Jul
13

The Next Phase

Hello all!  Thanks for all the messages of support since my last post at the end of February, where I asked the question as to what next for the website.  Many of you contacted me directly with a number of suggestions, and many gave direct offers of help, and I really appreciate all of your input.

In the end I have decided to continue the blog with support from those with more technical capability than myself!  As a result the blog will now be hosted by The Information Daily (www.theinformationdaily.com ), which will provide a much better platform for both hosting and disseminating the content more widely.

Just for the record I still do not receive any form of payment or income for the blog, which is, and always has been, designed to support those working in and with health.

The first of the posts on the new platform is now live, and you can access it by clicking here.  It is entitled, ‘NHS cannot transform healthcare while defending the status quo’, and I argue that radical change may need to come from outside the NHS.

For the next few months I will post a message as a prompt that the new weekly blog is out.  Thank you for your continued support, and do let me know (mail@clinicalcommissioninggroups.info) if you have any specific questions or topics you would like me to cover.

Thanks

Ben

Feb
23

I set ccginformation.com up at the start of 2012.  Since then I have posted every week for over two years about CCGs and all the issues that they have faced in setting up and getting established.  There are now 110 articles on the site, covering issues ranging from making commissioning support effective to the future of general practice. 

The information on the website is provided completely free of charge.  There are hundreds of subscribers to the site receiving the weekly blog.  The most popular articles are (surprisingly) the ones on estates and NHS Property Services! 

The site has offered support to CCGs in the year before they were formally established and in their first year with the new responsibilities.   As we now approach the completion of this first year of CCGs as statutory bodies it is time for a review of the site.  Over the course of the next month I will be considering the following options, and with this I would really value your help.

As I see it there are 6 possible ways forward:

  1. No change.  I could continue to produce a weekly blog as I do now and adapt the content to the changing needs of CCGs as they evolve into the future.
  2. Adapt the existing site.  I could continue with the current site, but adapt the content, format, style so that it better meets your needs.  For this you will need to tell me how you would want it to change.
  3. Start a totally new blog/website.  I could draw a line under the period of the establishment of CCGs, and leave ccginformation.com as it is without adding any further content.  I could set up a new blog or website and focus on a new or different area. 
  4. Start a podcast.  As far as I can tell there is no regular podcast within the NHS at present.  As podcasts grow in popularity there must be a place for one within the NHS.  I have no idea how to set one up, but could set about finding out!
  5. Work with others. I have largely produced the content for ccginformation.com on my own.  For any of options 2, 3 or 4 above I could work with any interested individuals to make them happen with a wider range of input (let me know if you are interested!).
  6. Stop altogether.  I could of course draw a line under the work to date, recognise the value that it has added so far, but stop and focus on other things.

As I carry out the review over the next month, I would really value your input.  It would really help me if you could let me know what you find valuable about the site, what does not work very well, and what you think of the options outlined above as regards a way forward.  Please email me on mail@clinicalcommissioninggroups.info to let me know your thoughts. 

Just to be clear this means that there will be no posts for the next month.  Before the end of March once the review is completed I will update on the way forward.  I look forward to hearing from you in the mean time, and thanks in advance for your help!

Feb
16

The closest I have been to death was a few years ago when I was playing golf in France.  I remember the day vividly.  It was a bright, sunny Sunday morning, but the weather was very much in contrast to the way the three of us were feeling, as we struggled to recover from two nights over-indulging in the local red wine.

After the usual frenetic battle to get to the course on time (missed alarm call, rapid check out, the impossible task of finding a golf course in a foreign country armed with only an out of date map and a singular lack of helpful signposting), we finally arrived at the first tee.  But we needn’t have rushed, as the queue was three groups deep, and it was the best part of half an hour before we were on our way.  Our frustration grew.

Even when we got going the pace didn’t pick up.  We had to wait to play every shot, which meant we also got to watch the group in front.  There were two men and a lady, all of whom were French.  The second hole was a par three.  One of the men and the woman hit reasonable tee shots; the second man hit two tee shots into the deep rough, and rather than play a third just picked up his tee and trudged towards the green.  I know the feeling.

