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NHS England plans to lead 'radical' service change

NHS England is planning to continue the health service’s current savings drive after 2015, and to recast it as a programme of “ambitious and radical” service change led by its area teams.

The organisation, formerly known as the NHS Commissioning Board, will extend the quality, innovation, productivity and prevention savings programme beyond its current April 2015 end date, which is also the end of the current spending review period.

In an exclusive interview with HSJ, NHS England policy director Bill McCarthy revealed it was drawing up plans for the programme to focus in future on large-scale service reconfiguration, rather than on smaller incremental savings schemes.

Unlike the current QIPP programme, which was initiated by the Department of Health, the next phase will be developed and led by NHS England. The current programme is intended to generate about £20bn of NHS efficiency savings over the four years to April 2015.

However, Mr McCarthy told HSJ the bleak outlook for public finances beyond 2015, and the fact that the NHS was already relatively efficient by international standards, would force the service “into the direction of strategic change”.

He said “year after year whittling away of unit cost” did not “seem to me to be an answer to the challenges we’re facing”.

After the current comprehensive spending review period, “we’re going to have to be more ambitious and radical in the way we look at service change”, he continued.

NHS England is also in the process of drawing up a 10-year strategy for the health service.

Mr McCarthy said: “It will be surprising if that didn’t [also] lead us to a place where we’re [taking] some views, or decisions around configurations of services into the future.”

He added that NHS England’s 27 local area teams would drive reconfigurations, working within a national framework developed by the organisation.

This could include leading public consultation processes and coordinating input from clinical commissioning groups.  Area teams will also ensure CCGs’ own service change and QIPP plans do not contradict one another.

He said: “We are all one organisation, and the benefit of NHS England happens locally. That’s where we’re improving outcomes for patients, engaging the public, and collaborating with local authorities and other partners.

“What we’re doing [centrally] is putting a consistent frame around that. The implications for that are for area teams to work with partners… and come up with the priorities for the change that will make the most difference in Newcastle as opposed to Oxford, for example.”

NHS England revealed in its business plan last week that it was drawing up a framework for “major service reconfiguration”. Mr McCarthy said the framework would be “fairly fundamental” to the future of QIPP.

The reconfiguration framework will be developed over the coming year, and will set out the roles of different commissioners in planning service change. Mr McCarthy said it would also give a clear signal to providers about how they should prepare for service changes, for instance giving indications of where they should or should not be making capital investments.

HSJ understands local area teams are already beginning work on reconfiguration, with a view to consulting on proposals in 2014 so savings can be made after 2015.

Charles Alessi, chair of NHS Clinical Commissioners, said: “I’ve got no problem with local area teams leading, but they need to understand what leading is. Leading does not mean telling people what to do. They should be convening, encouraging and educating [other players in the local health economies]. It’s an enabling role, rather than a dictatorial one.”

Mark Hayes, chief clinical officer of Vale of York CCG, said in his area CCGs were directly involved in reconfigurations.

And he added that local area teams “did not have the capacity or the contractual levers to force a foundation trust to do anything they don’t want to do”.

QIPP monitoring to be ‘lighter touch’

NHS England is to adopt a “lighter touch” approach to monitoring the quality, innovation, productivity and prevention programme in 2013-14, HSJ has learned.

Instead of the detailed monitoring of local QIPP milestones seen in 2012-13, this year local area teams will be checking clinical commissioning groups have a savings plan and that they have a project management structure in place to deliver it.

CCGs’ overall plans will be rated red, amber or green based on whether they are realistic and the extent to which they are being achieved.

Local area teams’ own QIPP plans will be similarly assessed by NHS England’s four regional teams.

HSJ has also learned that in many areas CCGs are signing off their provider trusts’ cost improvement plans.

Commissioning sources said CCGs were in effect taking more responsibility for ensuring providers’ savings did not harm service quality than local commissioners had done previously.

The move away from monitoring each individual local QIPP savings scheme was welcomed by one local area team director, who told HSJ that NHS England was not resourced sufficiently to micro-manage CCGs. “The degree of detail we had to produce in the QIPP plans last year was just frankly ridiculous”, he added.

