NHS chief executive David Nicholson's exhortation to look out to communities, not up to the DoH at Richmond House, is starting to look like lip service, given the new operating framework's raft of extended targets, writes Sally Gainsbury

'Stop Kremlin watching. Look out to your communities, not up to Richmond House,' NHS chief executive David Nicholson has been fond of saying to the NHS over recent months. It has been a slogan popular with the NHS, simultaneously tuning into the aspirations of trusts gearing up for foundation status and primary care trusts working on bringing care 'closer to home'.

That was the rhetoric. But according to the NHS Confederation, it does not fit the reality, particularly not the reality of the year ahead as laid out in last week's NHSOperating Framework.

'It's look out and up,' PCT Network director David Stout tells HSJ. 'So far I have counted 60 instructions to PCTs, and some of those are instructions which have other instructions within them. There is a denial that these are top-down targets, but that doesn't stop them being so. It does not sit well with a localised approach.'

The potential for 60 or more new or extended targets did not even include a full list of the indicators - called 'vital signs' - against which PCTs and other NHS organisations will be judged next year. HSJ understands the list was detached from the document a day before its publication, but the final version said only that the vital signs will emerge from the Department of Health 'soon'.

The framework did explain that the vital signs would be divided into three parts. The first will be national 'must dos'. Most controversially, these include an instruction to all PCTs that at least 50 per cent of their GP practices must offer extended opening hours.

The second sub-set will be made up of national priorities which by implication will need to be acted on by all, but to differing degrees and with varying intensity, depending on where they are starting from. These priorities include a pick of some of the issues - such as mixed-sex accommodation and learning disability services - that have occupied the health and spending watchdogs over the last year, fuelling newspaper headlines decrying localism's uncomfortable bedfellow, the postcode lottery.

Summaries of those first two sub-sets of the vital signs run breathlessly over the opening 13 pages of the framework before PCTs are told that 'beyond this [they] should develop local priorities based on what their local communities tell them is important'.

Justifiable concerns

A flip to the back of the document confirms that a further 20 pre-existing national targets remain in place.

Mr Stout argues: 'It's perfectly reasonable to measure performance on a set of agreed measures to ensure public accountability, and most of these are good things for the NHS to do. But it's how they then get used for performance management that is the problem. That's where the impact of targets becomes particularly unpredictable. They can have unintended consequences when people start chasing the target rather than the initial point behind it.'

Not everyone disagrees with the emphasis on national targets. King's Fund chief executive Niall Dickson says: 'It is right that the government should set national priorities and right, too, that it should maintain the assault on hospital infections and the drive to cut waiting times. These are areas that patients are justifiably concerned about and it is imperative the NHS makes progress in them.'

But Mr Stout says he is concerned about how the targets implicit in the framework will feed into the Healthcare Commission's health check ratings. In turn, he asks how that will relate to the assurance framework being developed around the DoH's world-class commissioning drive. Its aim is to create some real 'carrots' - such as earned autonomy from inspectors - for high-performing PCTs. But it will be hard to measure well-performing PCTs if they are all pursuing different, locally determined targets. The pressure to supplant local priorities with more easily measured national ones could become even greater.

But it is not just PCTs that are worried about the reassertion of central targets. NHS Confederation policy director Nigel Edwards says the framework read like 'a large shopping list for PCTs to take to their acute trusts'. However, with the payment by results tariff to increase by just 0.2 per cent above inflation, acute trusts will struggle to meet the requests. The framework contains a number of financial penalties PCTs can use to back up their demands, for example by docking up to 5 per cent of contract income for breaches of the 18-week target.

Shadow health secretary Andrew Lansley says such penalties would only serve to 'demoralise staff and make the NHS less responsive to the needs of patients'.

Mr Stout argues that their significance could be overestimated but there was one penalty he would have liked to have been stronger. From April, PCTs will be able to delay paying up to 10 per cent of a bill for hospital treatment until they are given the full documentation relating to the procedures carried out. That follows a growing volume of disputes between NHS organisations over the accuracy of bills levied by trusts under the payment by results tariff.

