Refreshing NHS plans for 2018-19

The NHS planning guidance in England is a key document that sets out the ‘must do’ priorities for the health service in the year ahead. It’s therefore an important piece of background for anybody wanting to do healthcare IT business with commissioners and trusts. Lyn Whitfield looks at this year’s guidance and reaction to it.

What is the planning guidance?

It’s the NHS’ annual ‘to do’ list. The document that tells chief executives, finance directors, and other senior policy makers and managers what their absolute ‘must do’ priorities are going to be for the coming financial year.

The financial year that starts in six weeks?

Indeed. NHS England and, these days, the regulator NHS Improvement, try to issue the planning guidance in the autumn. Or failing that, at Christmas. Refreshing NHS Plans for 2018-19 is late because of the autumn Budget.

The Budget that found more money for the NHS, just not enough?

That one. In the run up to November’s speech by the chancellor, there was an unusually fraught series of briefings and counter briefings about the NHS’ finances.

Some of this focused on whether the service had enough money to get through what was always going to be a tough winter. But the big, underlying question was whether the NHS could deliver the Five Year Forward View – NHS England’s big plan to close £22 billion of a potential funding gap of £30 billion.

Successive chancellors have insisted that they are “fully funding the NHS’ own plan” by promising an additional £8 billion for the health service by 2020-21 or, following the general election, by 2022-23.

However, most think-tanks, management organisations and medical bodies have concluded that the plan won’t be delivered or, perhaps, that whether it is delivered or not the NHS needs more cash to address deteriorating hospital finances and waiting times.

NHS England chief executive Simon Stevens spent two years treading a careful line between these two positions; arguing that while the government has put in more money, it has not phased it in effectively, leaving the NHS with two ‘lean years’ this year and next.

Just before the Budget, to the annoyance of Downing Street, Stevens told the NHS Providers conference that it would help if the government could make up the difference of about £4 billion a year. In the event, the chancellor found £350 million for winter pressures and £2.8 billion for revenue support over the next two years, plus a bit extra for capital funding.

Or, to put it another way, a bit under half of what the NHS lobbyists were looking for?

Exactly. NHS England said it would have to go away and make some ‘hard choices’. The Treasury said it expected it to deliver its NHS Constitution commitments in full.

So, what does the planning guidance say?

It starts by spelling out what additional funding the health service is getting in 2018-19; which is £540 million from the 2015 settlement, and £1.6 billion of the new Budget money.

It then goes on to reiterate the NHS’ existing priorities, which are to invest in mental health, cancer and primary care. After that, it addresses the health service’s underlying financial problems.

Clinical commissioning groups will be expected to break-even next year but there will be a new, £400 million commissioner sustainability fund for those in trouble. For trusts, £650 million will be added to the £1.8 billion sustainability and transformation fund, to create a £2.45 billion provider sustainability fund.

The second move is disappointing, as it effectively confirms that all the central money that was initially ‘earmarked’ for ‘front-loading’ the new ways of working outlined by the Forward View will instead go on bailing out the acute sector.

Trusts will have to sign-up to central ‘control totals’ to access the fund; those that refuse to do so will be subject to a new ‘single oversight framework’ that will strip them of significant freedoms.

Even with this tough regime in place, the planning guidance assumes that it won’t be possible for the NHS to hit its key waiting time targets until late in 2018 or during 2019; and shifts the focus to containing the overall size of the waiting list.

Any movement on the reform agenda?

NHS England asked health and social care organisations to set up sustainability and transformation plans to work out how to implement the Forward View locally. In the end, 44 STPs were set up.

A handful of these were slated to become accountable care organisations this spring. This would allow them to hold a single, capitated budget to deliver integrated health and care services for an entire population.

The term ACO was changed to ACS, when policy makers realised the general election and the slow-moving Brexit negotiations would make it impossible to pass a new health and social act and create a new type of NHS body. However, the creation of ACOs/ACSs is now on hold, pending legal action by left-wing campaigners who argue that Parliament should over-see such important reforms.

