Every sector, every industry has its 'moment', those long-awaited announcements that set out the stall for the coming year. For the NHS I’d suggest the planning guidance is our moment, reflected in the huge amounts of commentary already committed to the twittersphere in particular.
For the lay reader the planning guidance essentially tells the NHS – commissioners and providers and anyone in between – what it needs to deliver for the coming year, what resources the frontline will get, the assumptions on which plans should be drawn up and the rules that will apply.
For those who have not yet read the detail, here’s a quick low down on the main points:
- of the hard won, although insufficient, NHS cash announced in the November 2017 budget £650 million is allocated to NHS trusts and £600 million to CCGs
- CCGs will receive a total injection of £1.4 billion, once other pots of money have been liberated, with an explicit instruction that one of the uses of the money is to ensure "universal adherence" to the mental health investment standard
- recovering constitutional targets has been delayed – for A&E performance trusts will be expected to be at 90% by September this year and a full recovery by March 2019; waiting lists should be no higher in March 2019 than in March 2018 and, where possible, be reduced
- acronyms have been replaced, reinvented or created – the sustainability and transformation fund is now the provider sustainability fund; commissioners now have their own commissioner sustainability fund (CSF); and accountable care systems (ACS) are now integrated care systems.
Usually we’d pore over the detail to work out what’s really going on in the minds of those who plan our health and care system. However this year, for me, it’s the themes we can extrapolate that say most.
It is also recognition that transformation does not just happen on its own. As we have seen from work to date on new models of care transformation requires a substantial investment of time, money and energy, all of which are in short supply.
First – mental health. There’s a lot of gloom around but on mental health the explicit recognition that we can’t just go on trying to do the same thing is welcome. Hope for the sector comes in the £1.4 billion made available to CCGs with an explicit instruction that one of the uses of the money is to ensure "universal adherence" to the mental health investment standard, requiring every single CCG to boost funding for mental health in line with their own budget increases. This is a further signal that the importance of investing in mental health has truly registered. We, amongst others, will be keeping a close eye on the details, and how that works out in terms of money reaching the frontline.
Second – the performance targets. They are no longer deliverable, and the guidance makes this very clear. It sets out a slow recovery timeline for the constitutional standards for the A&E four hour and 18 week waiting time targets. This is welcome, public recognition that the NHS cannot do everything. At NHS Providers we’ve been saying for well over a year that there has to be an honest conversation about how much the service can deliver, given rising costs and demand, and a level of funding that dramatically undershoots this.
Third - transformation. If you read the planning guidance, from a funding perspective transformation no longer figures, as the sustainability and transformation fund for NHS trusts has been renamed. Once again this is open recognition that the current challenge facing the NHS is an immediate one: to treat the growing number of patients and service users coming through the doors as safely and quickly as possible in the context of severely constrained funding.
Once again this is open recognition that the current challenge facing the NHS is an immediate one: to treat the growing number of patients and service users coming through the doors as safely and quickly as possible in the context of severely constrained funding.
It is also recognition that transformation does not just happen on its own. As we have seen from work to date on new models of care transformation requires a substantial investment of time, money and energy, all of which are in short supply. Transformation also requires 'double running' – creating the new system we want to see while also running the existing services until we are ready to move over. However we do not have that luxury in these times of austerity.
The final theme - accountability. Renaming accountable care systems to become integrated care systems may well be a move to describe their function more accurately and this is fair enough. However the cynic in me wonders whether it may also be an opportunity to put a clear separation between old style ACS and the controversial and now legally contested concept that is the accountable care organisation.
No matter what the reason for the 'rebrand', it is significant that the concept of accountability has explicitly disappeared from this arena. We know that in the development of both sustainability and transformation plans/partnerships and accountable care systems it has been very hard to pin down accountabilities. Given that legal accountability still rests with individual institutions, ensuring good governance has been tricky terrain to navigate.
As we have seen from work to date on new models of care transformation requires a substantial investment of time, money and energy, all of which are in short supply.
While governance and accountability may not be regarded as a 'sexy' topic for some people and those concerned with it are accused of using it as an excuse to block change – it is essentially about risk management. There are few who would disagree with the importance of this remaining front and centre when delivering patient care. And this will still be the case for integrated care systems, regardless of the name change.
So, with the planning guidance the sector has had its 'moment'. A few weeks ago we talked about a watershed moment for the NHS in the midst of winter pressures. We have not left those pressures behind and it will be very useful if the planning guidance were followed by an announcement on how the Government will develop a long term sustainable funding solution for the NHS, which included investment in much needed, long overdue transformation.
This article was first published by the HSJ on 7 February 2018.
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