MEDICAL AND NURSING DIRECTORS NETWORK POLICY UPDATE

23 June 2016

Siva Anandaciva Head of analysis

Contents

01 FINANCES & PERFORMANCE

02 PLANNING

03 REGULATION

04 WORKFORCE

05 NEW CARE MODELS

06 CONCLUSION

Pulled in different directions between the system and the institution, between local and national, between quality and finances

Asked to do perform difficult and awkward manoeuvres on financial plans, control totals, prudential accounting, performance trajectories

Contents

01 FINANCES & PERFORMANCE

02 PLANNING

03 REGULATION

04 WORKFORCE

05 NEW CARE MODELS

06 CONCLUSION

System under sustained operational pressure 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

Worst A&E performance figures since the standard was introduced – 4Q 87%

Ambulance services under sustained demand and performance pressure

Elective operations cancelled

District nursing and health visiting

caseloads increasing just as contracts come up for tender

Mental health referrals increasing

Struggle through 16/17… but 2017-21 U-Bend is coming

It looks like we will just struggle through 2016/17, the

supposed year of plenty…

…but current profile of additional NHS funding, increasing activity and new policy

commitments leads to crunch period in 2017/18 – 2020/21

% in

cre

ase

in N

HS

Bu

dge

t

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

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

The £22 billion savings plan – how credible?

Source: Comprehensive Spending Review 2015, FYFV savings technical note May 2016

• 1% public sector pay cap to 2019/20

• Renegotiating the community pharmacy contract

• Income generation • Reducing central admin costs

• RightCare • Self care • QIPP and demand

management • New Care models

• Lord Carter • Classics CIPs

HMT worried about institutional grip

What is the calibration of ‘good’ when everyone is in deficit, and it becomes about ‘not being the biggest failure’ – do I just need

to be in the middle of the peloton?

How do you motivate staff in this environment when it feels like

you are 10-0 down at half time?

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

Conflicting views on what’s the problem and what to do

1. Individual providers responsible for provider deficit

2. Must eliminate deficits and recover performance in 2016/17 year of plenty

3. Top-down individual control totals and performance trajectories right mechanisms

4. Provider Boards must be held to hard account, up to and including removal, if they miss a quarterly milestone

1. Provider deficits are a system issue

2. Realistically no chance of financial or operational balance by 2016/17

3. Control totals must be credible and owned by provider boards

4. Support and accountability in balance are needed, recognising where factors are beyond board control due to system impact and overall context

MUST. TRY. HARDER IT’S THE SYSTEM STUPID

And pressure to be part of the solution not the problem

How will you

explain to your

neighbouring

trusts that you

have not signed

up to a control

total?

Ask not what

your STP can do

for you, ask what

you can do for

your STP

16/17 finances: best guess on what happens next

Control totals • 139 signed up in February • Further 80 signed up in May • Individual follow-up for the

rest • Post-Brexit firebreak point in

August if on track for-£500m to -£1 billion deficit

Performance trajectories Strong emphasis on back loading trajectories to Q4 to minimise Q1-3 trajectory misses Indemnity if trajectory missed due to circumstances clearly beyond control

Success is now proof of concept/capability?

Source:

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

individual deficit > £50m

• 4 providers meeting last quarter’s A&E standard

• 68% of providers requires improvement or inadequate. 16

providers in special measures

• 80% of providers in surplus & sector in surplus

• Meeting operational standards

at aggregate national level

• Bending CQC curve

• 20% of NCM delivering, 50% of population covered

2015/16 2020/21

Contents

01 FINANCES & PERFORMANCE

02 PLANNING

03 REGULATION

04 WORKFORCE

05 NEW CARE MODELS

06 CONCLUSION

Emerging tension between different forces

CENTRIFUGAL

CENTRIPEDAL

• Control totals for providers

• 1% hold back for CCGs • Increased CCG

assurance • STPs

• Co-commissioning of primary care and specialised care

• Devolution / Delegation

• Earned autonomy • STPs

Does the city come before the citizen?

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

• 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

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

Contents

01 FINANCES & PERFORMANCE

02 PLANNING

03 REGULATION

04 WORKFORCE

05 NEW CARE MODELS

06 CONCLUSION

NHS Provider Sector - regulation

All data correct as of June 2016

16 Trusts are in special measures

68%

Of rated trusts are rated ‘requires improvement’ or ‘inadequate’ by the Care Quality Commission (CQC)

13 Trusts are in success regime areas

Clear Jim Mackey narrative emerging

We're here to support, we're here to support, but there has to be accountability

• Trying to build headroom for leaders. In

• Interventions on the contracting round and

tendering already.

• 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.

• As legislation intended NHSE and NHSI balancing each other.

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 either flip a coin to see where the financial

risk sits, or we ask NHSI and NHSE to slug it out and tell us what our local contract value is.

NHS FT Finance Director

A new oversight framework

QUALITY CQC rating, patient

& staff surveys

MONEY Old metrics

Use of resources Carter

OPERATIONAL PERFORMANCE

Small set of constitutional

standards

LEADERSHIP Well led framework

Organisational health

STRATEGIC CHANGE

In progress, likely to include STPs & 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

Ten initial thoughts on new NHSI oversight framework

Danger of two competing CQC /

NHSI ratings

Individual institutional vs

system accountability

Relative or absolute standards

in current environment?

Developing leadership and

strategic change domains

What, when, how and why moving

through segments

How practical will benefits of full

earned autonomy be?

FT pipeline and FT status

Clarity on voluntary support

& intervention incl. mandation

Legal base

Overall narrative and relationship to

current strategic context

CQC new strategy to 2020

Encourage improvement, innovation and sustainability in care • More flexible registration e.g.