Readers' comments (35)

  • Very welcome development and indeed, the only way we can manage post 2015. However, the current system construct of FTs, tariff etc does go against this grain somewhat. Macro planning against micro-delivery models. Intellectually incoherent, at best

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  • Coordinating plans makes sense but I thought the whole purpose of the reforms was to have GP lead commissioning and through that the decisions and strategy for service reconfiguration.

    Not sure where the mandate for centrally driven reform is derived in that legislation.

    But like many NHS England intiatives it seems the legislation is ignored in favour of central power retention to control all.

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  • It's been glaringly obvious for years that this is the only sensible way to go. A QIPP approach which focused on savingas on a single year by single year basis was short-sighted and unlikely to drive the majopr changes needed. Ministers and Treasury will need to hold their nerves and their press offices and accept that if you want big change (and big bucks) you've got to look beyond the constraints of indvidual financial years.

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  • I work in a non-FT so forgive my ignorance but don't FTs have certain core services that they are bound to provide under their Monitor licences. What happens if NHS England wants to reconfigure these?
    Also, whilst I would love to overcome the frustration felt in many parts of the NHS over recent years around constructive radical service reconfigurations aimed at driving up quality standards which have failed to be implemented, the reality seems to be that it is increasingly difficult to align all the stakeholders and satisfy the choice and competition police in order to do this.
    I wish NHS England Good Luck!

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  • Sounds promising but with every area team in meltdown and primary care contract management having stopped overnight due to lack of policy or direction, shouldn't that be the first priority?

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  • Nusrat Latif

    Long term financial planning.

    Finally.

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  • Certainly centralised planning for the equitable coverage of health care is long overdue. No CCG, or CCGs working in collaboration, would be able to make this sort of change without centralised direction.
    BUT any changes need to be made on the understanding that a reasonable level of patient accessibility is assured. There is no point at all in reconfiguring services to such an extent that they become too remote for the poor, the elderly, the ill, the disabled, the double-buggy users etc to access. For these groups, centralised planning could be disastrous.

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  • Well dont be shocked when allthe CCGs walk away and say lets not bother.Weve got Area Teams behaving like SHAs, a central dictat for reconfiguration, and no evidence of support for primary care to fundamnetally change their way of working.

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  • Steven Burnell

    I am a great believer in the NHS being based more on design that piecemeal evolution, but in the current circumstance my preference would be for NHS England to focus on just 2 big important priorities:
    1. Help build & protect a strong, open culture based on positive values as these naturally encourage good things to flow to improve performance & eject bad practices & poor ethics.
    2. Rethink mechanisms such as Tariff & Targets so that service providers see them as supporting greater collaboration, rewarding upstream investments, & the provision of seamless, integrated care pathways.
    I would suggest that these 2 things together will be more powerful, effective, & longer lasting than any centrally imposed transformation plan, no matter how well conceived or robustly enforced.

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  • It is true that Lansley's structural reforms have been largely negated by NHS England and LATs. It was also entirely necessary. The sad thing is billions have been wasted throwing the pieces up in the air and then putting them back together again.

    Service change is essential and has to be led from somewhere if the NHS is to survive and improve. CCGs are not big enough and don't have the reach - reconfiguration is likely to cover larger areas than CCGs do - and if their solution is to walk away, they will go bust before long in a system that is not clinically or financially sustainable.

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  • sjburnell@focused-on.com | 17-Apr-2013 1:36 pm

    Spot on. Especially re openness and transparency and good culture. Some are trying hard but as far as I can see too many organisations just dont seem to be able to throw off old habits. Its the workforce that will make this work. Good leadership must win its trust before it can mobilise it. Or it wont work

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  • The logic is sensible, but the degree of management resource needed to manage a major reconfiguration (see the 10 years for paediatric cardiac surgery) is not reflected at all in the management structures of area teams. There is no programme and project management, inadequate and distant communications, ditto information and analyst capacity.

    If such a programme is properly managed and resourced fine, if not then lawyers should put the deposit down on new ferraris as business is looking up

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  • Given the volume of secondary legislation arising from the Bill, I have a more direct question. What plans, if any, do Ministers have to make this easier through changes to the law?

