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The pressures being put on the NHS by a changing population – Dr Nadim Fazlani

Following publication of NHS England’s Planning Guidance in December, four CCG leaders have agreed to give their perspectives on the planning process in their local health economies:

Dr Nadim Fazlani, Chair, Liverpool CCG and chair of the NHS Commissioning Assembly CCG Development Working Group; Lou Patten, Chief Officer, Aylesbury Vale CCG; Jonathon Fagge, Chief Executive Officer, Norwich CCG and Helen Hirst, Chief Officer, Bradford Districts CCG and Bradford City CCG and Director of CCG Development, NHS England, will provide insight with a series of blogs in the coming months on the process of developing, and delivering, the two year and five plans in their area.

CCG colleagues who want to continue the conversation are invited to join CCG Connect, part of NHS Community England.

In his second blog Dr Nadim Fazlani, Chair of Liverpool CCG and chair of the NHS Commissioning Assembly CCG Development Working Group, examines the pressures being put on the NHS by a changing population:

In my last blog I reflected on the fact that society is at a crossroads and we need to take a different path.

Change is inevitable, and working within resources is now a reality, whatever the results of future general elections. An ageing population, rising expectations, changes in society itself and medical advances make that inevitable. From 2012 to 2032 the populations of 65 to 84 year olds and the over 85s are set to increase by 39 and 106 per cent respectively.

Across the European Union there are currently four people of working age to every person over age 65 and this is projected to be 2:1 by 2050. Add to that the increasing geographical movement of children away from parents; the changing roles of women, who have traditionally made up 80 per cent of informal carers; and in some cases marital or partnership decisions leaving more people living alone, and there will be fewer people to care for the sick and vulnerable, so that responsibility will fall to the state.

We are not going to solve today’s problems with yesterday’s thinking. Everyone Counts:  Planning for Patients is not yesterday’s thinking. It is nothing less than a roadmap for transformation. Those of us in the NHS who have been around for some time think that we have seen it all before. ‘’No man ever steps in the same river twice, for it’s not the same river and he’s not the same man’’. This is different planning guidance and we live in a different time. There are lots of unanswered questions, some of which I will cover in this post.

Last month we held a meeting to discuss the Liverpool unit of planning. All providers based within the unit were in attendance, as well as the city’s other commissioners – NHS England and Liverpool City Council. Liverpool is one of the most complex units of planning in the country; let me illustrate this by providing an overview of those present at the meeting: Aintree University Hospital and the Royal Liverpool & Broadgreen University Hospitals are two big teaching trusts which provide acute services to this unit of planning, and specialist services to Merseyside and beyond. Alder Hey Hospital, based in Liverpool, is one of the biggest children’s hospitals in the country; our contract there is £27million. Liverpool Women’s Hospital is one of the two biggest maternity hospitals in the country. The Walton Centre is a major neurology hospital, and although we don’t have a contract there it is within the city’s boundaries and part of our local health economy. We have a small contract with Liverpool Heart and Chest Hospital, which provides specialist cardiac services for the north-west and beyond. The Clatterbridge Cancer Centre is not currently situated in Liverpool but by 2017 we will have a cancer service on this side of the River Mersey.

Also at the meeting were Mersey Care mental health trust, North West Ambulance Service and Liverpool Community Health.

Liverpool, a city of 490,000 people, has among the worst health outcomes in the country, with hospitals which are ranked among the best. In common with other northern cities, our local authority has a significant budget gap (that well-known euphemism for cuts). In the last three years Liverpool City Council has had to make savings of £156 million, and over the next three it will cut a further £150 million. All of this paints a challenging picture for our unit of planning.

At the meeting we had a frank and open discussion and considered the challenges of financial tightening. First we looked at the affordability challenge set by Monitor to NHS Foundation Trusts, which is unprecedented. Add tariff deflation which is front loaded for first two years. Liverpool CCG’s allocation is among the lowest in the country, 2.14 per cent and then 1.7 per cent.

Old ways of doing things and salami slicing are no longer possible. The challenge to providers is that although there is a limit to efficiency, the reference data would suggest there is still some way to go before that is reached. I suspect this will be reflected around the country, and there will be areas where the CCG has a deficit or is projected to have a deficit. This is not the case in Liverpool, but we have recognised for some time that we need transformation to improve health outcomes.

For the past nine months we have been working on our transformational programme – the Healthy Liverpool Programme. Planning guidance entirely supports our direction of travel, in that we need to be radical and look at system change. NHS England specialist commissioning faces a major challenge in terms of NHS units of planning as their unit is England, or in our case ten units across the north-west. It is therefore working on the basis of services and providers not in defined population terms. In Liverpool we have agreed that our unit will consider in its plans all the activity of the city’s providers. This concept has been agreed by NHS England as well as neighbouring CCGs. So Aintree University Hospital will appear in Liverpool’s unit of planning as well as that of our neighbour Sefton.

We have proposed a ‘Healthy Liverpool Programme Transformation Fund’, to be spent on Liverpool patients with Liverpool providers. Pending confirmed redesign, this would maintain CCG provider income at 2013/14 plan less tariff uplift. Existing CCG reserves, tariff reductions and growth would create the resources for transformation over five years, and deliver the Better Care Fund (BCF).

This is a credible plan but it will require commitment and during our recent meeting we debated whether Liverpool could work this way. Our co-commissioners are comfortable with the approach, and we will continue to have one-to-one meetings with providers to resume the discussion. In my future blogs I will share more information about what decisions have been reached.


clare-howardDr Nadim Fazlani is Chair of Liverpool CCG and has been a GP in Kensington Liverpool for the past 22 years, having worked in the NHS since 1983.

A Fellow of the Royal College of General Practitioners, he  was Chair of Liverpool Health Care Practice Based Consortium from 2006 – 2011 and Chair of Liverpool Central Clinical Consortium from 2011 to 2012, before being elected as Chair of Liverpool CCG.

He has also been a long standing GP trainer and an examiner for MRCGP conducted by Royal College of General Practitioners since 2004.

In addition, he is also a performance assessor for General Medical Council, a role he has undertaken since 2005.

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