Key issues for NHS provider trusts March 2016 Our first briefing paper summarises the current key issues facing NHS providers and highlights plans for new ways of working, workforce issues, the scale of the financial challenges and issues specific to community and mental health trusts New models of delivery Conversations on new models of delivery can have one of many starting points. In their entirety, new models of delivery encompass the national initiatives of the Five Year Forward View vanguards, the Better Care Fund (BCF), devolution and seven day working, as well as local changes being undertaken across the various health economies in the country. The national initiatives are all in their infancy with the BCF being the most mature and have a common theme of transformation; the redesign of service delivery to be more patient-focused and more efficient. Each requires collaborative working with many partners. The BCF and devolution require partnership working across the local government and health sector, while the Forward View vanguards are more NHS focused, with some cross over with local government. Much is expected of the initiatives as, taken together, these new ways of working are central to the NHS being able to deliver a high level of patient care and patient experience in a financially sustainable manner. CQC will have a key role in monitoring the impact of this. In March 2015, NHS England announced 29 vanguard pilots for developing and co-designing new models of care as one of the first steps in delivering the Five Year Forward View. They include three prototype models: 1 Integrated primary and acute care systems (PACs) will bring together GP, hospital, community and mental health services. Money will be directed from a joint budget to wherever patients are judged to need it most 2 Multispecialty community providers (MCPs) will bring specialist services such as chemotherapy and dialysis out of the hospital and closer to people s homes 3 Models of enhanced health in care homes will enable the NHS and councils to work together to provide more healthcare in care homes and to provide better preventive services In the summer of 2015, 21 vanguard pilots were approved across two further prototype care models focussing on: 1 urgent and emergency care (UEC) to accelerate the implementation of the Keogh Urgent and Emergency Care Review 2 acute care collaboration to develop new clinically and financially sustainable models for acute care hospitals and take forward Lord Carter's recommendations on efficiency. The vanguards are at the cutting edge of change and inevitably not all will be successful, or meet NHS England's aim of pilots producing simple, standardised approaches and products that can be quickly replicated across the country. It is acknowledged by NHS England that demonstrable quantified change needs to be implemented by the end of the 2016/17 financial year. The pilots have agreed programmes of transformational change, initially through to April 2016. However, the basket of agreed performance metrics by which to measure success has not yet been determined. What is accepted is that existing performance metrics are not suitable. They will need to ensure that both financial and quality outcomes are measured. Successful transformation requires a number of essential ingredients: a clear vision of what is trying to be achieved; shared buy in; a relentless drive to deliver with clear accountability; and strong leadership, not from just one accountable individual or leading organisation, but collectively by many stakeholders. There are many hurdles to overcome, including: putting aside competitive tensions created by the internal NHS market; overcoming differing views about the future; and creating the time and space for strategic thinking. The early vanguards and devolution deals stand out because of strong visible leadership prepared to try something new. In some cases this is coupled with a track record of joint working. Achieving NHS England's vision of rolling out new ways of working nationally will be challenging; collaborative working within individual health economies will sit on a wide 'maturity index'. The 2016/17 NHS planning guidance provides a framework for a national rollout, but it asks local leaders to create a.