When we got to the third tee, the group ahead had already teed off and were in the fairway waiting to play their next shot.  Then all of a sudden one of the men fell to the ground.  He didn’t get up.  We just stood there, staring, not sure what was going on.  Our trance was broken when all of a sudden the woman started haring towards us, screaming in French at the top of her voice.

As she came towards us, I asked if any of us knew CPR.  None of us did.  We weren’t even sure what it stood for (this was before we had the ‘Staying Alive’ adverts, so we didn’t even have that to guide us!).  However, one of my group did speak reasonable French, so we agreed he would ring for an ambulance and then ring the clubhouse for the defibrillator, whilst we would see what we could to help.

When we got there we couldn’t find a pulse, but given none of us had ever looked for one before it didn’t mean he didn’t have one.  We tried the breath and pushing the chest but the man’s body kept making noises and we panicked that we were making it worse.  We decided the best thing to do was to try and find someone who did know CPR, and sprinted round the course like madmen trying to find someone.  Eventually I found a couple who could help and they took over.

In what seemed like an age later, and what in reality was at least half an hour, the paramedics arrived.  They arrived via golf cart, and it was quite a sight: three paramedics on hanging off the cart with another running alongside, all in full uniform, like superheroes coming to save the day. 

But unfortunately it was too late.  Maybe competent help at the outset would have helped him, but by the time the paramedics arrived there was nothing they could do. 

It is easy to look back and try and apportion blame: blame to myself for not learning CPR, blame to the golf club for not having a defibrillator, blame to the French ambulance service for taking so long to respond to such an important call.  But in the end blame doesn’t help.  I think what is important is to try and take the learning and understand what we can do differently.

Recently I came across a Ted Talk by Eli Beer.  He speaks of how he took an experience not dissimilar to mine and set up a community rapid response service in Jerusalem to support the ambulance service.  They take thousands of volunteers who fill the critical gap between the ambulance call and their arrival.  They save people that otherwise would not be saved.  The response time is three minutes.

http://www.ted.com/talks/eli_beer_the_fastest_ambulance_a_motorcycle.html

And it is not a one off.  They have recently started in Panama and Brazil.  It could be set up anywhere.  As he says, ‘We all want to be heroes.  We just need a good idea, motivation and lots of chutzpah, and we could save millions of people that otherwise would not be saved’.

I wish I could have done more to help on that golf course, and I wish a service had been in place that could have responded more quickly.  As our ambulance services struggle to meet their response times, is it time for us in this country to look at this approach, and to turn our aspirations of local integration into something that tangibly saves lives?

Feb
09

Remember independent bookstores?  There was a time when they were the sole provider of must-read bestsellers.  Each sold at full price and carried a 40% profit margin.  Business boomed.  But then along came book megastores like Borders Books and Waterstones.  They had more inventory but needed traffic, so sold bestsellers at hugely discounted prices.  End of independent bookstore profits.

They regrouped and focused instead on niche markets with targeted discounts in these areas.  Then came Amazon, with its selection and discounts across the board, and this sealed their fate.  Books are more available (and cheaper) than ever, but independent bookstores are, sadly, now a dying breed.

What did it feel like when the owner of one of these stores heard that Borders Books was opening across the road?  How did they then feel when they heard that Amazon was setting up an online bookstore? 

By now you might be wondering why I am writing about books!  Is the story of independent bookstores relevant to primary care?  The Royal Pharmaceutical Society certainly thinks so.  In its new document, ‘Now or never: shaping pharmacy for the future’.  (find it here), point 1 is ‘The traditional model of community pharmacy will be challenged as economic austerity in the NHS , a crowded market of local pharmacies, increasing use of technicians and automated technology to undertake dispensing, and the use of online and e-prescribing bear down on community pharmacies’ income and drive change.

It goes on to say, ‘In a market which has become increasingly crowded, a recent report by AT Kearney estimated that these challenges would reduce the profits of the average community pharmacy by 33%, resulting in the closure of 7.5% of all England’s community pharmacies by 2016.

These pressures will continue and intensify past this date, and community pharmacy will face significant challenges where it does not (change).

But what about general practice itself?  The advent of PMS and APMS contracts signaled a desire to broaden the range of general medical service providers, and it was almost in response to this that some practices started the uncomfortable conversations with their neighbours about mergers.  But a much more fundamental shift is happening: the advent of integrated care.