Despite this, the planning guidance says STPs will take an “increasingly prominent role in planning and managing system-wide efforts to improve services” and that they should “resource their infrastructure” to do this. Also, that ACOs/ACSs will go ahead, but under a new name; integrated care system or ICS.

A new TLA?

Oh yes. It wouldn’t be the planning guidance without at least one, new, three letter acronym to wrangle. The planning guidance also says NHS England and NHS Improvement will work on a new regulatory regime for ICSs that will enable them to take their own enforcement organisation and juggle funds between partner organisations.

Anything in there about IT?

Not much. The planning guidance says what it expects to happen with some national IT initiatives, such as the global digital exemplar programme, which will see the mental health fast followers come online next year.

There’s not much tech direction for frontline organisations; although it’s clear that there won’t be much capital funding around for new systems (or anything else). The planning guidance notes that the Budget will inject just £354 million of capital funding into the NHS next year; otherwise, trusts will pretty much be expected to raise funds themselves, in line with the Naylor review.

It also suggests that the priority for spending any capital that is around will go to STP projects; which might include IT developments such as analytics or shared care records. However: “In updating 2018-19 operational plans, STPs and providers should not assume any capital resource… unless NHS England and NHS Improvement have given written confirmation.”

Has there been any reaction to the planning guidance?

Richard Murray, the director of policy at the King’s Fund, put out a blog noting that the planning guidance has arrived “desperately late in the day” and without an update to the NHS mandate which, in theory, is the government’s vehicle for telling the NHS what to do.

This might have been difficult to agree, given the open tension between Downing Street, the Treasury, and the NHS top-brass that surfaced ahead of the Budget; but it does leave open the question of what success for Stevens and the NHS is supposed to look like.

In the absence of clarity, Murray notes that the guidance is almost more interesting for what it doesn’t say than what it does.

For example, he notes that central bodies are now in control of significant amounts of revenue spending – which looks a lot more like the pre-trust world than the “world of autonomous local organisations working within a relatively loose performance framework” that was envisaged by the 2012 Health and Social Care Act.

Any more for any more?

Over at the Nuffield Trust, Sally Gainsbury argued that the return of what used to be called “grip” is unlikely to solve the problem of NHS trust deficits, since cuts in the NHS tariff mean that trusts “will make an average 5% loss on each patient they treat” – and the number of patients that they treat is going up by an average of 3% a year.

Indeed, she argues that putting significant chunks of the Chancellor’s £1.6 billion into heavily policed funds will make the problem worse, since trusts will have to accept even lower prices for treating patients to meet the control totals that gate access to them.

“There is a view among some senior NHS figures that this approach is necessary to show the Treasury, in advance of a hoped-for funding boost come a spending review this autumn, that the necessary financial grip can be restored and the NHS made to live within its means,” she writes.

“But the risk is that this strategy boils down to asking the NHS to deliver the impossible, just to provide it is impossible.”

NHS Providers was blunter, arguing that the additional Budget cash had turned “an impossible task into an extremely difficult one” and the government needed to get on with a spending review that would deliver “the right long-term settlement for health and care.”

Take-outs:

This year’s NHS planning guidance is important because it sets out what the health service is going to do with the limited amount of additional funding unlocked by the autumn Budget.

Also, because it indicates that outside the NHS’ stated priorities of mental health, cancer and primary care, the focus will be on controlling deficits by controlling access to new commissioner and provider stabilisation funds.

This means that while there may be some movement on the STP/ICS agenda, trusts will have relatively little room for making large, autonomous spending decisions. Healthcare IT suppliers are therefore likely to find the market flat; unless they can find alternative ways for trusts to invest in their products or prove a return on investment that fits the centre’s desire for “grip.”

Meanwhile, although the guidance quietly accepts that the NHS can no longer deliver on its access targets, the all-important question of whether the NHS can deliver on reform has been quietly parked; and the imperative is to make it to the next spending review.