INFORMATICS LEADS NETWORK

21 April 2016

Ben Clacy Director of development & operations

What’s happened since our first meeting?

Shared place-based planning guidance

Financial deficit continues to

escalate

NHS Improvement team and approach

clearer

16/17 financial recovery plan and

control totals

Junior Doctors industrial action & contract imposition

More new care models and MH & maternity reviews

What is the current mood music?

• Reversing the car out of the financial ditch … but is 16/17 plan enough? • Danger car veers straight back into ditch once frontloaded spending runs out

• Very difficult driving conditions!

What will we cover?

Informatics policy

Five Year Forward View & Devolution

Workforce including Leadership Development

Regulation

Funding & Finances

Planning

What will we cover?

Informatics policy

Five Year Forward View & Devolution

Workforce including Leadership Development

Regulation

Funding & Finances

Planning

Sustainability and Transformation Plans

• 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

Objective

• Agree footprint: 44 now set; interplay with other footprints • Identify named co-ordinator: being set; mixed setting process (agreement /

vote / central influence); mixed profile of provider, CCG, local authority leaders

• Milestones: • April short return per footprint including gap analysis, governance and

priorities; refine plans over April, May, June; more on nine ‘must do’s’ identified for 16/17 and beyond;

• Summer: 30 June: submission of final plans – including local digital roadmaps; July: regional conversations with area teams over July

Process

Issues and risks

Whose STPs are these: each local system’s or the centre’s?

Danger of this becoming the usual top down, centrally driven, Xmas tree bauble laden, NHS planning process

This will only work if local systems come together, own the process and tackle the difficult issues…

… Given this, are the scope and timelines too ambitious?

What early signals have been sent on footprint; appointment of co-ordinators; timeline?

What will we cover?

Informatics policy

Five Year Forward View & Devolution

Workforce including Leadership Development

Regulation

Funding & Finances

Planning

2015/16 heading into 2016/17

Number of trusts in deficit Net aggregate deficit

Underlying deficit of £3-4bn

Rising level & complexity

of demand

Additional costs of NI

etc.

Costs of new policies 7DS,

IAPT

Source: Health Foundation

-105 -75 -108

-467

-630.2

-788.2 -821.6 -930

-1616

-2263

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2013/14 2014/15 2015/16

Deficits eat funds for

transforming

16/17 control totals: “No financial bridge explains our target”

Source: NHS Providers survey (Jan 2016)

THE ASK • Of 60 respondents

• Majority (40) allocated surplus control total

• Control totals range from a deficit of -£42m to +£14.7m

• Average control total of £0.2m • Significant gaps between 2016/17

plans and what control totals require

YOUR VIEWS • 20% planned to reject total. For others: • Numbers do not make sense - the floor has

fallen away since M6; does not take account of non-recurrent schemes; wildcard of CCG penalties

• Hobson’s choice – need STF so will sign and try our best, or sign and risk under delivery. Heavy caveats.

• What happens – if we underdeliver, how do we agree trajectories, what happens if we said no?

• Governance issues and consequences to work through

And where are we up to with the £22 billion? • Carter Review: 15 recommendations for NHS

Improvement (mainly) to adopt / you to deliver • Range from new metrics (care hours per patient

day) to reduction in administration costs & need for a national people strategy

• Ongoing work with mental health now, model hospital and potential NED training

• At max, adoption will save £5bn by 2019/20 but providers only signed up to £3 bn.

• On the rest of the £22bn: “You have to ask the Olympians for the rest of the view. I’m just one of Santa’s little helpers.” Lord Carter of Coles

Where’s plan / comms / service validation? • Worry that £22bn savings relies far too much on:

o 1% pay increases for rest of parliament o Demand management o New care models savings o Benefits from service reconfigurations

Overview of finances

2015/16

2016/17

2017/18

Rising deficits met with kitchen sink: agency controls, cap/rev swaps and balance sheet adjustments. Real vs reported picture.

Extra funding through STF and more helpful tariff vs. constantly growing pressure. Best current provider sector guess -£500m.

DH budget growth starts to slow just as new initiatives such as 7DS come online. More sustainability funding needed for provider surplus

Frontloaded 2016/17

and 2017/18 settlement gets car

most / all way out of ditch but huge

challenge to deliver.