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  • Clive Peedell

    Seems like most commentators here have not read or understood the S75 regulations, which are being debated in Parliament on the 24th April. How can you plan a service in a top down way, if CCGs are forced to put virtually all services out to tender? The legislation enshrined within the Health and Social Care Act cannot be ignored, and it sets the framework for a market driven system, not a planned system

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  • Thanks Clive, that's cheered me up no end! This is all utterly, utterly frustrating. How are we to have integration and collaboration in a market system where plurality of provision and AQP contracting is just going to further fragment service provision and make multi-agency co-ordination ever more complex and difficult? I seriously wish I was nearer to retirement as I can no longer get my head round the competing forces that seem to pull us in all directions. However, I have very low expectations about the range, quality and accessibility of services that will be available as I enter old age!

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  • Surprisingly I find myself disagreeing with SJBurnell (nice ideas, but the big challenges are too 'here and now' for the moore philosophical approach) and agreeing with Clive Peedell.

    The S75 regularion has the potential to more or less neuter effective strategic planning. It's what La la and the various hardline marketeers on the right wanted, since that mode of thinking feels the market will determine all. It won't, of course. Masses of individual market exchanges can never drive long term change in healthcare by themselves. It needs collaboration and co-operation and long term vision. But these need to start now, and Se&% could tie everyone up in competitive knotes and paperwork, sapping innovation, energy amd time.

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  • Members of the public should really know what both commissioners and providers measure to determine performance and quality.Many would be shocked and dismayed how many national, regional, local, internal KPIs exist which aren't grounded nor aligned to commissioner priorities nor reported properly. That needs to change and simplify. It is absurd how many change and reconfiguration programmes exist and are implemented without any evaluation or benefits realisation or ROI analysis reported. Perhaps because they are poorly thought through or shifting problems elsewhere. No other business could operate with such an incredible amount of waste in the system, extremely poor processes, and the appallingly neglectful approach to reducing this waste where it matters. No business would stay afloat unless the budget balanced and decisions were made by people who knew what they were doing. No amount of reconfiguration or a more strategic approach will make much difference if the basic housekeeping of a complex organisation is not clear, simple, and functional. Your guitar will sound rubbish if it is out of tune irrespective if you're an expert and have six strings.

    I don't usually comment on here, but I fear the NHS is becoming more dysfunctional every day until someone steps up (or down). There are plenty of leaders within the service/system with the skills to get our NHS organised and coherent - But they are getting fed up and some have already taken money and gone. Culture is a major problem too - the more senior and experienced should learn to listen. There are very few 'teachers' who develop talent and mentor junior clinicians and managers. Until all these things are considered important enough to do something positive about them, we will only continue going in circles and maintaining services for patients, rather than what we should do which is develop simple, smart and polished ones that positively impact on patient care and our society.

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  • In my part of the world clinicians seem to be leaving the CCGs - 3 more announced in the local press today. The press reports they are leaving "to spend more time with their patients." Or, is it because they fear they will have limited influence when it comes to reconfiguring services when compared with the might of NHS England or otherwise spend all of their time reviewing glossies from private providers in competitive tendering......but didn't we know this from the very beginning?!

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  • The focus has to be on improving public health so that people live healthier lives that need fewer health service interventions. This would divert resources away from secondary and tertiary care into primary care - perhaps based on a systme to fregular halth checks (lets face it, we are expected to go at least annually to the dentist or optician, but not for physical or mental health checks,whats that about? A lot of conditions could be nipped in the bud if caught early through regular check up and changes to lifestyle).

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  • Anonymous | 18-Apr-2013 1:18 pm

    Fair point, but, it takes years for the prevention interventions to reap their rewards. i agree that they do in the long run, but the funding flows are agreed now, so initially you have an element of double costs, treating those for whom the preventative services were too late as well as funding the preventative services to prevent the population becoming ill years down the line.

    The economic crisis is now!

    The whole new health bill was about local decision making, but lately it seems that NHS England wants to control everything. I agree that major service change should have a national steer otherwise we will end up with a postcode lottery as we did with fundholding, but CCG's need to be allowed the freedom to make local decisions not be dictated to.

    I wholly welcome long term financial planning and cannot underestimate the massive change that this will bring. Short term planning has historically been one of the reasons why whole scale has not taken place. In adition I would also welcome planning cycles NOT coinciding with general elections so that the short term future of the NHS becomes a party election tool. If long term (10 years) planning is really going to become a reality then we should start to see freedom from political motivation (to a point!)

    Ramble over.....

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