common vision for the transformation of their local health economy in a short timeframe. Devolution Like the vanguards, the devolution agenda burst into life last year. The first signed deal was in Greater Manchester, followed by agreed deals between the government and: Cornwall; Sheffield City Region; Leeds City Region; Liverpool City Region; West Midlands; Tees Valley; and the North East. Of these Greater Manchester, Cornwall and London's 'devolution deals' include health and social care. Greater Manchester The devolution deal in relation to health and social care continues to develop. The strategic partnership board is made up by representatives from the 12 CCGs, 15 NHS trusts, 10 local authorities, local voluntary services and Healthwatch. The board has been described as the cornerstone of the new decision making structure for health and social care in Greater Manchester and meetings are streamed live, enhancing the transparency of decision making. The final draft of the Greater Manchester health and social care strategic plan, 'Taking Charge of our Health and Social Care in Greater Manchester', was issued in December 2015. The strategic plan sets out the challenge to be met that without radical change by 2021 more people will be suffering from poor health within Greater Manchester but the area will be facing a 2billion shortfall in funding for health and social care services. The plan also recognises that actions should not just be limited to health and social care but across a range of public services to ensure people can 'live well'. The plan sets out the challenges to be faced and the journey so far, along with early implementation priorities. The main part of it looks at the 'reimagining' of services across the whole care system in Greater Manchester including: upgrading population health prevention transforming community based care and support standardising acute and specialist care. The plan, which is part of the overall preparation for the region taking full responsibility for the devolved 6billion health and social care budget from 1 April, has been built on the ten locality plans submitted jointly by NHS organisations and councils within the ten boroughs. Cornwall In July, Cornwall became the first rural authority in the country to be offered a devolution deal. The Cornwall Devolution Deal, which was signed by the Secretary of State for Communities and Local Government; the leader of Cornwall Council, the chair of the Cornwall and Isles of Scilly Local Enterprise Partnership and the chair of NHS Kernow CCG, gives Cornwall greater powers over public sector funding including health and social care. The deal sets out that local partners will work with the government, NHS England and other national partners to co-design a business plan to move towards integration of health and social care across Cornwall and the Isles of Scilly bringing together available local health and social care resources to improve outcomes for the local population. The deal also highlights that NHS England and local organisations will remain accountable for meeting the full range of statutory duties. Cornwall Council and NHS Kernow CCG are currently seeking the views of residents to help shape the future of the services for both adults and children. Through an online survey and a series of community events across Cornwall and the Isles of Scilly during March the aim is to help ensure plans being developed are focused on the things that matter to the local populations. London The 'London Health Devolution Agreement' was published in Decemeber 2015. The 'London Health and Care Collaboration Agreement' sets out how government and national bodies will support the overall vision of transforming the health and care system in the city on a gradual basis. The parties in the agreement are: all London CCGs and local authorities the Greater London Authority a number of national parties including HM Treasury, the Department of Health (DH), Department for Communities and Local Government (DCLG) and NHS England. Initially there are five pilots focused on different aspects of health and social care including: the Lewisham pilot to integrate physical and mental health alongside social care Hackney running a health and social care integration pilot, aiming for full integration of health and social care budgets and service provision the development of an accountable care organisation across Barking and Dagenham, Havering and Redbridge. Capacity and demand management Demand management in the NHS is vitally important to maximise the efficiency and value from pressurised budgets. Understanding capacity, for both the human and the physical estate, is essential in order to match demand and ensure patients receive the most appropriate care, in the right setting, at the right time. Some of the most successful ways to do this include: reducing unplanned hospital admissions through the use of multi-disciplinary primary, community and social care teams to manage the care of patients concentrating on reducing the effect of bottlenecks in patient care pathways by increasing the availability of doctors with specialist skills focussing on the various needs of patients with comorbidity (multiple conditions) so they are
