Archive

Archive for January, 2014

Jan
26

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.

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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.

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Jan
12

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.

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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?

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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!

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