Asking or Telling? NHS England Planning Guidance

Interested in localism, citizenship and communities? Then read and take a position on the latest NHS England Planning Guidance. Unlike previous planning guidance although NHS England is calling the shots this is issued jointly with Public Health England, Monitor, Care Quality Commission, Health Education England, NICE and the NHS Trust Development Authority.

This planning guidance follows on from the 5 Year Forward View – which I broadly welcomed here.

Changing Relationships

I think that there is a change of tone compared to the original mandate that NHSE received from Government. We we see a toughening up of Government expectation – with greater direct control and performance management – this is fairly typical behaviour for 2nd term Governments.

At the same time NHSE continue to promote (an albeit imperfect) localism as is shown through their impending devolution of commissioning of General Practice to CCGs.

What I think this means – Simon Stevens continues to push the line that local solutions are the way to address the 3 big challenges highlighted in the guidance (equitable health outcomes, quality of services and financial savings), however, NHSE will be more closely monitored on this approach and held to account (blamed?) if this does not succeed.

Producing local health system Sustainability and Transformation Plans (STPs)

“We are asking every health and care system to come together, to create its own ambitious local blueprint for accelerating its implementation of the Forward View. STPs will be subject to formal assessment”

What I think this means – These proposals seek to accelerate system level action on integration, to some degree they can be read as a belief that Health and Wellbeing Boards have lacked the impetus and capability to do this by themselves.

Those of you who are long in the teeth will remember local Health Improvement Plans (HIMPs) which were a similar intervention brought in by the Labour Government and more recently Joint Health and Wellbeing Strategies – no mention of them in the guidance!

Carrot and Stick

NHSE has to ‘ask’ – it cannot tell local government what to do. However, there are different ways of asking.

“The STPs will become the single application and approval process for being accepted onto programmes with transformational funding for 2017/18 onwards. The most compelling and credible STPs will secure the earliest additional funding from April 2017 onwards”

So this is tough love from NHSE to drive transformation locally. The principles that it sets out with regard to what a STP should involve are hopeful:

“(i) the quality of plans, particularly the scale of ambition and track record of progress already made. The best plans will have a clear and powerful vision. They will create coherence across different elements, for example a prevention plan; self-care and patient empowerment; workforce; digital; new care models; and finance. They will systematically borrow good practice from other geographies, and adopt national frameworks;

(ii) the reach and quality of the local process, including community, voluntary sector and local authority engagement;

(iii) the strength and unity of local system leadership and partnerships, with clear governance structures to deliver them”

Implications

First, NHSE is moving into wider territory seeking to engage with and influence – some might say control areas of social policy that it is not directly responsible for – social care and the broader prevention agenda.

Second, it has set local health and care communities a real challenge – to develop a joint strategic approach that brings together NHS Commissioners, Providers, Local Government and to some degree the VCS. Many of the structures that delivered these have been weakened or dismantled – such as Local Strategic Partnerships. In addition dominant market and Westminster cultures have not fostered the culture and skills to make this sort of local collaboration work. Some Health and Wellbeing Boards are still not mature or inclusive enough to be fit for purpose to respond to this challenge.

Finally, NHSE has a managerial culture and staff establishment that lacks the ability to adequately assess, support and engage with the ambition described here, so there is a real risk that it will fail to establish the processes needed to determine what a good STP is. See my recent experiences of engaging with NHSE here.

Actions

Despite the above caveats I think there is a real opportunity for those of us who believe that if any solution to unmet need, fairer and better services exists in the current policy environment it has to be a local one.

The ambitions require a response from more than the usual suspects. We urgently need to develop local approaches that establish relationships to jointly solve systemic challenges rather than just protect organisations or services this means:

• Coherent approaches to engaging with and supporting citizens who are already or want to be involved in their communities
• Building on the work that some GPs and community anchor organisations have been doing creating neighbourhood services that often have some element of social prescribing.
• Ensuing that the big NHS Trusts are ‘asked’ to engage with this whole system agenda rather than just focussing on the concerns of their own organisation

What do you think?