NHS England planning guidance for NHS 2017-2019

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NHS England Planning Guidance for the NHS: A

Briefing

Jim.mcmanus@hertfordshire.gov.uk

September 26th 2016

Introduction

NHS England [NHSE] and NHS Improvement [NHSI] (the combined regulator of

NHS provider Trusts which replaced Monitor and the Trust Development Authority)

have issued jointly their planning guidance for the NHS for the period April 2017 –

March 2019) Copies can be obtained at

https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/

National Planning Guidance is issued for the NHS every year. This time (Sept 2016)

the guidance is for two years. This guidance is part of the programme to get to the

very ambitious financial and outcome targets for the NHS for 2020-21.

Commentators are already asking whether the significant financial, quality,

operational and reconfiguration work needed can be delivered within the timescale.

The guidance shows no let up in a range of national targets or actions such as

waiting times, and shows a determination to get to parity of esteem for mental health.

The document rewards close reading and has significant implications for how local

authorities and other partners work with the NHS system.

This will obviously have commissioning and service configuration implications for

local authorities, public health and providers.

A range of commentators have already begun to consider implications of this and

some are questioning whether this can be achieved.

What does the guidance do?

The guidance sets a range of expectations for the NHS to achieve. It will need to do

this with partners.

The best way of considering the plan is to consider it as covering actions across four

domains of action required to meet the vision for 2020/21 of a better access,

reconfigured, operationally and financially sustainable NHS:

1. System reconfiguration – the NHS will work as one system and this will be

based on STP footprints. CCGs will be encouraged to merge leadership and

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governance where sensible. But the emphasis is on working as an STP

footprint.

a. On a by-application basis, there will be flexibility, by agreement with

NHS England and NHS Improvement, for STP partners to adjust

organisational control totals (both for providers and for CCGs) within an

STP footprint, provided the overall system control total is not breached.

Deadline is 31st October 2016.

b. Governance across the STP footprint is required

2. Finances – there is significant pressure to achieve financial balance

nationally and across STP systems for both 17/18 and 19/20 with an

expectation that each STP area achieves financial balance by 2020/21.

There is transitional funding available. This is including, according to some

commentators, heroic assumptions about what can be achieved through

demand reduction and provider efficiencies

3. Outcomes and quality – no let up on targets, expectations or waiting times

and a heroically ambitious new scale of work on pathways, commissioning

and access across almost every area of healthcare. Significant ambitions on

prevention which are clearly implicit but poorly spelled out.

4. The guidance includes a commitment to the national prevention

transformation programme and two-year prevention-focused

Commissioning for Quality and Innovation (CQUIN) schemes - The CQUINs

will provide a financial incentive to secondary care providers to make progress

on a number of areas including:

improving NHS staff health and wellbeing;

screening and providing brief advice for tobacco and alcohol use;

reducing the impact of serious infections;

Weaknesses

Poor conceptualisation of the implications for partner agencies and similarly poor

conceptualisation of the importance of prevention even though prevention is

mentioned repeatedly as a key mechanism for the future NHS. The whole document

feels very NHS inward facing in some respects.

There is little in the plan about any democratic accountability or engagement.

Patient engagement feels patchy but there is a clear commitment to the NHS

constitution

Appendixes

There are numerous appendices to the guidance, of which the following are most

important:

1.The Government Mandate to NHS England: Summary 2020 Goals

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2.CCG improvement and assessment framework

3.NHS Improvement single oversight framework

4.October guidance to Sustainability and Transformation Plans

5.NHS England and NHS Improvement Approach to Establishing Shared Financial

Control Totals

6.General Practice Forward View planning requirements

7.Cancer services transformation planning requirements

8.Mental health transformation planning requirements

Key Points

The emphasis is on single whole systems with a focus on making two years’

worth of progress towards 2020/21 when systems are expected to achieve

financial balance and close their financial gaps

Two year focus very different from previous years

The guidance strengthens the importance of the STP (Sustainability and

Transformation Plan) including introducing financial control totals for the

whole STP footprint, assurance mechanism, performance standards and a

risk pool.