The system is no longer prepared to accept general practice operating in isolation, with the inherent variation that multiple small businesses present.  Some Foundation Trusts are looking at general practice and exploring how it fits within their model of integrated care.  My view is that it is only the general ignorance that resides within secondary care about the operation of general practice that has prevented this happening further and faster. 

But a more real and present danger are community trusts.  If I ran a community trust the first line of my strategy would be to become the lead provider of primary and community care for specific locality areas.  For community trusts to secure the investment that has historically gone into hospitals they need to reduce demand, and the only way they can do this is to partner effectively with (take over) general practice. 

General practice’s ‘amazon moment’ is actually the Better Care Fund.  Millions of pounds are being invested into community health and social care with clear markers of success predicated on managing emergency demand.  Whatever plans are made, they will only be successful with general practice at the core.  This cannot be as a collection of disparate providers; someone is going to need to bring practices together.

So the race is on for general practice.  The runners are Foundation Trusts, community trusts and general practice itself.  My worry is that the majority of general practice is looking out of the window with an ‘on-line bookstores will never catch on’ mentality.  If it is, I fear the fate of the small businesses that make up today’s general practice will mirror that of independent bookstores.

Feb
02

It was never going to be easy for CCGs, as membership organisations of GP practices, to be effective commissioners of general practice.  This has been brought into sharp focus by the planning guidance, which states this,

36. CCGs will be expected to support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions by providing funding for practice plans to do so. They will be expected to provide additional funding to commission additional services which practices, individually or collectively, have identified will further support the accountable GP in improving quality of care for older people. This funding should be at around £5 per head of population for each practice, which broadly equates to £50 for patients aged 75 and over.’

The first thing to say is that no one was expecting this within the guidance.  And the result of this is, frankly, confusion.  There are a number of practices who understandably, because of the link in the guidance to the over-75s, have assumed that this funding is the replacement funding for the retired QOF points.  Interestingly I asked a number of individuals at a regional and a national level and none were clear whether there was a link between the two or not.  Eventually I found out from a senior member of the GPC that there is, conclusively, no link; the retired QOF points have been replaced by an uplift in the global sum.  But the confusion is important.  It is one conversation for a CCG to have with its member practices as to how the £5 should be invested when it is ‘new’ money; it is quite another when it is money taken off the practices via another route.

A further issue is the complication of timing.  CCGs are responsible for commissioning local enhanced services (LES) from general practice.  As from April these enhanced services can no longer be contracted for as enhanced services within the overall framework of the core GMS/PMS contract, but need to be contracted separately on standard NHS contracts.  Now, this might not be much of a problem in many areas, but in larger CCGs it is. 

This is because the legacy passed by historic commissioning organisations is often one of differential enhanced services being available within even relatively small geographical areas.  Through the passage of time, often going back 10 or 15 years, different deals were done in different places where different enhanced services were moved (or not) into MPIG or baseline or who knows where.  So what this means is that CCGs either have to decommission the service or make it available to all practices and potentially other providers. Neither are particularly attractive options. 

CCGs are accountable for improving quality and outcomes through effective stewardship of NHS resources, and at the same time are membership organisations of a collection of practices.  The reality of commissioning any service direct from member practices means that there will be occasions when the CCG has to make decisions that will be unpopular with some or all of the practices (because the decision negatively impacts upon the practices as businesses), because of its overriding duty to the population that it serves.  Decommissioning LES’s is one of these decisions.

So the question for CCGs (where this is an issue) is whether to link the decommissioning of existing LES’s with the £5 per head, or whether to treat the two completely separately.  The challenge is to ensure that, whatever decision the CCG takes, it is able to realise maximum value for patients for the money it invests.

A further issue is whether to set the expectation that the funding streams that are created are recurrent or non-recurrent. Paragraph 37 of the planning guidance states,

‘Practices should have the confidence that, where these initial investment plans successfully reduce emergency admissions, it will be possible to maintain and potentially increase this investment on a recurrent basis’

This is a fudge.  To create real change providers, whether they are practices or anyone else, need to take on staff and make them part of core business.  When funding is only available on a temporary basis how are organisations, particularly small organisations, supposed to effectively staff the new services?  CCGs need to be bolder and be clear whether the services they put in place are going to be commissioned recurrently or for one year only if they really want them to be successful.

