not if (for now) • Growing concern though that nursing is different and
bursaries will have an impact on supply e.g. Entry age, part-time work
Move to bursaries for healthcare
education funding
• Growing focus on clinical productivity and output per WTE • Extend Prof Tim Briggs GIRFT to new specialties including
paediatric surgery • Still planned roll-out to mental health by end of calendar year • Quick on metrics & regulation but not support
Lord Carter - Mark II
• Attempt by NHSI to rebalance and move from agency being used to meet 1:8 and fear of CQC at all costs: • Flexibility in skill mix • Focus on outcomes not inputs
• Concern from Royal Colleges that this does not learn mistakes from Mid-Staffs
• Concern if CQC on same page
Safe and sustainable staffing
Safe & sustainable staffing
There will be times of course when the safety of patients requires agency staff to be brought in and nothing being announced
will prevent you from doing that
Ruth May,
NHSI Nursing Director
But may be more complicated than that
• NHSI “Ok, yes we know you need nurses, but they cost too much so
try not to get them from agencies unless absolutely necessary in which case you’re welcome to do so.”
• Provider “Ok fine, what constitutes ‘absolutely necessary’ – is it still the same as what currently constitutes ‘absolutely necessary’?”
• NHSI “That’s your call”
• Provider “Ok fine, what’s CQC’s call on that going to be, given I’m supposed to be making the most efficient use of resources but not compromising patient safety?”
• NHSI “We’ll know the answer to that next time CQC does a CQC inspection.”
Source: NHS Providers policy advisor
And that’s before we get to Junior Doctors
On course for phased introduction
Provisional agreement on new contract not ratified by referendum Plan is still to introduce in phases
Additional costs to providers including additional employer pension contributions 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
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 hitherto 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
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