COMMUNICATION LEADS NETWORK

24 May 2016

Siva Anandaciva Head of analysis

Contents

01 FINANCES & PERFORMANCE 02 PLANNING 03 REGULATION 04 WORKFORCE 05 NEW CARE MODELS 06 REASONS TO BE OPTIMISTIC

Beware the U-Bend

Sep 2015 Jan 2016 May 2016

Time to deliver

Reverse the car out of the

financial ditch

Profile of additional NHS funding, and profile of increasing activity and new

policy commitments leading to a crunch period in 2017/18 and 2018/19

Contents

01 FINANCES & PERFORMANCE 02 PLANNING 03 REGULATION 04 WORKFORCE 05 NEW CARE MODELS 06 REASONS TO BE OPTIMISTIC

A&E still the canary in the mine

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

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 may eat new policy commitments and transformation for

breakfast

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

2016/17

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

3.7

1.3

0.3 0.7

1.3

0

1

2

3

4

2016/17 2017/18 2018/19 2019/20 2020/21

% in

crea

se in

NH

S Bu

dget

And plan for 2020/21 is challenging

Source: Comprehensive Spending Review 2015, FYFV savings technical note May 2015

Historical NHS 3.6% average annual funding increase and 3.5 to 4% average

annual cost and demand increase

• 65% of sector in deficit, £2.5bn overall deficit, 11 trusts with

individual deficit > £50m • 4 providers meeting last quarter’s

A&E standard • 75% of providers requires improvement or inadequate. 16

providers in special measures

Success is now proof of concept/capability?

Source:

• 80% of providers in surplus & sector in surplus

• Meeting operational standards • Bending CQC curve

• 20% of NCM delivering 2015/16

2020/21

Contents

01 FINANCES 02 PLANNING 03 REGULATION 04 WORKFORCE 05 NEW CARE MODELS 06 REASONS TO BE OPTIMISTIC

Emerging tension between different forces

• Co-commissioning of primary care and specialised care

• Devolution / Delegation

• Earned autonomy

• STPs

• Control totals for providers

• 1% hold back for CCGs

• Increased CCG assurance

• STPs

CENTRIFUGAL CENTRIPEDAL

Does the city come before the citizen?

• 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

• Our future lies in networks and health systems; not individual go-it-alone institutions - Simon Stevens.

But several tricky issues to work through The ask

1. Timelines too ambitious 2. Too many baubles on the Christmas Tree. What is the

problem to address? 3. Did you really wake up and smell the coffee

The players 1. Different patches going at very different speeds based

on appetite, relationships and resources. Some STPs have no leaders, some have a plan ready to go, for some people the plan is still to improve as an org (e.g. special measures).

2. Relatively few LAs or clinicians are STP leads & unclear what the JD is for an STP lead. Do we have the capacity and capability?

The arena 1. STPs have no statutory basis, governance or clear

future. How are disagreements resolved? 2. Still regulated as individual organisations and that is

where a director’s legal duty lies – some significant governance and accountability issues feel parked not solved.

3. When everyone is responsible who do you hold to account when things go wrong e.g. System control totals for finance and performance

And multiple overlapping footprints

• 44 Sustainability and transformation plans

• Local education and training boards

• Academic Health Science Networks

• Ambulance services • Local Digital Roadmaps • Urgent and emergency

care networks • Maternity networks

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

Bao Tong

Source: Financial Times

The seated guard’s job was to record Bao

Tong’s every action in a notebook 24 hours a

day, one entry a minute, for seven

years. “20:00 hours – prisoner 8901 sleeping. 20:01 hours – prisoner 8901 sleeping. 20:02

hours – prisoner 8901 sleeping…”

Contents

01 FINANCES 02 PLANNING 03 REGULATION 04 WORKFORCE 05 NEW CARE MODELS 06 REASONS TO BE OPTIMISTIC

Clear Jim Mackey narrative emerging We're here to support, we're here to support, but there has to be accountability

• Genuinely trying to build headroom for

leaders. In Northumbria he had a stated board objective to have nothing to do with the regulatory system unless they had to – so there are plenty of people at the regulator he has never met.

• Interventions on the contracting round and tendering already. As legislation intended NHSE and NHSI balancing each other.

• 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.

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 wither flip a coin to see where the financial risk sits, or we ask NHSI and NHSI to slug it out and tell us what our

local contract value is.