provided care in the right setting, reducing the demand on inappropriate services. This is increasingly important with an ageing population with a variety of needs ensuring good quality data is collected on types and sources of demand increase, so that care resources are in place to meet it. By sharing data, commissioners and providers can work together to provide the best possible care to patients in the best possible setting. With the move to seven day access to NHS services, the peaks in demand and capacity are likely to shift. Systems will need to be in place to be reactive to the changes in demand, capturing weekends as routine and ensuring any move to seven day opening will improve access to services. This may take the form of more technological solutions to increase the capacity in the system. Financial challenge The NHS remains under unprecedented and sustained financial pressure. Reports from the NAO, HFMA, CQC and many others describe a sector that is feeling the financial strain of sustained long-term trends in demand, coupled with the cost of addressing access and service quality standards. The Trust Development Authority (TDA) reported a Quarter 2 FT and NHS trusts combined year to date deficit of 1.6bn. Indications are that although CCGs were in a better financial position than trusts last year, they are inevitably feeling the strain this year too. The NHS forecast deficit gap of 2.1billion may just be the tip of the iceberg with a slow start on stretch targets and winter pressures. Transformational change remains the only sustainable option to address the medium-term financial outlook while not impacting on quality of service. 2015/16 cost improvement programmes are challenging and in the past many have relied on non-current projects to make targets. Integration of health and social care must form part of the transformational change. With services and costs so interconnected, patient experience, new ways of working, capacity and demand management and financial balance are dependent on the success of this integration. The sector welcomed the spending review announcement that 3.8 billion of the promised 8bn additional monies would be frontloaded into 2016/17. However, this must be considered alongside the significant cash cuts to other health monies such as the 4% real term cut in public health funding, effecting preventative support on key areas such as obesity, smoking, alcohol and exercise, and the use of capital budgets to support current shortages. The additional monies include the introduction of a new, dedicated Sustainability and Transformation Fund. In addition to individual NHS organisation plans, every health and care system will be required, for the first time, to work together to produce a sustainability and transformation plan covering Oct 2016 to March 2021. Agreeing numbers for these plans provides a significant challenge for many health economies. As part of the Success Regime, NHS England, Monitor and the NHS TDA are working on a joined-up approach to providing challenge and support to enable both short term improments and longer term strategic transformation. Lord Carter's review of operational efficiency in the NHS The DH has summarised the findings of Lord Carter's review of operational efficiency in the NHS. Overall he concluded that the NHS could save around 5 billion a year by 2020/2021 by reducing variation in care and improving the way they care for patients. The review says hospitals must standardise procedures, be more transparent and work more closely with neighbouring NHS trusts. DH states that, for the first time, the activity carried out by all NHS hospitals has been reviewed together and broken down by clinical speciality. The results show huge variations in clinical costs, infection rates, readmission rates, litigation payments and device and procedure selection. In conclusion the review highlights the huge opportunity for hospitals to tackle these variations. Lord Carter and Professor Tim Briggs (newlyappointed National Director for Clinical Quality and Efficiency) have been visiting hospitals across the country as part of this review. The savings targets have been provided to trusts alongside a model hospital, highlighting best practice so local NHS leaders can mirror the best performers. Lord Carter will continue to engage with and support trusts to achieve the efficiency improvements they can make over the coming months. NHS Improvement will lead the implementation of the recommendations and Lord Carter will become a non-executive director of the regulator in April. Agency cap On 23 November 2015, Monitor and the TDA introduced a set of rules capping the cost of agency staff across the NHS. The aim of these caps is to help trusts manage their workforce in a longer-term manner by reducing the reliance on agency staff and increasing the level of permanent and bank staff that they employ. However, we recognise this is proving challenging for trusts to implement as some agencies are still providing staff at rates which are above these caps. While there are some ways to override the cap in place to ensure patient safety is not compromised, any breaches must be explained to Monitor or the TDA. Should either not be satisfied with the explanation regulatory action may follow, such as a requirement to improve the organisation's workforce strategy.
Rostering Linked to the issue around the agency cap is how trusts ensure they are undertaking staff rostering in the most efficient and cost-effective manner possible. Some of the challenges trusts face include ensuring the availability of permanent and bank staff is considered first, with agency staff only filling the gaps when no other staffing options are available. Trusts will also need to strengthen their ability to match staffing capacity to demand, so that when agency staff are brought in they are fully utilised. As well as getting the staff in the first place, compliance with the use of e-rostering is a major issue for many trusts. E-rostering can provide significant savings when used properly to effectively match the use of staff with shift requirements. Given the increased scrutiny of agency staff costs and the worsening overall financial position within the NHS, trusts need to make sure they have a strong grasp on this issue so that it doesn't adversely impact on the services they deliver. Junior