This guidance feels intended to identify those health systems not working as

one

A fast pace of delivery is expected

There are nine MUST Dos

STP Footprints

The Nine Must Dos

For STP footprints. These are summarised in pages 7ff of the planning guidance,

each with a sub section of must dos. This is summarised here:

1. Deliver the STP milestones agreed nationally

2. Control totals for finances introduced and must be achieved. Financial

balance at national level for both provider and ccg sectors in each year to be

achieved. Additional monies available but looks like deficits in one part of the

system will be offset by balances elsewhere, even if only notionally

a. Deliver demand reduction

3. Series of must dos to ensure primary care sustainable including expansion

of access. Significant work

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4. Urgent and Emergency Care: Four hour A and E standard and response

times for ambulances to be delivered. Seven day hospital services by

November 2017 for all urgent specialist services at network level. Prepare for

waiting time standard for mental health crisis

5. Referral to treatment times : deliver 18 week wait and patient choice,

implement local maternity systems

6. Cancer – implement cancer task force, retain 62 day waiting standard, follow

up and recovery packages to be commissioned

7. Mental health – significant series of must dos to achieve parity and prepare

for new waiting times. Eliminate out of area placements by 2021

8. People with Learning disabilities – reduce bed capacity, improve access to

healthcare and reduce premature mortality. Enhance community provision for

people with learning disabilities and /or autism

9. Improving quality -

Contracting, commissioning, targets and incentives

Move to two year contracts to reflect two year planning timeframe

NHSE and NHSI will intervene where contracts with providers cannot be

agreed between NHS commissioner and provider. The impact of this on

£3.6bn of NHS sustainability funding will be used to close provider financial

deficits

CCGs will be “supported” in merging leadership and governance

financial incentives (using new commissioning for quality and innovation

payments or CQUINs) have also been announced to improve care for children

and young people, and patients attending A&E with mental health problems.

Children and Young People

new CQUIN intended to incentivise providers to ensure young patients have a

transition plan, dedicated key worker and are involved in planning their care

with their parents and carers. The payments will be available to providers

where patients are transferring between organisations.

Demand Reduction measures required

Demand reduction measures include: implementing RightCare; elective care redesign; urgent and emergency care reform; supporting self care and prevention; progressing population-health new care models such as multispecialty community providers (MCPs) and primary and acute care systems (PACS); medicines optimisation; and improving the management of continuing healthcare processes.

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Efficiency measures for providers required

Provider efficiency measures include: implementing pathology service and

back office rationalisation; implementing procurement, hospital pharmacy and

estates transformation plans; improving rostering systems and job planning to

reduce use of agency staff and increase clinical productivity; implementing the

Getting It Right First Time programme; and implementing new models of

acute service collaboration and more integrated primary and community

services.

Specialised Commissioning

Among the appendices is a detailed guide on specialised commissioning intentions

which signals they will work more and more with STP footprints as a system.

Mental Health (Children and Adults)

A range of commitments have been made but in summary commissioners and

providers must deliver in full the new mental health implementation plan (the

Five Year Forward View for Mental Health), which was published in July 2016

and the £1bn investment money for mental health cannot be used for other

services, it “must not be used to supplant existing spend or balance

reductions elsewhere.”

Specific commitments in the specialised commissioning guidance on

reprocuring and reframing tier 4 CAMHS support. Worth reading for anyone

interested in child mental health (section 5.1 page 24ff of the specialised

commissioning appendix to planning guidance)

“Savings arising from new services… resulting from this new investment need

to be reinvested to maintain services and ensure delivery of the commitment

to treat an additional 1 million people with mental illness by 2020-21.”

Mental health and acute trusts will be encouraged to improve recognition and

coding of patients presenting with mental health problems to drive down

repeat attendances via a new commissioning for quality and innovation

payment or (CQUIN).

areas must commission eating disorder teams so that 95 per cent of children

and young people in routine cases receive treatment within four weeks of

referral, while urgent cases receive treatment within one week.

IAPT services will have to be integrated with physical healthcare from 2018-

19, with 3,000 more therapists to be co-located in general practice by 2020-

21.

The guidance says suicide rates will be published as part of the new mental

health dashboard, which HSJ understands will be published later this month

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or early October. This will coincide with national suicide guidance which gives

areas duty to produce local plan.

To extend the provision of liaison psychiatry NHS England says more cash

will be made available which the new A&E delivery boards will be able to bid

for from next month. The document does not say how much money will be

made available.

A central pot of transformation funding will be available over the two financial

years, with £215m set aside for 2017-18 and £180m the following year. Little

more detail as yet.