NHS FT Finance Director

A new oversight framework

QUALITY CQC rating

MONEY Old metrics

Use of resources Carter

OPERATIONAL PERFORMANCE

Small set of constitutional

standards

LEADERSHIP Well led framework Systems leadership

STRATEGIC CHANGE

In progress, likely to include 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

CQC new strategy to 2020

• More flexible registration e.g. NCMs • Assessing use of resources • Views of quality across populations and

local areas

• Development of CQC Insight • Targeted and risk-based inspection where

comprehensive inspection is exception to the norm

• Alignment with NHSI oversight framework

• Focus on CQC VfM and changes to fees

Contents

01 FINANCES 02 PLANNING 03 REGULATION 04 WORKFORCE 05 NEW CARE MODELS 06 REASONS TO BE OPTIMISTIC

Junior doctor contract

Some other workforce developments

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

Further clampdown on agency and locum spend

bending cost curve

Some expected zero-sum

behaviours

And some unexpected

consequences e.g. therapists

Nurses to remain on the shortage occupation list

Consultation on “nursing associate”

role

Consultation on reform of

healthcare education funding

New safer staffing work on-going

Consultant contract bubbling in the

background

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

But some green shoots?

• (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 developing new roles and

training programmes

Contents

01 FINANCES 02 PLANNING 03 REGULATION 04 WORKFORCE 05 NEW CARE MODELS 06 REASONS TO BE OPTIMISTIC

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

Five vanguards

losing funding in 2016/17

as risk appetite grows (or shrinks)

And new care models are like marriages

• They look wonderful from the outside

• They have tax implications

• But they take a lot of work

• They cost a lot of money up front

• It’s the little things that count

• And they don’t magically solve a dysfunctional relationship

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

And a renewed focus on prevention

Source: Sir Michael Marmot

Looks like frontier shift but little catch-up

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.

So where are we?

New care models starting the right conversations, but perhaps different exam questions

Junior docs tentative agreement

New and more aligned approach to regulation

Considerable variation in early days of place-based planning

Finances continue to deteriorate

Contents

01 FINANCES 02 PLANNING 03 REGULATION 04 WORKFORCE 05 NEW CARE MODELS 06 REASONS TO BE OPTIMISTIC

The glass is half full

• Modelling out zero sum game behaviours (slowly)

• Top-down relationships evolving e.g. Ethos of Lord Carter work; No blame culture of Mike Durkin safety unit

• Beefed up assurance framework

• Federating to scale • Voluntarily passing

responsibilities to other congresses, councils, providers

• Like working in a knotted ball of string

• Building locus of strategic planning

• Core competency of new leaders

• 10 year contracting & 5 year planning timeframes

• Systems as the unit of planning; CQC quality in a place; success regime; devolution

All in this together

Commissioning & primary care

Starting to think at the

right scale and timeframe

Systems leadership

Welcome to Croydon

• 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 • 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

Governance Conference

Annual conference & exhibition 2016

Event bookings open for our annual event at Birmingham ICC on 29-30 November Delegates can take advantage of group discounts of up to 25% Please see our website for further details and to book your place Confirmed speakers include the Secretary of State for Health and chief executives of CQC, NHS England and NHS Improvement 89% of delegates rated 2015 event as ‘good’ or ‘excellent’

Backup slides not for display

Genuine strategic commissioning

Provider CEO: I never talk to commissioners about beds. Beds are an internal decision.

Commentator: but that's not the narrative CCGs have been given. CCGs want to see consultant job plans and bed and inputs. Politicians and regulators want to see bed availability.

I don't speak to politicians about beds. They don’t need to know. They would ask ‘how many beds do you have’ and I would say I don't know how many beds I've got – its changes from hour to hour, so stop asking. We have let CCGs into areas they didn't need to be in and as a result they have not been in the place they should have been in

CCG letter • I am sending this letter to clarify our general position on this. In summary,

clinical commissioning groups (CCGs) must ensure that they secure the best deal for their patients by contracting with the most appropriate providers.

• • In order to secure the best deal for patients, we expect CCGs to have fair and

transparent processes and engage with existing providers. If CCGs are not happy with the service being provided under an existing contract, they need to give their current providers the opportunity to address concerns under the terms of their contract before considering other options. In those cases where CCGs can roll over or extend contracts, this should not happen when the provider has failed to respond appropriately to such concerns.

• • For the avoidance of doubt, tendering is not the automatic solution in every

case. But there is definitely a requirement for CCGs to have good processes to ensure that chosen providers are best placed to deliver what patients need locally.