Recovery Watch: The return of DToCs

NHS England’s long-awaited “phase three letter” calling for non-covid health services to return to “near-normal” performance before winter was published on Friday. And the well-rehearsed planning guidance dance swiftly followed (don’t lie, I know you all know the moves):

Pick any guidance you fancy in the last five years and you will see a similar sequence of events: the centre sets out a variety of super-stretching targets and trajectories designed to return the system back to parity; local leaders warn they are unrealistic; the targets are duly not delivered.

By way of example, the 2018-19 guidance said the NHS would be expected to hit the four-hour standard “within the course of 2019”. In December 2019 every major trust missed the target as performance plummeted.

So, it wasn’t a great surprise when both NHS Confederation and NHS Providers swiftly raised concerns about ambitions set out in the letter titled Third phase of NHS response to covid-19. The guidance has also appeared far later than expected with many of the goals set out required to be met this month, which is far from ideal (see box: Key phase three targets).

The premise of the guidance is sound enough. It says the system must take advantage of a “window of opportunity” in the next few months to try and re-boot core services before the first covid winter — a season which could bring huge pressures and may see electives wound down again.

Where local leaders disagree with the centre is on the level of recovery achievable within that window, given the significant practical constraints imposed by covid means services are having to be run at significant reduced capacity. Trusts are grappling with how to best separate clean and dirty services, the time and labour-intensive cleaning regimes required, staff constantly donning and doffing personal protective equipment, and other covid hangovers.

The money

The letter promised a new deal for private healthcare providers, and changes to the NHS block payment model which kicked in when covid got serious. However, while the bones of both of these policies are set out (moving to a slightly bigger system role in both cases) the detail is not — as the new arrangements are not actually finalised.

There is a suggestion that trusts will see their block payments docked if they don’t hit the recovery targets above: A recipe for new tensions as people try to nagivate system arrangements and access to the independent sector.

Notably on that front, an earlier proposed move by NHS England to introduce shared waiting lists across whole systems does not appear in the guidance which simply makes the broader point that “elective waiting lists and performance should be managed at system as well as trust level”.

But whatever the settlement, getting anywhere near most of the targets would require a monumental effort and a fair wind, the like of which is unlikely to materialise.

Other significant financial news in the letter was confirmation that NHS England sees its funding settlement for the remainder of 2020-21 as unfinished business with the Treasury. It says government has yet to sign off on the new finance arrangements, and it appears to be holding out hopes for money for extra capacity later in the year.

Negotiations are understood to be fraught and not expected to be finalised for at least another month. As NHS Providers chief Chris Hopson noted, it is hard to really draw a full conclusion on the guidance until the revenue settlement for delivering the latter part of the plans is known.

An old discharges headache comes back

The government’s decision to re-introduce Continuing Healthcare assessments from September 2020 has not gone down well at a local level. Thousands of patients seeking care between 19 March and 31 August have been funded by the NHS without assessment. From next month they will now “need to be assessed and moved to core NHS, social care or self-funding arrangements”.

But trust leaders have raised concerns delayed discharges could rise back up – an area where huge change has been seen since March. That should be mitigated by confirmation of ongoing funding for discharge-to-assess, in which the NHS will pay for care for six weeks after leaving hospital, to smooth flow; which is better than now.

The return of the absurd CHC process — which discriminated between those with ongoing cancer care needs and dementia — was perhaps inevitable in the circumstances, but remains a damning indictment of governments’ failure to fix care funding. 

Putting ICSs on a statutory footing ‘by the backdoor’?

On the structure front, an HSJ reader suggests the phase three guidance, by stating there will “typically” be a single clinical commissioning group in each integrated care system, puts ICS on a statutory footing “by the backdoor”.

It is in fact very similar wording to 2019’s NHS long-term plan, but supports the expectation that, in the wake of the pandemic response, 2021 will see further major consolidation of commissioning groups. In terms of integrated working, the phase three letter in fact goes a little further than the long-term plan in other areas, requiring: “Clearly defined arrangements for provider collaboration, place leadership and integrated care partnerships.”

Mental health services bracing for a surge

The letter also sets out the short-term priorities for mental health services, setting out proposals on IAPT, crisis, children and young people services and those already suffering from a serious mental illness.

The sector is of course bracing itself for a further significant surge in mental health needs. The implications for mental health services will be explored in greater depth in our next Mental Health Matters briefing.

• GPs asked to keep doors open after ‘significant incidents’ warning
• Trusts given five years for leadership to match workforce diversity