What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West
After the reset
The announcement of the NHS’s first outstanding and inadequate clinical commissioning groups last week saw an anachronistic ratings regime bent by officials as far as they could manage to support their two pressing objectives: system planned service change, and regaining financial control.
For commissioners, the glare of the “NHS reset” was put on groups at the sharp end of financial trouble – with a set of CCGs placed in the latest iteration of NHS England’s ad hoc “special measures” regime and told they will receive heavy intervention.
In classic NHS England style, the details of the interventions had not, as of Tuesday, been communicated to the groups other than via HSJ and press releases.
But the emphasis in them is clear, and is squarely on trying to strengthen strategic planning across larger systems. Two CCGs will, it is implied, become part of some form of “structure”. Two are instructed to share management with neighbours, which could well lead to merger. Other CCGs in special measures suspect that, though it’s not yet been directed, a similar fate is in store for them. What has not yet been achieved – but is reiterated in the reset document – is the centre’s desire to hand some CCGs’ jobs to accountable providers or to local government.
For commissioners, then, the reset was a relatively successful hijacking of an organisational assurance process to cement the message that it is the system, not organisations, which comes first.
On some patches whole system planning is now becoming real, despite the legal and structural framework. A number of local leaders I’ve spoken to in recent days and weeks have happily declared that the transactional, organisational era of the past few years is dead and buried.
The upshot for NHS providers from the reset, though, is somewhat different. It has added to the sense of increasing intensity, and desperation, about containing trusts’ deficits.
That is partly because it is clear that the cupboards at the Department of Health, and of commissioners, are now bare – bar, that is, the £800m stockpile withheld from commissioning budgets and under control of the Treasury.
With the provider side already at least £330m short of plan, 23 trusts refusing to agree control totals, and several chief executives insisting that they can’t make further clinical workforce savings, it looks likely that a good chunk of that reserve fund will indeed be required for plugging deficits. The prospect of failure at the national level to overshoot spending controls for a second year running – and the existential questions which might flow from that – shouldn’t be quickly overlooked.
Heads and beds
The task now being put in front of local system leaders is to marry their plans for moving to financial balance – expressed in nascent sustainability and transformation plans – with operational reality.
Jim Mackey and Simon Stevens have had a busy July, making panel interrogation visits to leaders of the 44 STPs. The instruction commonly being issued is to translate the emerging proposals into clear actions with a quantified impact on “heads and beds” – ie: workforce and acute capacity – to be submitted in October.
According to the centre’s timetable, these will feed directly into two year operational plans and contracts – meaning the often negative consequences for individual organisations will also be spelled out – and agreed by Christmas.
The hope in the centre is that breaking the NHS’s annual planning cycle will also help break its habit of failing to deliver on well meant strategies for change.
The question staring everyone in the face is how this will square with reality – the same reality being experienced by the trusts that have explained they can’t cut capacity or workforce spending amid growing demand.
- Senior commissioning leaders are invited to our Commissioning Summit event in September – a high level forum for debating how commissioning should develop, delivering STPs, and the financial climate. Confirmed contributors include Simon Stevens and NHS England’s new director for commissioning operations and informatics, Matthew Swindells, and Alberto De Rosa, chief executive of the Ribera Salud Group in Spain, whose model of accountable, integrated care is widely praised internationally. Get in touch via the website.
The Commissioner’s reading list
A weekly pick from the barrage of publications, articles and tweets which may interest commissioners:
- Interactive map of the first “Ofsted style” ratings for CCGs. Congratulations to the outstandings, it wasn’t easy to achieve.
- The NHS has been left with no financial wriggle room − a succint piece outlining the gap this year from the Health Foundation and King’s Fund finance gurus, Anita Charlesworth and Richard Murray. Also well worth reading are Anita’s past pieces on the workforce issues underlying the overspending woe.
- Rebecca Rosen, GP in Greenwich and senior fellow at the Nuffield Trust, has written about the Nuffield’s new report on large scale general practice.
- Fund community interventions to improve population health, so says Emily Crawford of the think tank ResPublica, responding to the new prime minister’s indication, in her first speech in post, that she is concerned about health inequalities linked to deprivation.
- NHS England forecasting first ever overspend – the new financial reality on the commissioning side.
Dave West, senior bureau chief