doctors Junior doctors are set to take further industrial action as lack of progress in reaching a contract settlement with NHS Employers continues. Concerns continue to be raised over the cost of implementing a new junior doctor contract, with some estimates suggesting it could cost individual trusts more than 1m. The impact of industrial action on trusts, staff and the public alike include: cancelled non-emergency operations and reduced access to services increasing costs with further pressures on cost improvement targets impact on staff morale across all grades patient dissatisfaction and loss of trust and goodwill pressure on NHS s waiting time performance concerns over funding of contract costs if planning assumptions prove to be incorrect. Nurses remain the owners of their own revalidation process. Employers, however, need to consider how they can support nurses by raising awareness of the revalidation process and putting in place basic plans such as providing confirmers, reflective discussion partners and possibly linking the process to the annual appraisal process. Employers also need to ensure they have a process to confirm all nurses remain registered. Where a nurse s registration lapses, the nurse has to make an application for re-administration which can take up to six weeks. In that time the nurse cannot practise until their registration has re-commenced. Employers need to manage this risk by identifying when a nurse s registration is due to end and the potential impact on staffing levels, as well as having policies and processes in place to manage nurses whose registration has lapsed. Community services demonstrating their impact Community trusts (CTs) play a key role in enabling and driving new ways of working. For CTs, a major issue is demonstrating their impact. How do you demonstrate success when it is not measured by how many people have been treated, but by the number that are being kept out of hospital, remain healthy and active, and spend longer in their own home? CTs look towards admission avoidance indicators, but the shortage of measureable outcomes makes it difficult to demonstrate to communities and commissioners the impact the CT has on the local health environment. In a climate of ever increasing hospital visits and reducing budgets, they must work with other organisations to provide integrated care combining mental health, social and community services to be capable of spotting and dealing with a variety of problems at an early stage, delivering caring, high quality and efficient services to the needs of the individual, while also preventing duplication of visits from multiple agencies. However, this shared responsibility means demonstrating their impact remains a key challenge. Nurse revalidation From April 2016, nurses (and midwives) need to undertake a revalidation process to maintain their registration with the Nursing and Midwifery Council. Revalidation is required every three years to enable registration to be renewed. As part of revalidation all registered nurses need to complete 450 practice hours (900 hours if registered as a nurse and a midwife), 35 hours of CPD including 20 hours of participatory training, five pieces of practice related feedback, five written reflective accounts, a reflective discussion, a health and character declaration and a professional indemnity arrangement. Nurses need to demonstrate that all revalidation requirements have been met to an appropriate confirmer.
Mental health collaboration Inadequate support for people with mental illness has replaced the difficulty of getting a GP appointment as the public's main frustration with the NHS, research by Healthwatch England shows. Bed occupancy in inpatient facilities is frequently well above recommended levels and lack of beds is leading to a high number of non-specialist out of area patients which are costly and disruptive to family support. In February 2014, the Mental Health Crisis Care Concordat report 'Improving outcomes for people experiencing mental health crisis' recognised that the way in which health services, social care services and police forces work together, has a significant impact on the patient. It is widely acknowledged that close partnership working can prevent crises from escalating and significantly improve an individual's wellbeing and recovery. Appreciating this, a mental health commission has recently been established by the West Midlands Combined Authority and the region is currently at the forefront driving forward some exciting initiatives. We recently ran a mental health collaboration seminar in the West Midlands covering providers, commissioners, local government, police, fire and ambulance. We will be releasing our findings in Spring 2016. Contacts Alison Hughes James Cook Simon Hardman Healthcare Advisory Services T 0113 200 1533 E alison.m.hughes@uk.gt.com National Commissioner Lead T 0121 232 5343 E james.a.cook@uk.gt.com (North) T 0161 234 6379 E simon.hardman@uk.gt.com Peter Barber Darren Wells Terry Tobin (South West) T 0117 305 7897 E peter.a.barber@uk.gt.com (London and SE) T 01293 554 120 E darren.j.wells@uk.gt.com (Bulletin Editor) T 0121 232 5276 E terry.p.tobin@uk.gt.com 2016 Grant Thornton UK LLP. All rights reserved. Grant Thornton means Grant Thornton UK LLP, a limited liability partnership. Grant Thornton UK LLP is a member firm within Grant Thornton International Ltd ( Grant Thornton International ). Grant Thornton International and the member firms are not a worldwide partnership. Services are delivered by the member firms independently. This publication has been prepared only as a guide. No responsibility can be accepted by us for loss occasioned to any person acting or refraining from acting as a result of any material in this publication. www.grantthornton.co.uk