In this feature, Thoreya Swage, Healthcare Consultant, describes the NHS Planning Guidance which will be operating over the next two years.
In September, NHS England and NHS Improvement jointly published the planning guidance for the NHS, NHS Operational Planning and Contracting Guidance 2017–2019. This guidance differs this year as it sets out the expectations over the next two years (normally, it covers just one year) and has been published three months earlier than usual to allow health systems based on the Sustainability and Transformation Plan (STP) footprints enough time to plan and agree their strategies and contracts for the future.
What are the aims?
The key aim of the planning guidance is to continue the implementation of the Five Year Forward View by promoting improvements in health and social care, achieve and maintain financial balance and ensure that the core access and quality standards are delivered.
The main vehicle of the NHS planning process is now through the STP which emphasises partnership working as the preferred behaviour. It is no longer tenable for individual organisations to ignore the needs of patients, communities and systemic care pathways to focus on their own interests.
What are the priorities?
Nine “must dos” have been identified. These are areas that were first highlighted in the planning guidance last year and continue to be a priority over the next two years. In summary, they include the following.
Continued development and achievement of milestones of local STPs.
Achieve financial controls and put in place more efficient processes.
Implement the General Practice Forward View.
Deliver urgent care and seven-day working.
Deliver referral to treatment standards.
Deliver cancer referral to treatment standards.
Implement the Mental Health Forward View.
Enhance care for people with learning disabilities.
Improve quality of care in organisations that are in special measures.
Implementing the General Practice Forward View
The guidance sets out the requirements for the General Practice Forward View plan to be submitted by clinical commissioning groups (CCGs) by 23 December 2016 covering the following areas for investment:
plans for the deployment of online general practice consultation software systems (nationally £15 million is available for 2017–18 with a further £20 million in 2018–19)
training for care navigators and medical assistants within practices (nationally £10 million is available for 2017–18 and a further £10 million in 2018–19. £5 million has already been allocated for 2016–17)
the resilience programme to support struggling practices (nationally £8 million has been made available for both 2017–18 and 2018–19 with £16 million already allocated for 2016–17)
improving access to general practice services
estates and technology transformation (bids were invited during 2016 for this fund).
In addition, there are one-off funds held nationally for targeting the following areas:
increasing the number of GP trainees funded by Health Education England
nationally procured general practice IT systems
greater funding for GP screening and immunisation services
an extra 3000 mental health therapists to be based in general practice.
Evolution of commissioning
The planning guidance takes into account the changing functions of CCGs by noting that over half of CCGs now have delegated responsibilities for commissioning primary care, with the expectation that all will have that responsibility by the end of 2018–19.
There is a requirement for CCGs and local authorities to agree a joint plan for use of the Better Care Fund (BCF) through the medium of the Health and Wellbeing Boards for the next two years, basing this on the outcomes of the BCF plan for 2016–17. A key target for the BCF plan is to describe how unplanned admissions and hospital delayed transfers of care can be reduced.
Another area where the role of the CCG is evolving is in the context of the new models of care. Here, the boundary between the role of the CCG and the integrated care organisation will change leaving the CCG to continue executing the many functions of commissioning, ie setting local priorities, providing funds, overseeing contracts and ensuring best value for the taxpayer within the resources available.
In addition, CCGs will be required to continue to develop new models of care within the context of the STP and determine how this will be converted into contracts. A key element will be the development of multispeciality community provider (MCP) and primary and acute care systems (PACS) models of care. If the new models include services that have previously been delivered by hospitals revised contracts will need to be negotiated with these providers.
To support the longer term view of care redesign as highlighted in the STPs, contracts for healthcare will be for two years rather than one as they are currently. In addition, in order to provide certainty about the type of care, commissioned contracts are now required to be signed by 23 December 2016 — three months earlier than in previous years.
The STPs have funding to support the changes that are being proposed in the core priority areas of cancer care, mental health, primary care and technology over the next five years starting in 2016–17. Providers will be able to access the STP funding if they meet their control totals and any associated conditions.
For primary care around an extra £8 billion will be allocated in 2017–18 and £8.3 billion in 2018–19. In addition, CCGs are required to spend around £3 per head from their existing allocations to support general practice transformation as set out in the General Practice Forward View.
Diabetes has a boost with the NHS Diabetes Prevention Programme run by Public Health England to be rolled out across practices over 2017–2019.
This initiative offers advice on improving dietary intake, achieving weight loss and increasing physical activity programme for people at high risk of developing type 2 diabetes. A key part of the programme is the NHS Health Check that is offered to 40–74 year olds by general practices.
For people who have diabetes CCGs will have the opportunity to bid for extra funding to improve the uptake of education and to have greater access to specialist in patient support and to a multidisciplinary foot care team focusing on diabetic foot care.
