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Critical News (Published 18th December 2017)

Week Commencing 11th December 2017

5 Insights You Need to Know

Welcome to the NHS WEEK THAT WAS, a Monday synopsis of the most important things that happened last week, with a degree of interpretation. No waffle, no minor news – just the significant stuff to ensure you are current. Enjoy! And to bring more joy than sorrow, as it is Christmas week, we have sought out good news to balance the less good.

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QUICK PERSPECTIVE

Seeing as how it is Christmas, a time of joy and cheer, we wanted to highlight as many goods news stories as less good. As I sat down, my concern was whether that would be even possible, given the paucity of good news currently. And then it hit me… sometimes the terrible news for one is brilliant news for another and so I can confidently say that every news item this week is good… for someone. Some are even good for everyone. Merry Christmas!

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1. HAVING YOUR CHRISTMAS CAKE AND EATING IT

The emergency winter money ‘arrived’ this week. The £335m ‘extra’ pledged by Mr Hammond was allocated largely based on activity and communicated to Trusts. Now, you could be forgiven for pointing out that it hadn’t arrived prior to one of the coldest snaps we’ve seen for some time but better late than never. The more significant news in this news, though, is that the first ‘half’ of it has been designated for paying for things you are already paying for i.e. reducing Trust deficits for things ‘loosely’ called extra winter capacity, or similar etc.

The second tranche of funding has been made contingent on achieving certain A&E performance improvements. So, and I joketh not, you have to demonstrate better 4-hour performance to be eligible for ‘support’ that will arrive after the fact, to help you out of your winter crisis. In truth, this is actually consistent with recent allocations in other forms, where those that arguably prove they don’t need the support get it and those that are struggling, and thus need it far more, do not. I think I am hearing mumbled questions to the effect “just how is this ‘good’ news, Andrew?” and so I would like to explain.

This is very good news if you are a.) the Treasury, b.) NHSI and c.) the Department of Health. In a year that was financially crashing and burning, for the above, this is a super little lifeline. The cake recipe works like this:

  • Take a large chunk of winter funding and re-announce it as ‘new’ funding at the budget (based on providers getting winter funding most years) – take a large bite of the good news cake
  • Allocate it to Trusts but stipulate it can only be used to pay for things they are already paying for (resulting in no new commitments but a nice slice of their deficits) – take large bite out of the bottom line cake
  • Stir in the remaining funding mixture according to a strict ‘improvement’ recipe, at the end, ensuring that only good cakes get the right ingredients to mature and go on show – take a huge bite of your celebrity success cakes (whilst quietly shovelling the failed ones into the waste bin)

So, in effect, the DH gets to serve up ‘normal’ winter funding as new money but without it funding anything new, whilst lowering their deficit catastrophe at the same time – winter support and financial improvement in one carefully crafted recipe. Just how is that NOT good news… if you are Jeremy?

 

2. COMMISSIONING FLEXIBILITIES EMERGE

This last week saw the announcement that Kernow CCG will become a department of Cornwall Council, who will, in effect, assume full strategic commissioning responsibility for the county. In many respects this is an extension of the devolution agenda that has been in full swing for some time, running suspiciously concurrently with the decline in system performance.

This is probably good news for the people of Cornwall, as the devolved approach will most likely better recognise the uniqueness of this region, which has given rise to so many issues when ‘centre-mediated’ plans and initiatives are thrust on regions they don’t suit. For others, it signals that it may become more possible to adopt commissioning mechanisms more suited to local eccentricities. However, it also raises a number of concerns too, including:

  • Is it even legal?
  • Will it simply mean that social care gets more of the commissioning cash by circumventing ring-fence protections?
  • How will disputes be resolved… fairly?

My own concern is a bigger picture one, partly surrounding timing too. Without agreeing or disagreeing with the agenda, we are moving headlong towards Accountable Care Organisations (ACOs). Even this week, there has been further discussion on the creation of a new type of ACO ‘Trust’ to effectively quell some fears and circumvent the pesky problem that an ACO is actually at odds with the Health and Social Care Act 2012 (which enshrines separation between commissioning and provision). So, the concern is that with a ‘clear’ agenda under way, just why is this anomaly being permitted (assuming it is)?

We had PCT-commissioning – a national system, CCG-commissioning – a national system and now we seem to be developing a pathwork system in which healthcare is commissioned differently from one place to the next, including CCGs, ACOs and now a council. Perhaps the common thread in them all is devolution, with each new form effectively being a further disconnect from the DH, which I have argued is the key driver – devolve responsibility for what isn’y working. The implication, though, is that it will either result in expensive but redundant change, abandoned when a new ‘national’ system emerges, or that it will be impossible to come back from and thus another nail in the coffin of a ‘NATIONAL’ Health Service. Call me cynical but the latter worry carries a considerable consistency with so many recent news items. I will be watching this space, so stay tuned.

 

3. DToC DETOX

I am delighted to share news that is genuinely good for all, although not necessarily for all quite ‘yet’. This week saw the publication by Local Government Chronicle of Delayed Transfer of Care (DToC) performance following recent targets and pushes to improve discharge by incentivising and cajoling social care. The news must be combined with other news to be called good for all though, as you’ll discover below.

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DToC remains one of the most toxic issues facing acute providers and that current data does not entirely dispel that. In fact, the number of DToCs overall has risen (OK, Andrew, not getting a very ‘good news’ feeling so far…) The good news is that some are hitting very admirable targets and others are improving, and the overall rate attributable to social care has declined, suggesting a genuine improvement in performance, albeit negated by bigger declines most likely from front end demand. The less good news is that a third have deteriorated further. That hardly seems good news for all and in fact, for some, it is extremely worrying when combined with last week’s winter frailty news. However, in my commitment to bring joy at Christmas, I want to take you to slightly less recent news from one of the most troubled health economies that is now firmly in the green – Medway.