Lack of clarity on savings; impact of

extra policy commitments; and

0.3% and 0.7% funding increases 2018/19 and

2019/20 mean car heads straight back to

ditch after 2017/18

And what about transformation funding – short term fire fighting vs long term transformation?

What will we cover?

Informatics policy

Five Year Forward View & Devolution

Workforce including Leadership Development

Regulation

Funding & Finances

Planning

NHS Improvement’s approach

• Short term “grip”; longer term, return to “earned autonomy”

• Shared measures of success and

recognition of the interplay between quality/finance/access:

- CQC rating of “good” and above - access targets - financial balance/control totals • Board structure announced • Keeping TDA regional model, aligning

with NHS England teams • Provider ‘roadmap’ and 11 Feb event

gave a good indication of focus and future direction.

Source: diagram from NHS Improvement (Feb 2016)

• Use CQC’s quality rating • Success will be a good or outstanding rating Quality

• With CQC, co-developing use of resources assessment • Methodology will reflect recommendations of Carter • Focus on returning to financial balance asap

Finances / Use of resources

• Focus on small number of core NHS standards and targets Operational performance

• Build on existing governance tools (e.g. well led framework) • Shared system view on what good leadership looks like Leadership

• Developing an assessment of strategic delivery with NHS England Strategic change

A shared definition of success

Source: Recreated from NHS Improvement slides, provider event, 11 Feb 2016

Alignment with CQC’s new strategy 2016-21

A focus on six themes: • Improving CQC’s use of data and information * • Implementing a single shared view of quality between

providers and the regulator * • Targeting and tailoring inspection activity to ensure become

more risk based – the comprehensive inspection may become the exception not the norm

• Developing a more flexible approach to registration in part

to accommodate new care models • Assessing how well hospitals use resources in alignment

with NHS Improvement * • Developing methods to assess quality for populations and

across local areas • Overall, a greater focus on CQC’s own value for money

underpinned by significant changes to fees to offset reduction in grant-in-aid funding

*= area of focus for us

Our position and approach

Recognise the importance of NHS Improvement within the national landscape

Recognise that the financial and operational environment in which NHS providers operate has altered significantly

Strong relationship with new NHSI senior leadership team. Privately, remain supportive to maximise influence, but robust in our discussions.

Publicly, tolerate some shorter term “grip” to return the sector to balance and while NHS Improvement establishes itself….

….on the understanding that NHS Improvement’s philosophy for the medium to long term really is underpinned by a belief in, and a return to, provider autonomy

Continue to champion the pillars of FT status and to ensure that board accountability is not blurred

Explore opportunities where we can work with NHS Improvement in support of the sector

Six things we are, privately, being very robust about

16/17 financial outcome and control totals

NHS Improvement and short term grip vs longer term earned autonomy (we have been commissioned for rapid work on this )

NHS England, CCG, and specialised commissioning understanding of provider task & support for providers

Provider size of task vs available management capacity

New, uncosted, policy commitments, priorities, and Ministerial initiatives

National system leadership on workforce issues

What will we cover?

Informatics policy

Five Year Forward View & Devolution

Workforce including Leadership Development

Regulation

Funding & Finances

Planning

Junior doctor contract

THE PAST

Best and final offer from Sir David Dalton

rejected by BMA

Saturday pay still a major sticking point

Secretary of State’s decision to impose

new contract

48hr strikes, with emergency care

THE PRESENT

Final contract published, local

engagement beginning

Full withdrawal of labour 8am-5pm on 26

and 27 April

BMA and separate crowd-funded judicial

reviews of the decision

High frustration, and low morale

THE FUTURE

Centre clear that consistent and universal

imposition required

Long term impact on morale and need to address with strong

emphasis on local action

Rip plaster off quickly?

Consultant contract: on hold while junior dispute

continues?