NCMs • Assessing use of resources • Views of quality across

populations and local areas

Intelligence-based approach • Development of CQC Insight • Targeted and risk-based

inspection where comprehensive inspection is exception to the norm

Promote a singly shared view of quality • Alignment with NHSI oversight

framework

Improve CQC efficiency • Focus on CQC VfM and changes

to fees

Contents

01 FINANCES & PERFORMANCE

02 PLANNING

03 REGULATION

04 WORKFORCE

05 NEW CARE MODELS

06 CONCLUSION

What do we want?

Happy staff who find joy in work

Working in new settings

Working with new partners

Working across 7 days

Involved in the business

Coping with more demand

Taking a role in chains, turnaround, commissioning

Staff under pressure

NHS Staff sickness

absences is 27% higher than any

other public sector

organisation average, and

46% higher than

the average for all other sectors

Source: Nuffield Trust

Staff morale a major concern

Though some movement on junior doctor contract

Provisional agreement on new contract but needs to be ratified by referendum with results on 6 July

Additional costs to providers including additional employer pension contributions – needs close tracking

Significant additional duties for monitoring safe working hours and breaks and rotas

Need to track impact on wobbly existing rotas

Still significant trust and morale issues

Source: Junior Doctor Blog

Is this contract safe? On paper yes – the new safeguards reduce runs of shifts and provide a system that could

both address individual overworked doctors and collect data on understaffed rotas for the first time.

But in practice? In practice there has been no

groundwork laid for the expanded roles of educational supervisors, no realistic investment in the Guardian role in many trusts, and the financial pressures on hospitals right now are mounting. I simply cannot see hospitals

having the will, the manpower or investing the resources to make this work.

The old banding system was difficult enough- some

trusts actively hid hours monitoring data, and flat out refused to sort out rotas that breached safe working. But

where it did function, speaking from personal experience, it worked very well and effectively.

What is our offer?

Source: Roy Lilley, NHS Managers

…flexible rotas; child friendly (a crèche); a culture that is kind, creative and fun;

whole person training and development; dump bully-bosses and staff who behave

badly; listen to people; realise your people have a life outside work; find out what inspires people and do more of it; show people what good looks like and help them achieve it; accept pay is a

'national thing' but figure out what you can do locally with access and discounts

to become the local employer of preference...

Consultant contract

Radical contract reform

All change is painful, so change in one go

Put forward joint position from as least worst option

available through negotiation

Less radical reform Negotiate a package that

achieves delivery of 7DS but at a cost

Defer reform

Avoid strike of juniors and consultants at same time

Scale back 7DS ambitions

Supply of staff

• Significant variation in vacancy rates from 15% in London to 3% in parts of the North

• Expectation that by 2019/20 ‘we will have it right’ in terms of supply and demand for nurses and that in the meantime, agency staff and overseas recruitment must plugged the gap

Agency and locum caps

Source: HSJ, Liaison

• Zero-sum game • Unintended

consequences e.g. therapists

• Additional levels of management sign-off on bookings

• Review of job planning • Sharing capacity across

wards • E-rostering • New posts e.g. physician

associates, associate nurses

So a workforce squeeze regardless of the contract

Pressure on rotas and

performance and CQC

requirements

20% vacancies in specialties even

in some attractive deaneries

Exiting training Locum & Agency

caps

New limits on consecutive long

days

“ We need more nurses and junior doctors than we have at present to run these rotas. The posts we need are not being allocated, and even if they were allocated in sufficient numbers we do not have enough people in the right parts of the country and the right specialties to fill the posts. ” NHS Foundation Trust CEO

Some other workforce developments

HEE accepts Shape of Caring Review

recommendations

Nurses to remain on the shortage occupation list

Consultation on “nursing associate”

role

Consultation on reform of

healthcare education funding

Safe staffing guidance

Lord Carter and clinical productivity

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

Regional planning to solve the insolvable

NHS England, NHS Improvement, HEE, CQC, PHE, NICE new regional structure based on four areas

Create Local Workforce Action Boards. Aligned to STPs (albeit < 44). Lead on local workforce issues. Jointly chaired by HEE and local CEO

Baseline health & social care workforce and identify issues. Develop a high-level workforce strategy to meet STP ambitions and an action plan for required investment in workforce

Providers not standing still

• Ask patients what extended hours they would value

• Use evidence to target services and particular periods to extend service

• Listen to concerns of patients over impact on staff

• Then start conversation with clinicians and support staff

• Get details right e.g. canteen

Contents

01 FINANCES & PERFORMANCE

02 PLANNING

03 REGULATION

04 WORKFORCE

05 NEW CARE MODELS

06 CONCLUSION

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

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.

But needs considerable commercial partnership

working

Source: Anna Kovecses

Contents

01 FINANCES & PERFORMANCE

02 PLANNING

03 REGULATION

04 WORKFORCE

05 NEW CARE MODELS

06 CONCLUSION

Things that have changed since we last met

2015/16 closes with a £2.45bn / £3.3bn deficit and 65% of

providers in deficit; 2016/17 control

total exercise round two; £22bn plan

“unveiled”

Second cut of place-based STPs being

developed & a new strategic framework

for specialised services

Government and junior doctors

committee reach initial agreement on

contract with growing questions

over implementation

impact

New care models sees large funding cuts for vanguards

and new programmes for maternity, U&EC, cancer and MH,

diabetes

New CQC strategy unveiled and NHSI

oversight framework to

shortly be unveiled

A lot going on across a range of different fronts

Final thought: 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