Mr Stout says that should help prevent PCTs being presented with large, unanticipated bills, which will improve their ability to plan as well as supporting practice-based commissioning. But PCTs would have preferred to have been given the option to withhold payments altogether and are sceptical as to the impact temporary payment delays will have.

Fears over problems with financial planning were also confirmed. As announced by health secretary Alan Johnson in November, PCTs have only been informed of their funding allocation for 2008-09 as the allocation formula used to determine how funds are distributed is still under review. While the framework detailed that that would mean an extra 5.5 per cent before inflation for each PCT, it also told PCTs to continue to sign off standard three-year contracts with trusts and other providers by March 2008, despite not knowing their funding.

But for the minority of NHS organisations in real financial difficulty, the framework offered hints of a reprieve. Although the NHS as a whole reported a surplus in 2006-07, 55 individual PCTs ended the year in deficit, with their total overspend reaching more than£600m. Many of those will have now resolved their financial difficulties but the framework says that for those that have not, 'the [general] requirement will be for strategic health authorities to have resolved all outstanding legacy debt in PCTs by 31 March 2008'.

Andy McKeon, managing director of health at the Audit Commission, says the framework implies that in some cases SHAs were being given permission to redistribute surpluses generated by the SHA itself, to balance the books of their most beleaguered PCTs. As for 'financially challenged trusts', the framework gave another 'strong reminder' that the DoH will be looking for more successful organisations to take them over, says Mr McKeon.

There were hints elsewhere that after a period of market instability and competition, the DoH could be moving away from the view that contestability is a good thing in and of itself. 'The NHS is not a collection of separate and autonomous units of varying degrees of independence, responding to the invisible hand of the market and incentives and reforms,' the framework states. 'It is, in fact, a healthcare system requiring active management by both PCTs and SHAs.'

Yet 18 months after the issue first caused controversy, the framework returns to tackle direct service provision by PCTs, instructing them to review their arrangements and consider 'all options for models of provision'.

Space and headroom

The reviews will be aided by the launch in March of a web-based tool to help PCTs and SHAs decide 'whether and how to increase diversity of supply to support patient choice or provider responsiveness'.

All that suggests there is still plenty more to come from Richmond House. Nigel Edwards says the rub lies in how the framework will relate to junior health minister Lord Darzi's next stage review - due to be published in the summer.

'The framework becomes current from April onwards, and in early July or late June Darzi will produce his review. So where's the space and headroom for that? Are we to assume we're not going to have to do anything he says next year or that he's just going to say everything we're doing is already fine? Are we going to be able to say: "That's very nice, but we're a bit busy at the moment"? That's a bit unlikely.'

Another clue that the DoH will publish further targets and initiatives just a few months into the next financial year is that, once inflation is accounted for, the PCT funding increase this year is around 3.4 per cent - more than half a per cent less the overall increase awarded to the NHS in October's comprehensive spending review.

'So they will be sitting on some spare cash to pay for Darzi and that means there will be a whole load of extra things we'll be asked to do in the summer,' Mr Edwards said.

It seems the smart idea may be to keep at least one eye on Richmond House after all.

Targets: five 'must do' areas to improve

  • Cleanliness and HCAIs

  • 18-week target and extended GP opening hours

  • Public health and health inequalities

  • Patient experience, staff satisfaction and engagement

  • Emergency responsiveness - pandemic flu and terrorism

National priorities

  • Equality and vulnerable groups

  • Mixed-sex accommodation

  • Learning disabilities

  • Diabetic screening

  • Mental health crisis resolution

  • Access to psychological therapies

  • Dementia services

  • Palliative care

  • Disabled children

Debts and savings

SHAs continue to be able to determine the level of contingency necessary for their local area through topslicing.

The 2007-08 underspend will be carried forward and SHAs should plan to produce a surplus in 2008-09 'at least' equivalent to that of 2007-08.

All PCTs have received the same increase to their allocations of 5.5 per cent before inflation. The payment by results tariff for acute trusts will increase by 2.3 per cent. All NHS organisations are expected to make 3 per cent cashable efficiency savings.

SHAs should ensure outstanding 'legacy debts' in PCTs are cleared by March 31 2008, or the following year in 'exceptional circumstances'.