Other workforce developments

1% 2016/17 pay award for all NHS staff, no targeting

Staff survey results – overall engagement level up but mixed

picture

Further clampdown on agency spend

Nurses to remain on the shortage

occupation list

Consultation closes on “nursing

associate” role

Consultation opens on reform of healthcare

education funding

NAO criticism of NHS clinical workforce planning

“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. Equally, the way in which staff shortfalls are filled can be, and often is, unnecessarily costly and inefficient. Since clinical staff are the NHS’s main resource and cost, these shortcomings are serious and the current arrangements do not achieve value for money.” Amyas Morse, head of the National Audit Office, February 2016

MAC criticism of nursing workforce planning

It is clear to us that the current shortage of nurses is largely of the health, care and independent sectors’ own making. The sectors failed to train enough nurses or failed to make provision to train their own nurses should the supply of publicly funded nurses fail. They have taken either no or insufficient account of the needs of other sectors when making their planning assumptions. They restricted pay growth. They have complex institutional structures, which blur the decision-making process and lead, amongst other things, to poor information and data making it difficult for them (and us) to understand and respond meaningfully to labour shortages. They did not learn the lessons from the late 1990s/early 2000s when a similar shortage (and reliance on foreign nurses) occurred. Almost all of these issues relate to, and are caused by, a desire to save money. But this is a choice, not a fixed fact. The Government could invest more resource if it wanted to. Migration Advisory Committee, March 2016

So… time for a National Workforce Strategy Board?

“December 2014 saw the announcement of a Workforce Advisory Board chaired by Health Education England. However, its terms of reference, membership, agenda and minutes have not been published, it is unclear if it has met, and HEE does not have the reach across the national architecture to convene the system or to steward organisations over which it has no formal authority.” “We recommend the formation of a National Workforce Strategy Board to take forward this new approach. Responsibility for workforce policy is widely distributed, yet the Department of Health remains the most influential single workforce organisation and should convene and lead this group.” Health Foundation, March 2016

Meanwhile… an emerging workforce strategy?

• (Demand) Quality/Finance balance; new safe staffing guidance (MDT approach?)

• (Supply) Agency controls, MAC shortage list & Tier 2 visas decision, move from bursaries to student loans and increase training places

Stabilise the market

Transform

• Coordinated approach to supporting leadership pipeline - aspiring CEOs programme

• New roles such as Band 4 nursing associate • New care models • Much better and more dynamic matching of

supply and demand

• Overall staff engagement levels up again, but health and wellbeing results mixed, with pay restraint and more bruising contract negotiations to come

• Agency controls having some impact, but £2.7bn agency spend still £1bn over plan at Q3 2015/16

Current position

Leadership Development – We Need Your Support • Concrete action to support senior provider leaders, working

closely with NHS Improvement and NHS Leadership Academy

• Aspiring CEO programme: 1st cohort of 14 recruited and 30% through programme; 2nd cohort recruitment about to start; NHSI funded. We need you to: o Identify candidates o Use graduates as first port of call for CEO candidate pool o Identify potential Stretch assignments

• Support for newly appointed CEOS: already launched via

NHSLA website; action learning set plus mentor plus coach plus learning; provider funded. We need you to: o Encourage / require new CEOs to join

• Currently talking to NHSI about developing existing aspirant

trust programme into wider Provider Board Development programme. We need you to: o Help set up top class senior provider leader reference

group: volunteers please

What will we cover?

Informatics policy

Five Year Forward View & Devolution

Workforce including Leadership Development

Regulation

Funding & Finances

Planning

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

£116m funding

allocated in

2015/16

Recent wider 5YFV initiatives

10 towns with Plans include homes with virtual

GP access fast-food-free zones around schools etc.

Personal budgets, review of tariff, neonatal review, learning culture, develop local maternity systems

Integrated mental and physical health, 7 day NHS, mental health inequalities, promoting good mental health, prevention, but unclear funding overlaps

What will we cover?

Informatics policy

Five Year Forward View & Devolution

Workforce including Leadership Development

Regulation

Funding & Finances

Planning

What is happening in informatics policy

Central integration: Local Digital Roadmaps alignment with STP planning and 5YFV work programme.

Spending review: £1.3bn allocated to delivering paperless NHS by 2020 - allocation rules to be determined.

Wachter review: Capability within second and tertiary providers for adoption of digital technologies to be published in June 2016

Data security standards review: Standards to be used by CQC as part of regulatory framework and will make recommendations for simple patient opt out system – delayed till July 2016 HSCIC to become NHS Digital in July 2016 to recognise their role in demonstrating “how technological development and effective use of information can transform the quality of care a patient receives.”