System control totals
Although each commissioner and provider has agreed a budgetary total which they will not exceed with NHS England and NHS Improvement respectively, the guidance emphasises the need of whole health systems based on the STP to agree and achieve a system wide control total. This should be the sum of the control totals of the individual organisations within an STP area.
The aim of this requirement is to facilitate the development of planning and care across boundaries, to reduce risk and to reduce individual organisations from focusing on their own financial situations at the expense of others in the system.
Managing the performance of the health system
In response to the move towards managing health systems, the performance of commissioners and providers have been brought into alignment with the CCG improvement and assessment framework for CCGs and the Single Oversight Framework for providers.
The CCG improvement and assessment framework
The CCG improvement and assessment framework is designed to help CCGs deliver the Five Year Forward View taking into account system transformation. Although it is a tool that will be evolving the indicators that measure performance are located under four key domains and cover six clinical priority areas. The four domains are the following.
Better health — this focuses on improving health and wellbeing of the population.
Better care — this is centred around the redesign of care, attainment of the NHS constitutional standards and outcomes including maternity, mental health, learning disabilities, dementia and cancer.
Sustainability — this assesses the achievement and maintenance of a financial balance and ensuring value for money in the use of public funds.
Leadership — this assesses the quality of the leadership of the CCG, how the organisation engages with its partners, the quality of the plans and governance arrangements to ensure probity and that there are no conflicts of interest.
The six clinical areas are maternity, mental health, learning disabilities, dementia, diabetes and cancer care. The clinical indicators and ratings are overseen by independent groups led by experts eminent in the relevant area.
CCGs are assessed and rated according to one of four ratings; outstanding, good, requires improvement or inadequate.
Depending on their assessment rating, CCG will be offered different levels of support.
Support that is forward-looking — this provides a picture of what “good” and “excellent” look like plus practical support to help the organisation achieve this.
Support that is facilitative — this focuses on issues around delivery and guides the CCG back to the appropriate performance level.
Support that is bespoke — this is targeted support in one or more areas of poor performance particularly in matters that are chronic or persistent. This is designed for the most challenged CCGs.
Single Oversight Framework for NHS providers
The Single Oversight Framework for the NHS is designed to help providers achieve and maintain the Care Quality Commission (CQC) ratings of “Good” or “Outstanding”. It is a supportive process that aims to align the areas of performance with the quality domains of the CQC assessments, as well as addressing issues of financial sustainability.
The five themes covered in the Oversight Framework include the following.
Quality of care — using the most recent CQC assessment of the quality of care (safe, effective, caring and responsive), a provider delivers together with current information. In addition, the achievement of the four priority standards for seven-day hospital services are assessed.
Use of resources and finance — overseeing progress to a provider’s financial control total (the agreed total of the budget that should be met at the end of the financial year). This is an approach that is being implemented jointly with the CQC.
Operational performance — this includes the constitutional standards of A&E, cancer, referral to treatment and ambulance response times as well as access to mental health services.
Managing strategic change — assessing how effectively providers are working with their partner organisations to deliver the changes set out in the five-year plan for the NHS, the Five Year Forward View with a specific emphasis on their contribution to their local STP, new models of care, and where appropriate, implementation of devolution.
Leadership — this aligns with the CQC domain of “well-led” which assesses leadership and governance capabilities and the willingness and ability of an organisation to learn and improve.
The framework permits the implementation of the statutory duties of Monitor and the NHS Trust Development Authority with respect to NHS Foundation Trusts and NHS Trusts respectively. In addition, the framework covers the five domains of the CQC inspection process and asks another question about the use of resources and finance.
Through the Oversight Framework, NHS providers can be assessed regardless of their legal form and NHS Improvement can identify the support needed and tailor the help required according to their needs.
The support provided is segmented into four different levels.
Maximum autonomy — no support from NHS Improvement is required.
Targeted support — support is required from NHS Improvement for one or more of the five themes, however the licence is not breached and no action is required.
Mandated support for significant concerns — suspected or actual breach of licence (or NHS Trust equivalent).
Special measures — suspected or actual breach of licence (or NHS Trust equivalent) with serious or complex issues.
It is clear from the guidance that the transformation of care should continue at a pace and that the changes are embedded securely within health systems. Any slowdown of the pace may impact negatively with STP funding being withheld.
NHS England and NHS Improvement, NHS Operational Planning and Contracting Guidance 2017–2019, September 2016, available at www.england.nhs.uk
NHS Improvement, Single Oversight Framework, 2016, available at www.improvement.nhs.uk
NHS England, CCG Improvement and Assessment Framework 2016/17, 2016
Last reviewed 14 November 2016