Next year’s planning guidance is an opportunity to reset the NHS

The NHS will be publishing two planning documents in December. Most attention is focussing on the long-term plan but the 2019-20 planning guidance will be just as important.

Flawed planning

Recent annual NHS planning processes have failed trusts. Despite working flat out and performing well, trusts have consistently missed the financial and performance targets they’ve been set.

Over a five year period, we’ve gone from the vast majority hitting all their constitutional standards and financial targets to only a handful doing so now.

Some would like to pretend this is because trusts haven’t been performing well enough or have been poorly led. In reality, they’ve been grappling with an unholy combination of rapidly rising demand, the longest and deepest financial squeeze in NHS history, and a once in a generation workforce shortage problem.

But recent planning processes haven’t helped. We’ve seen year after year of undeliverable financial targets, overambitious performance targets, and impossible recovery trajectories.

All based on over optimistic assumptions around demand reduction and efficiency. All of them missed. The result is a debilitating narrative of frontline failure that hits staff morale and the public reputation of the NHS.

The service needs time to work out how to implement the long-term plan, so 2019-20 will also be the year with the lowest level of new commitments and transformation requirements

Next financial year is therefore a pivotal moment. It’s the first year of a new, larger, financial settlement and the year with the largest percentage increase.

We’ve already agreed that the service needs time to work out how to implement the long-term plan, so 2019-20 will also be the year with the lowest level of new commitments and transformation requirements.

It’s therefore an ideal opportunity to break out of the current, ever worsening, cycle and start recovering financial and operational performance.

And the importance of that task has been massively heightened by the NHS getting the lion’s share of available extra public spending whilst others remain on a meagre diet. The NHS must be seen to deliver for this extra investment, in spades.

Essentials for trusts

What do trusts need from this reset year?

Above all, they need a set of financial and operational performance targets they can actually deliver. A set of targets based on realistic demand and efficiency assumptions.

Targets that honestly recognise where we will actually start 2019-20, rather than where we’d like to start from. Targets that take full account of current workforce shortages and are ruthlessly prioritised so that everyone knows where to focus when the pressure comes on and something has to give.

Trusts need a set of financial and operational performance targets they can actually deliver. Targets that honestly recognise where we will actually start 2019-20, rather than where we’d like to start from

Given how far trust finances and performance have fallen behind, recovery of financial balance and constitutional performance standards is a multiyear task.

The planning targets of 2019-20 must therefore be set in their proper context, so everyone can see that the tide of ever worsening decline has been halted and is starting to reverse but that full, universal, recovery will take considerably longer.

Other requirements

Trusts need four other things.

They need a strategy to rapidly address current workforce shortages, exploring incentives to encourage those who have left the NHS to return to work, and temporary expansion of the number of staff coming from overseas.

We should also look at how to quickly give other staff groups the clinical permissions that can currently only be held by registered doctors and nurses. And we also need to address current pension cap problems that are driving senior experienced staff out of the service.

There is a gravitational pull in the NHS towards acute services so it’s vital the 2019-20 planning guidance strikes the right balance between acute, ambulance, community and mental health services.

That means further steps to ensure that extra mental health investment actually reaches the frontline and a review of whether the amount of current earmarking for new priorities is excessively skewing local clinical priorities.

We need to assess the idea developed by the new Community Network for a community services and / or frailty investment standard. And we need to ensure that, where needed, the adequacy of local ambulance capacity is objectively reviewed.

The 2019-20 planning guidance also needs to help trusts start preparing for long-term plan implementation. We already know there will be a major focus on digitising the NHS, improving prevention and driving efficiency.

National system and trust leaders must use 2019-20 to lay foundations in these important areas so we can start fully implementing the long-term plan at pace from 1 April 2020.

The 2019-20 planning guidance also needs to help trusts start preparing for long-term plan implementation

And we already know that NHS winter performance between December 2019 and April 2020 will largely determine whether 2019-20 is seen as a successful year for the health service or not.

Planning for a winter that will not start for another 13 months may feel difficult and counter intuitive, and we will want to learn lessons from this year. But trusts need clear top level plans for winter 2019-20 in the guidance.

Next year will be much more difficult and financially tight than anyone is currently publicly admitting. That, finally, provides a clear warning to those drafting the long-term plan.

If we’re struggling to make 2019-20 add up, we should be very careful about how many new commitments are made and how much transformation is expected before trust finances and constitutional performance standards have been fully recovered.