Delivery expectations – 2018 complete uptake of urgent and emergency summary patient care record but other objectives not till 2020

THANK YOU Q&A

Images from Googleimages & HSJ

Roundtable discussions

Emergency Care Data Set (ECDS)

Local Digital Roadmaps (LDRs)

Other issues

Emergency Care Data Set (ECDS)

• The Emergency Care Data Set (ECDS) will be a new national data set for urgent and emergency care (from Type 1 Major to Type 4 Walk in departments). The ECDS will replace the current Accident & Emergency Commissioning Data Set (CDS type 010).

• Development led by Department of Health, Royal College of Emergency and partners, programme chaired by national clinical director for urgent care Jon Benger

• The problems to address through this work are: • Data not fit for purpose for meaningful clinical management or costing • Not collecting the right things e.g. some fields redundant, some fields need to be

added (e.g. acuity, injury data) • Poor completion and quality of data e.g. 50% of attendances lack a valid coded

diagnosis

• More information available from: https://www.england.nhs.uk/ourwork/tsd/ec-data-set/

What is it?

Emergency Care Data Set (ECDS)

• 50/50 split on how difficult it will be to implement ECDS

• Previous ISNs often not implemented due to:

• Potential enablers to support implementation:

Your views so far (survey 2016, n = 4)

Number of respondents Compliance of suppliers 4 Problems to incorporate into existing information technology systems 3Operational issues on gathering data 3Staff time spent on implementing changes 3Compliance from staff using and entering data 2Financial cost of implementing changes 2 Usefulness of data 1

Technical support 3 Nationally mandating through the standard contract or CQUIN 2 Information/ training information 2 Support to produce outputs to make it relevant to staff entering data 2

Number of respondents

Local Digital Roadmaps

• 25 trusts responded, representing a range of trust types and regions.

Progress and engagement so far:

10%

18%

29%

24%

48%

53%

10%

6%

5%

0% 25% 50% 75% 100%

Agreement onachievable plan and

timeline

Agreement of goalsand strategy

Very good progress Good progress

Fair progress Poor progress

Very poor progress

(n = 21)

(n = 17)

4%

56%

20%

8%

12%

Leading the process

Very involved

Adequately involved

Not actively involved butadequately consulted

Not actively involved orconsulted

(n = 25)

Timeline is unrealistic amidst existing pressures

Resource constraints

Complex infrastructure in different care settings

Locally it has been incentivised through

digital CQUIN and has proved to be very effective

in engaging informatics staff and clinicians

Process has just started

Local Digital Roadmaps Views on potential impact in…

17%

43%

35%

4%

Very helpful

Fairly helpful

Neither helpful or unhelpful

Fairly unhelpful

Very unhelpful(n = 23)

…delivering the ambition of an NHS that is paper-free at the point of care by 2020?

21%

46%

25%

8%

Very helpful

Fairly helpful

Neither helpful or unhelpful

Fairly unhelpful

Very unhelpful(n = 24)

…supporting the local area to think differently and transform the delivery of patient care?

The LDR will only transform patient care or deliver in paperless if there is the

leadership across all areas to affect the change. Part of that change needs to be a shift from thinking by service to enterprise

wide thinking.

This will depend on geography. LDRs, by being led by CCGs, are

mainly focused on local care. 50% of Trust workload is specialist

commissioned work and there is a need to share information outside local footprint. LDR is focused on

needs of local CCGs so doesn't take into account provider needs.

It is up to us as a digital health community to exploit the

opportunity

The process has been useful in getting more discussion and

collaboration

Roundtable discussions

• What would the barriers be to implementing an ISN for the ECDS? • What would the most effective enablers be? • Do you have any other thoughts on the ECDS proposals and would you like to get

involved?

Emergency Care Data Set (ECDS)

• What stage is your trust at in the LDR process? • How has the Digital Maturity Index been used at your trust? • What further information or support would be helpful?

Local Digital Roadmaps (LDRs)

• What is on your worry list? • What can we support you on by (i) collecting more information on it; (ii) showcasing a

peer’s work on it; (iii) telling the centre about it? • What are you doing really well that you want to tell other people about?

Other issues