And of course underpinning all of this is the need to transform general practice.  This is a key part of many CCG strategies for their local health economies.  We have considered previously on this site how this might happen (http://ccginformation.com/a-3-step-guide-for-developing-general-practice/).  The mandate to create funding of £5 per head of population is an opportunity to accelerate the transformation of general practice, and so consideration of how to achieve this has to form part of CCG thinking. 

So is the £5 per head of population an opportunity or a curse?  The money could provide the catalyst that is required to support the key role that general practice has within whole system transformation.  The challenge is whether CCGs can do this without losing their member practices along the way.

Jan
26

3 Ways to Create Trust

How do you create trust?  Is it even realistic to think that organisations that are competing with each other for increasingly scarce resources are going to be able to trust each other enough to allow credible whole system plans to be developed?

Joint working is essential, but the barrier to it often boils down to one of trust.  Do the CCG and council trust each other enough to pool budgets? Do the hospital and the CCG trust each other enough to enter a risk sharing agreement?  Do general practice and community services trust each other enough to build a single staffing model across a locality?

This can become a chicken and egg type scenario: we don’t trust each other enough to have a single health economy plan rather than a set of organisation specific plans, and we can’t develop trust because we are not working together closely enough.  So if trust is the secret ingredient, how do we create it?

Well I don’t claim to know the answer, but I was at a session with the previous NHS Confederation chief Mike Farrar recently and asked him this question.  His answer was so good that I thought it only fair that I share it with you!

He said that there are three ways to create trust.  The first is to agree a shared sense of purpose.  He said that many health systems do not put enough effort into this.  A system plan is produced, it goes to a whole system meeting, and is generally agreed.  What doesn’t happen is a stress testing of the purpose or a putting it under the fire of different scenarios.  Organisations don’t take the aims of proposed whole system plan back to base and work through with their Boards as to how the goals of the system can match with the goals they have set for their organisation.  More effort here, according to Mike, is an essential foundation to building trust across the system.

The second is to establish system wide clarity on the approach to competition or collaboration.  There needs to be a shared understanding as to how this will work across the health economy.  What doesn’t work is asking groups of clinicians from all organisations to work together to design a new model of care, and then the CCG springing a procurement on the providers that is not expected.

This does not mean that the CCG has to say that they will not be putting any services out to tender or that they will be procuring everything.  What it means is that a framework is established so that everyone is clear when services will be procured and when they will be developed through collaboration.  The rules of engagement need to be clear and signed up to by all partners.

The third is to establish who the system arbiter will be.  Given the challenges that all health economies face it is inevitable that there will be issues on which organisations do not agree.  It is not good enough to simply say that decisions will be taken that are in the public interest, because this can often be argued both ways. 

There needs to be agreement as to whether deviation from the collective agreement is ever acceptable, and if so in what set of circumstances.  Systems must establish an agreed point of arbitration, which everyone signs up to before such a situation arises, and which everyone agrees to abide by when a decision is made.

Trust is a critical but elusive ingredient of effective whole system working.  The current environment and the challenges that we face dictate that there is not enough time to spend years building it up, but what I think Mike’s answer has provided is a set of actions that systems can take now to make their 5 year strategies much more likely to deliver.

Jan
19

As CCGs consider their 5 year strategies to improve health outcomes and ensure maximum return on NHS funding, one of the questions that arises is whether we should incentivise individuals to be healthy. 

In South Yorkshire and Derbyshire a pilot scheme offering mothers £200 in shopping vouchers to encourage breastfeeding has been set up.  Breastfeeding has been shown to reduce cases of stomach problems, asthma and other respiratory conditions.  The business case is relatively straightforward: the cost of the incentives will be more than outweighed by the benefits realised later on. 

So is this, and other schemes like it, an approach that CCGs should be rushing to adopt?  Does the business case stack up, both on outcomes and financially?  Well there are other examples to learn from.  In 2009 a weight-loss scheme, Pounds for Pounds, was set up in Kent which offered participants cash payments of up to £425.  Less than half achieved significant weight loss and a high drop-out rate meant that evaluators were unable to recommend it as a way of tackling obesity.

