The Friday Blog: The Must Do Dozen
Well, yes, here we go headlong into another year, which surely cannot go as badly as the others in this cursed decade so far. I trust you all had a decent festive period and hope you were able to spend time with those you most wanted to spend time with. We learnt a few things. That eschewing the Rose Garden Chinese takeaway in Gorse Farm Road these past few years was a mistake, and that the Co-op delivered by far the most cost-effective option for a Christmas turkey. A snip at £20 for a crown joint (18 for the second one we brought when it was reduced on Christmas Eve), a fraction of what some of the high-end outlets were trying to relive us of, and decent enough to get the seal of approval from The Doctor and daughter. Twice. (A bit of a family tradition).
We were also reminded of something. Do you suppose you actually forget how hard having a puppy is, or is it automatically expunged from your memories, because, if you did remember, you would never put yourself through it again and all the dogs’ homes would be full. It may just be our age, but it is far from easy, and much harder than a baby. Put a nappy on a baby, stick it in a cot, job done. A puppy is mobile and can hurt you. We are all bearing the scars and counting down the hours before her second vaccination allows us out of the house. Still, she remains probably the most beautiful creature I have ever seen.
The week before Christmas means one thing for normal people and quite another for NHS DoFs and COOs. Last year it arrived on Christmas Eve, and Bob Cratchit late in the day at that. This year it probably counted as something of a gift for those at the sharp end of an increasingly beleaguered NHS, landing as it did a day earlier (ok, granted, it was a Friday) and it was, by the standards of these things, mercifully brief, the 20 pages being not too much longer than the NHS Providers’ summary. It was, of course, or maybe not of course if you do not share my wonkish tendencies, the NHS 2023/24 priorities and operational planning guidance. It also contained far fewer than the 130 do or die objectives demanded this year, few enough indeed that they could be summarised on a single page. Like a lot of people, I always wonder whether the way the order in which things are listed betrays any sort of priority on behalf of the author. If that is the case then top of the pile, and presumably top of mind for NHS England, is Urgent and Emergency Care, followed by Community health services and Primary care, which may explain why there have been so many conversations on the wireless this week about trolley waits, bed blocking and better ways to access the NHS in the first instance. Next come Elective Care, Cancer, Diagnostics and Maternity. Use of Resources (balance the books) and Workforce (stop nurses going to agencies or on the sick) get a shout out. The must do dozen is completed by Mental Health, Learning Disabilities and Prevention cum inequalities.
If there is some sort of priority to things, and remember that this is the one that will get us near as dammit to a general election, then the one thing HMG seems keen to crack on with might play out well at the polls, is access to the front door. More so, it seems, than waiting times for elective surgery. If you are with me on this conspiracy theory, then it has some logic. Why nail yourself to drastically reducing waiting times, when many of the factors are longer term and structural, workforce, provision of services, provider collaboration etc. Throw some energy behind getting ambulances to turn up on the same day. Not that Rishi is with me, or maybe he was not aware of the guidance, but in what was billed as a “landmark” speech on Wednesday, one of the five promises he made for the next year was to do exactly that. Good luck is all I can say as we brace ourselves for the worst that winter can throw at us and the next version of COVID gets on the march. Even if there is progress, the once sacrosanct 18 weeks looks a distant memory, the target of eliminating waits of over 65 weeks for elective care by March 2024 (except where patients choose to wait longer or in specific specialties), looks distinctly unambitious. Set against that, the distinctly ambitious target to increase elective activity by 30% of that pre-pandemic by 24/25, looks incredibly unattainable. It will be interesting to see how progress, or lack thereof, will be spun as we baton down the hatches for the political campaign 12 months hence.
Back to those front door targets, the aim is to improve A&E waiting times so at least 76% of patients wait no more than four hours and reduce general and acute bed occupancy to 92% or below. 92%! Wow. One of the longstanding issues we have is that we run the NHS incredibly hot, it is why we got hit so hard by the pandemic and why we are so slow to recovery. Most other jurisdictions think we are unhinged in tolerating anything above about 80%, so to imagine that getting to 92% represents some sort of progress is mind blowing. Category 2 ambulance response times are also planned to reach an average of 30 minutes in 2023/24 and there is an expectation of meeting the 70% 2-hour urgent community response standard.
At the same time as NHSE published guidance to Integrated Care Systems on how to construct five-year joint forward plans with ICBs and their partner Trusts, the operational planning guidance indicated that the centre will publish two-year revenue allocations for 2023/24 and 2024/25, and whist ICB allocations are flat in real terms, there is additional funding available to expand capacity, and elective recovery funding will be allocated to systems on a fair shares basis. The latter will be one to watch for Trusts, as they wrestle with their own activity as well as that of their systems and the tension between the two. How the £3bn of additional elective recovery funding allocated to ICBs and regional commissioners will be distributed will need to come out in the planning process, something which has been somewhat opaque in the last couple of years. The contract default for elective activity will be to pay unit prices for actual activity delivered. The requirement for ICBs to take on responsibility for commissioning appropriate specialised services has been pushed back a year to April 2024, something which many had advocated for.