The acute provider for Medway has had its fair share of troubles and the health economy as a whole seems a frequent bad news contender. However, in an inspirational story written for Health Service Journal by the CCG Chief Operating Officer, Stuart Jeffrey described how, at the time of writing in late November, Medway Foundation Trust has just two patients (not 2%, just 2 patients) on the delayed transfers of care list and had just closed an escalation ward that had been open for three years. Moreover, there were 32 empty community beds and the previous week’s accident and emergency performance was just a whisker under 95 per cent. The story brings genuine hope and all of the participants in a magnificent piece of collaboration deserve congratulations.

I don’t want to share too much of the story because I hope that you’ll want to read it in greater detail (link below). However, the very quick overview is that they identified 4 distinct DToC pathways and focused a significant collaborative effort in improving and optimising at all points along them. It was an iterative process they went through, highlighted what I have frequently pointed out, that complex problems are solved by rapid iteration i.e. trial and error, something we tend to ignore in the NHS in favour of the grand plan. That one of the most pervasive and toxic issues in healthcare can be resolved to that degree should bring hope, cheer and inspiration to all.

More detail: https://www.hsj.co.uk/quality-and-performance/we-threw-the-kitchen-sink-at-dtocs-and-it-worked/7021174.article

 

4. MENTAL HEALTH NEWS THAT ISN’T DEPRESSING

Now that I am surfing the wave of good news, this week also saw data emerge from the mental and physical health integration pioneers. The pioneers are front runners in the NHS England sponsored initiatives that are part of the 5 Year Forward View implementation document.

The benefits seen by integrating mental health services into physical health pathways are varied but include very significant improvements in some of the toughest challenges we face. We have to accept that the numbers are small, focused on distinct cohorts that could be properly evaluated, but targeted funding and progress has resulted in:

  • A&E attendances in their patient cohort to zero in Buckinghamshire and Oxfordshire
  • Oxfordshire reducing hospital admissions by 100%
  • Calderdale, Berkshire West and Berkshire East reducing GP appointments by nearly 50%

Some of the biggest improvements were seen across the Cambridgeshire and Peterborough CCG patch, where the introduction of talking therapies into diabetes, cardiovascular and respiratory pathways, across the trial cohort of 500 patients, saved £193,000 in a year by producing the following effects:

  • A&E attendances fell by 61%
  • Hospital inpatient admissions fell by 75%
  • GP appointments across the three specialties fell by 73%

The changes are profound and confirm what many have known for some time – that physical health patients with a mental health element to their needs are high resource consumers. NHS England is now supporting second wave pioneers but it it looks like the jury is no longer out when it comes to the benefits of this strategy.

 

5. NO NEWS IS GOOD NEWS… FOR SOMEONE

Now, just in case you were getting too comfy, with a glass of sherry and a mince pie, it would be wrong not to highlight a story that emerged late in the week – elective waiting lists and times. The news in question is that the highest ever number of providers are declining to report their waiting list numbers, meaning a whopping 6.5% of the waiting list is not being declared, based on the last known position of the Trusts in question.

Good news? For whom? Well, it isn’t good news for providers, transparency or the patients that now find themselves sub-radar at a time of declining performance. At the simplest level, it is good news if you are held accountable for waiting times because the absence of these figures improves the overall nationally declared time. Even without these figures, which come from some of the waiting time bad boys of the bunch like Barts Health, who last reported an average wait of just over 28 weeks, elective waiting times stayed above 20 weeks for the third month in a row in October, sustaining a run of national 18 week target breaches that started in March 2016 and now looks like a million miles from being resolved.

The real impact  of this news is on patients, who are increasingly forced to wait for what is at worst life-improving and sometimes life-saving elective care, and providers, who have this problem predominantly because the combination of DToC and increased emergency demand displace elective patients, and which find themselves with declining finances as their elective throughput declines. Since the reformation of Sustainability and Transformation funding to be dependent on emergency target attainment and finance, I have harboured the fear that we are seeing elective care abandoned as a ‘core’ NHS activity, possibly in favour of system redesign to have an emergency NHS and more private or insurance-based provision of elective services. The worry is not the direction of travel so much as the trail of destruction in providers and patients left by the journey itself.

I am sure you agree that even finding a good news element to this news is tough. However, if you are seeking to cushion yourself from bad news whilst allowing (or even secretly implementing, Jeremy) a fundamental change to the premise of the NHS, then bring on more ‘less’ news…

 

Some Final Thoughts

So, I know how much you value the service, even if there are weeks that can only be described as depressing. Being up-to-date is important. Almost everybody reading these synopses is either involved in or leading decisions and actions that affect services, patients and their own lives. How things turn out for us is dependent on what we decide and do. But our decisions and actions are based on how we feel and what we are aware of or sensitive to. Those thoughts, feelings and sensitivities are underpinned by how well you understand, it being so easy to misjudge what is happening. As we close 2017, many will be hoping that 2018 is different. I am certain it will be. As this week’s news highlights, there is always good news. What’s key is to be aware, understand the relative balance of good versus bad and very much learn to interpret things for what they are or are most likely to be, rather than how we’d like them to be or based on some misplaced understanding.

So, with all that said, I’d like to say Merry Christmas to All and to All a Good Night… for now!

 

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