However, a stop smoking scheme in Dundee had more success.  The NHS there ran a two-year programme offering smokers £12.50 a week to quit smoking.  By the end of three months, nearly a third of participants end up kicking the habit, more than twice as many as other smoking cessation projects achieved.

There are a number of arguments against this type of approach that I don’t intend to go into here, such as whether it creates perverse incentives, whether it is patronising, and whether it will simply result in paying people for something they were going to do anyway.  But there is one point that I do think is particularly important, and this is best made by Harvard University political philosophy professor Michael Sandel.

Professor Sandel’s lecture ‘Why we shouldn’t trust markets with our civic life’ (you can find it here) tells the story of a Texas policy that awarded children two dollars for every book they read.  He then asked the audience what they thought of the approach, and in discussion concerns were raised about the impact on the long term motivation of the children to read.

Sandel’s argument is that, when considering non-material goods, market mechanisms (e.g. putting a price on something, or using cash incentives) can actually change the nature of the goods. So if we pay children to read books, it can change their motivation to read and the types of books they read.  A key outcome of the Texas study was that children read shorter books!

He says that economists assume markets are inert, that they do not change the products that undergo market exchanges. This is likely to be true for material objects. However, for non-material values like learning and education and health, this is not true.  For us this means that the value of stopping smoking or breastfeeding or losing weight actually changes if we pay for it.  We risk eroding the intrinsic value of these things by paying for them.

For health the unintended negative consequences could be serious.  Will intermittent smokers start to smoke in order to receive the incentive to stop smoking again? Will obese people become morbidly obese to receive the incentive payments to lose weight? More importantly, will the value placed by individuals on their own health become a function of the return they receive for it, rather than something held as valuable in its own right?

Sandel himself says, ‘It is not about inequality and fairness but about the corrosive tendency of markets. Putting a price on the good things in life can corrupt them. That’s because markets don’t only allocate goods; they express and promote certain attitudes toward the goods being exchanged. Paying kids to read books might get them to read more, but might also teach them to regard reading as a chore rather than a source of intrinsic satisfaction.

‘Some of the good things in life are degraded if turned into commodities. So to decide where the market belongs, and where it should be kept at a distance, we have to decide how to value the goods in question—health, education, family life, nature, art, civic duties, and so on. These are moral and political questions, not merely economic ones. To resolve them, we have to debate, case by case, the moral meaning of these goods, and the proper way of valuing them.’

So for CCGs this approach is not something that can simply be adopted.  As leaders with responsibility for population health we need to carefully think through all the decisions we make, and the consequences that these will have not just on the balance sheet but on society as a whole.  Health and wellbeing boards are the perfect place to ensure these issues are fully debated on an individual basis, and it is our duty to ensure that this happens.

Jan
12

Something Has to Change

If we carry on down the same road we have been down every previous year, with providers operating in isolation from other providers and CCGs operating in isolation from all providers, where will we end up?

If each organisation continues to develop its own plans then it plays out something like this.  Providers and CCGs enter the contracting round with the figures they need out of the contract.  They argue about the likely success or otherwise of demand management plans.  With the deadline imminent they agree a figure on paper, but they both take away different assumptions about what will happen during the year.  The CCGs assume demand will be reduced, the providers assume demand will grow. 

The net result is a deficit gets built in to the health economy position, because both build different assumptions into their forecast outturn position.  Someone will be right and so a deficit will inevitably sit somewhere.  The value of the agreed contract figure becomes material only in terms of determining the level of monthly cash payments.  In terms of establishing an agreed end of year position it is virtually meaningless.

In 2014/15 the gap between what CCGs can afford and what providers will require is going to be bigger than ever.  Aside from ever increasing demand and inflationary pressures, the situation is exacerbated by the planning guidance.  Now we have the cost of introducing seven day working, the requirement for CCGs to fund £5 per head for general practice, the need for CCGs to keep 4% out of recurrent expenditure (2.5% non-recurrent, 0.5% contingency, 1.0% surplus), just to name a few.