NHSE will also increase the capital envelope for 2023/24 by £300m, with access to this additional capital funding being conditional on system financial performance in 2022/23. Much as any increase in capital will be welcome, there remains the distinct possibility that organisations desperate for maintenance and upgrades could be disadvantaged through no fault of their own.
There is, as might be expected, a number of initiatives aimed at increasing efficiency, and system plans are required to identify the sources of productivity loss and design actions to improve this. Examples set out in the planning guidance include initiatives to enable the flexible deployment of staff and improve theatre utilisation using the model hospital system theatre dashboard. Productivity loss post-pandemic is one of those things it is hard to talk about in polite company, and it is impossible to imagine politicians wanting to go anywhere near it, but it is a thing. Tim Briggs and his GIRFT programme is likely to have an increasingly significant role to play in this regard, especially as the guidance is wanting to embed minimum rates of 85% for both theatre utilisation and day case procedures.
Other requirements include reducing agency spending across the NHS to 3.7% of the total pay bill in 2023/24, a target which was cautiously welcomed by NHS Providers, but NHSE can huff and puff all it wants about agency spend, if there are shortages of substantive NHS staff, there are shortages of substantive NHS staff, and, whilst it is not mentioned, the spectre of pay and industrial action looms large. The service is required to reduce corporate running costs with a focus on consolidation, standardisation and automation to deliver services at scale across ICS footprints. There is also the familiar call to reduce procurement and supply chain costs via SCCL and the specialised services devices programme. In case you had not fully grasped this, these are issues you will be talking about for the rest of your career. Medicines are not immune, and must be purchased at the most effective price point through engagement with the commercial medicines unit and the national medicines value programme.
Other national targets called out were to continue to reduce the number of cancer patients waiting over 62 days, meet the cancer faster diagnosis standard by March 2024 so that 75% of patients who have been urgently referred by their GP for suspected cancer are diagnosed or have cancer ruled out within 28 days, and to achieve a 5% year-on-year increase in the number of adults and older adults supported by community mental health services.
Further actions designed to increase capacity and improve patient flow to ease the pressures in emergency departments include increasing physical capacity through maintaining the additional 7,000 beds which were funded for this winter and increasing the use of virtual wards to 80% by the end of September 2023. The Better Care Fund (BCF), the anti bed blocking initiative, should provide £600m in 2023/24 and £1bn in 2024/25 to support timely discharge.
Thera are a raft of initiatives aimed at easing front door pressures and making it possible to get to actually see a GP again. From self-referral programmes to the barn door obvious better use of community pharmacies, and money may actually follow with a 6% increase in ICB Primary Care allocations next year. NHSE will publish a recovery plan for general practice access in due course. Do not hold your breath, or, indeed, do anything else that might require you to be seen in short order,
The ambition is for systems to maximise the pace of roll-out of additional diagnostic capacity, delivering the second year of the three-year investment plan for establishing Community Diagnostic Centres (CDCs) and ensuring timely implementation of new CDC locations and upgrades to existing CDCs. Systems will be asked to deliver a minimum 10% productivity improvement in pathology and imaging networks by 2024/25 via digital capability enhancements. Following the October 2021 spending review, £2.3bn of capital funding will be made available to systems over 2023/24 and 2024/25 to support diagnostic service transformation.
The guidance asks all systems to refresh workforce plans to increase productivity, deploy staff more flexibly through digital solutions, improve staff experience and retention via a range of national strategies, and ensure there is adequate clinical placement capacity. To improve digital capabilities, more providers are expected to operationalise electronic health records and should work towards developing a population health and planning data platform. NHSE will provide targeted funding to enable ICSs to meet minimum digital capabilities and foundations. NHSE will also procure a federated data platform accessible to all ICSs and will improve the functionality of the NHS app.
The guidance expects systems to have local objectives in place which will feed into the national NHS objectives. The review of ICS oversight and governance led by Patricia Hewitt will look to enhance the accountability of systems to ensure the level of oversight systems have is appropriate and proportionate. This is a theme that will be returned to over the course of the review.
There are some conspicuous absences from the document, notably the “not me Guv” stance on social care, a position, I fear, which will persist long after I reach the stage at which I need it.
The digested read? The guidance sets out three key tasks for the next financial year, the most immediate being to recover core services and improve productivity. As recovery continues, systems should renew focus on delivering the key ambitions set out in the NHS Long Term Plan, and transform the NHS for the future.
If you want another take on it, you could do a lot worse then have a peek at the musings of my old pal, Roy Lilley, who, as ever, remains on very fine form indeed.
