The 2016/17-2020/21 planning guidance for the NHS came out just before Christmas. It has been fascinating to hear again the term ‘planning guidance’, something of a throwback to the pre-Lansley days when the NHS was a more integrated and managed whole.
Professor Judith Smith, Director, Health Services Management Centre
There is clearly a firm intention to signal that the ‘national’ in NHS is critical in these times of financial strife, and that the service has to pull together to try and balance the books, sustain care quality and deliver on key policy priorities. Notably, the guidance is for five years, mirroring the period of the Comprehensive Spending review, enabling longer term strategic plans to be developed at national, regional and local levels, again appearing to signal a desire for coherence and sustained collaborative effort, far from the ‘blue in tooth and claw’ market-based NHS some had feared would be in place, some four years after the passing of the Health and Social Care Act.
NHS planning guidance is, by definition, a major exercise in priority setting. It reflects explicit choices about what is to be funded in a period of sustained financial austerity for the NHS (and where scarce additional resources for ‘transformation’ will be allocated), issues that must be addressed, and ultimately what matters to the political masters. Hence we are left in no doubt that 7-day working, access to general practice, timely cancer diagnosis, and streamlined emergency care are among the 21 important ‘must dos’. At the same time, such guidance speaks implicitly of what has been left out, is not a priority, and might even (whisper who dares) need ‘decommissioning’, a vexed issue being researched in depth by HSMC.
The planning guidance is striking in three ways. First, it is set out in a very clear and accessible manner, leaving the boards of trusts and clinical commissioning groups (CCGs) in little doubt about the 'to do' list for 2016 and beyond. Second, it is very effectively connected to the overall strategy set for the NHS, the Five Year Forward View and the associated financial settlement secured by Simon Stevens' negotiations for the Comprehensive Spending Review. Third, it appears to signal a return to ‘central grip’ of the NHS that seems at odds with local clinically-led commissioning, a central tenet of the Health and Social Care Act.
It also indicates a move towards a different type of commissioning, emphasising ‘place’ or a ‘whole system’ rather than the 20-year purchaser-provider transactional approach, a move that has been advocated by the King’s Fund and others. In each area of England, ‘health and care systems’ are now required to determine the boundaries of their particular system and develop a Sustainability and Transformation Plan in a manner that is ‘open, engaging and iterative’ and ‘harnessing the energies of clinicians, patients, carers, citizens and local community partners’.
This shift in approach to commissioning is a welcome response to the mounting body of research evidence that the 25-year experiment with commissioning (and in particular having commissioners who are ‘split’ from and transact with providers) is not able to bring about the change required to enable a modern, sustainable and ‘transformed’ health system.
What is critical is that the new place-based approach draws on available evidence to be sure of having a fighting chance of achieving the 21 ‘must dos’ over the coming five years. As a starter for ten, I would suggest the following as priorities for NHS England, NHS Improvement and their partners.
First, make sure local health systems don’t get lost in a round of planning and design workshops that spend so much time involving people that they fail to concentrate on making the tough calls about what will (and will not) be funded. Second, acknowledge that tough priority setting decisions will have to be made, and look to the emerging body of evidence on decommissioning in health to inform how best to do this. Third, learn from reviews of extensive research into large-scale change in health services about the common pitfalls encountered, and how to avoid these, especially when embarked on pilots or ‘vanguards’ which risk being ‘policy fads’ if not crafted, supported, and refined over a long period of time.
Fourth, and perhaps most difficult to tackle, it would seem to be time to question whether we need 209 CCGs and their associated costly infrastructure. If local health and care systems are to act as accountable care organisations, we need a fresh approach to where we locate those critical functions currently described as ‘commissioning’, namely analysis of needs, activity and costs, review of service performance and patient experience, and support for planning and making service change. The NHS is understandably cautious about further structural change, still bruised by the Lansley reforms of 2010, but at a time of austerity when major and urgent service change is needed, the system itself has to be properly efficient and fit for the purpose ahead.