Once a figure is agreed on paper and the year starts, the cracks will start to appear.  CCGs facing financial challenges will shift down a route of increased contract challenges and reducing elective activity, and providers will try to do the reverse (improve coding and increase elective activity).  Throw in the last winter before a general election and the pressure will ratchet up, and relationships will become extremely fraught.  And if next year does not finish us off the year after will, with the transfer of funds from providers to social care via the Better Care Fund.

But there is an alternative.  We could work as health communities to have a single plan.  We could work together to take the resources that are available (knowing that they are insufficient) and use them collectively to deliver a single plan.  This requires each organisation to relinquish the sovereignty that it feels entitled to; actions would be determined by the greater good, not simply by what is best for any single organisation.

In this model organisations collectively commit to what the health and social care economy must deliver.  There is a single set of assumptions that all sign up to.  Agreement is made as to how the money will be used between the organisations in order to enable delivery of the plan.  The contract negotiations focus on this, rather than simply setting the level of cash flow. 

The alternative is harder to set up.  It requires providers to work with providers and CCGs to work with providers.  It will fail if alongside the one plan organisations have their own (secret? real?) plan.  Each organisation has to commit to the system plan.  Each organisation has to be accountable to each other for delivering their part of the plan. 

Clearly this requires trust between the partners. It introduces an uncomfortable interdependence.  If one organisation does not deliver, all will suffer because delivery of the overall plan will suffer.  And of course the worse the current position, and the longer we continue along the current course, the less trust there will be.  If we wait until we trust each other to do something different, we may never get started!

There is no doubt this alternative is harder to set up, but if we understand where the route we are currently on takes us then maybe we will think it is worth it.  After all, something has to change.

Jan
05

Clinical leadership sits at the heart of the thinking behind the introduction of CCGs.  But as a result great expectation and great responsibility has been placed on the GPs who have taken on leadership roles in CCGs.

These are not easy jobs.  There are a number of complex elements to them that we have explored in previous posts on this site:

In ‘the importance of localities’ we established the need for those GPs leading localities to build the relationship with member practices,

‘The relationship between the CCG, with all its statutory responsibilities, and its member practices, with all the pressures they face, will be a critical success factor for the long term success of CCGs.’ 

In ’8 top tips to drive GP engagement’ we identified that beyond developing the engagement of member practices a key role of GP leaders is to influence individual GPs, and that achieving this is no mean feat. 

Beyond that we determined in ‘CCGs are redefining out of hospital care’ that GP directors in CCGs have a key responsibility in the transformation of these localities around a redesigned general practice.

In ‘Is your CCG really clinically led?’ we established that GP directors have a corporate responsibility for the overall performance of the organisation and how it discharges its responsibilities,

‘An important question is whether the GPs on the CCG board are GP chairs – i.e. representing a specific group of practices or a locality – or are Clinical Directors.  The distinction is important.  A Clinical Director carries corporate responsibility for the organisation as a whole, including how areas such as finance and contracting operate.’

So in summary: build a relationship with practices, create an emotional connection between every member GP and the CCG, lead the transformation of general practice and community services, and take responsibility for the CCG hitting all of its statutory duties.

Can we expect our GP Directors to achieve all of this in 3 or 4 sessions a week?  Have we created undoable jobs?  Are we setting our GP leaders up for failure?  The public debate about GP directors has focussed on the potential for conflict of interests and how these are managed.  But it is missing the real question which is how realistic are the expectations we have placed upon these new GP Directors, many of whom have only been in these roles since April, and how are we supporting them to be successful?

And of course these GPs are primarily elected rather than appointed.  We give them the title of GP director, and then wait for the magic dust to descend and the great leader to emerge.  By and large it is sink or swim.  We are expecting leadership talent to emerge simply because they are GPs, without any structured development programme beyond that provided locally. 

There are examples of fantastic, courageous and highly talented GP leaders who are doing an amazing job and who provide inspirational examples of what is possible.  But how are we helping those for those learning the trade, who have taken on responsibility for leadership in the most testing time the NHS has ever known?  Doesn’t there need to be more: more structured leadership development, more visible support, more investment?  Isn’t this where we need those who are offering to support CCGs to focus their efforts?

Jan
01

Reading the planning guidance is always a treat(!), so it was very festive of NHS England to release this year’s guidance on Christmas Eve as a seasonal gift for CCGs and organisations across the NHS. 

It is a confusing time to be in the NHS.  We are so used to there being a plan dictated from above, and of taking on the job locally of putting this into place, that it can be quite disconcerting to receive guidance that reinforces that there is no overall plan for the NHS.  In the old days we received the ‘operating framework’, which described what local organisations needed to do to within the overall plan for the NHS.  We now have guidance ‘that sets out the need for bold and ambitious 5 year strategic plans’

It does claim to also ‘describe an approach to deliver transformational change’.  There is (inevitably) a framework (‘5 outcome domains with measurable ambitions, and three further measures of improving health, reducing health inequalities, and moving towards parity of esteem’), and then this strange concoction of ‘characteristics of transformational change’

These characteristics are by and large ambitions (e.g. ‘wider primary care, provided at scale’ and ‘a modern model of integrated care’).  They represent a direction of travel, but they do not of themselves constitute a plan.  In NHS England’s words they are the ‘characteristics’ of a plan. 

Of course NHS England does not claim to have a plan.  It is for local communities to use the guidance to create robust plans. ‘Plans must be owned locally and driven by local needs. Unlike previous years, this document is not prescriptive in how CCGs achieve this ambition.’ (p25).  So we are free to make our own plans locally.

But before we get too excited there are a few caveats.  There are 21 ‘fundamental elements’ that NHS England will use to assess the scale of ambition and plans for implementation, with 47 ‘key features’ to be demonstrated in plans.  These features include:

  • how you will enable primary care to operate at greater scale to improve access and continuity of care and to enable your urgent and emergency care network to function effectively’
  • ‘how you have considered your model of elective care for your local providers to achieve a 20% productivity improvement within 5 years, so that existing activity levels can be delivered with better outcomes and 20% less resource’
  • ‘how your strategic plans address whether your providers are seeing and treating a sufficiently high enough volume of patients to meet specified clinical standards, in line with the need to concentrate specialised services in 15-30 centres of excellence, linked to Academic Health Science Networks’

 The NHS has been trying to make these changes, or ones very similar to them, happen for a number of years.  But rather than tell you how to do it, NHS England is simply stating what must be done.  It is the freedom of how to get there that is the preserve of the CCGs.

But whereas previously funding has been available to smooth the delivery of such grand changes, the fiscal environment now offers no such support.  The NHS must save £30bn by 2021, and CCGs must operate within the financial rules handed to them.  These include a 4% non-recurrent requirement for next year (0.5% contingency, 1% surplus, 2.5% non-recurrent expenditure), rising to just over 6% with the money to be found for the Better Care Fund in 2015/16, with a 10% reduction in running costs in 2015/16 thrown in for good measure.

This financial pressure will hit providers, those that CCGs will be asking to support the delivery of these changes, hard.  Most providers already have very gloomy financial forecasts for next year, and I don’t think this guidance will have helped.

You may be thinking that this is beginning to sound like an impossible task, but help, it turns out, is at hand.  The ‘Any Town health system model’ is to be published in January.  This will show ‘how a typical CCG could achieve financial balance over the strategic period covered’.  Before you become too cynical about this please note that, ‘A number of ‘High Impact Interventions’ have been fully impact assessed and included in the report. Twelve ‘Early Adopter Interventions’ are also included; these have not been impact assessed to the same specification as the ‘High Impact Interventions’, but are innovative, cutting edge ideas which may be promising.’  Help, it seems, is at hand.

The big challenge ahead for CCGs could be working out how to make all of the pieces of the jigsaw laid out by NHS England in this guidance into a coherent local plan.  Or it could be finalising an approach that they believe will have the greatest chance of success.  In the little over 6 weeks that remain until the first submission, the question for CCGs is whether to focus on identifying how they will meet all 47 key features of the fundamental elements of the plan, or whether they should focus on getting local sign up and buy in to their approach to meeting the challenge ahead?  In the absence of a national plan, is stakeholder buy in more important than meeting all the requirements of the guidance? 

So in summary there is no overall plan.  The guidance is designed to help local plans be developed.  Whether it is ultimately a help or a hindrance remains to be seen.  Happy New Year!