Old and the new

Dr Nadim Fazlani, Chair of Liverpool CCG and chair of the NHS Commissioning Assembly CCG Development Working Group, gives his thoughts on the complexities of planning for the future:

ONE of the rituals in working in the NHS, at least for those of us involved in commissioning, is the annual operational guidance that arrives around Christmas.  Now it has been renamed ‘Planning Guidance’ and was published this week.

We are in a new age and time honoured ways of doing things are being challenged. We need to work towards an NHS focusing on outcomes not activity, and on outcomes which matter.  The NHS has become even more complex in terms of structure and, dare I say, more fragmented.  Let me give you an example of the national landscape before I move on to look at Liverpool.

There are 211 CCGs and each has its own Operational and Finance Plan. Then there are 157 Health and Wellbeing Boards each with its own plan and also an ITF Plan jointly with CCGs. Then there are 27 Area Teams with Direct Commissioning Plans and also the Specialised Commissioning plan, which are national but with a local overlay. I have not mentioned the providers who have their own plans and they may or may not be aligned with commissioning plans – and if they are it was probably not by design.  Historically, all of the plans were annual.

Of course the planning process was not designed to deliver transformational change as the new planning process has to.  We are in year zero and the role of clinical commissioning in the culture change within and outside NHS is key.

The key hallmarks of good planning is alignment of plans with common timelines, common operational and financial metrics, and common incentives, so we now have  “units of planning”  crossing CCGs, Local Authorities and providers and not necessarily in line with Area Teams,  and these units are to build 5 Year Strategic Plans owned by the “health economy.”  CCGs and providers will have a 2 Year Operational Plan and 5 Year Strategic and Financial Plan.

This is the concept, but I will point out the challenges in a Liverpool context.   The Health and Wellbeing Board has a two year plan outlining the approach to integrating health and social care, enabled by what was previously called the Integration Transformation Fund and is now called the Better Care Fund.

This is a movement of three per cent of NHS spend from hospital to community/social care settings. I would argue that this is not ambitious enough as all of the evidence is that population outcomes are changed by spending at the community level, not hospitals. In fact Medicare data suggests the curve in terms of hospital outcomes actually levels with spend and starts to fall over a certain point.

Area Teams’ plans for directly commissioned services will also be with two and five year time lines and will be aligned to CCG and Health and Wellbeing Board plans over units of planning.   This is a new approach and the system will need to be supported.  Much is made of CCGs being new organisations, but the same is true for NHS England and Commissioning Support Units.   Individuals within these organisations are of course often very experienced but all organisations are still developing.

On top of the layers, time lines are challenging, as two year and five year Strategic Plans will need to be in draft form by the end of March.  In April, final two year Operational Plans will need to be submitted and by the end of June, the third and final submission of five year Strategic Plans.   There will be bespoke support for all components of the health economy through the “Framework for Excellence in Clinical Commissioning.”

Now the Liverpool perspective:    We are coterminous with Liverpool City Council, responsible for nearly half a million people with eight providers in the city. Our transformational plan, The Healthy Liverpool Programme, was launched in April 2013.   We have had a number of events with providers as well as commissioners including Liverpool City Council and NHS England, and this will set our five Year Strategic Plan and determine our two year Operational Plan.

Thinking over suggested units of planning is still being developed, 90 units were initially proposed and it now appears there are around 150 units but planning guidance suggests that this will develop over a period of time.

CCGs are accountable for developing a Strategic, Operational and Financial plan. To enable wider and more strategic health economy planning, CCGs will work in close collaboration with relevant Area Teams, providers and local authorities and where appropriate they may also choose to join with neighbouring CCGs in a larger ‘Unit of Planning’ to aggregate plans, ensure that the strategies align in a holistic way and maximise the value for money from the planning resources and support at their disposal.

This is important for providers who often are providers for more than one CCG, there are also clearly interdependencies. Decision making will involve number of partners and we in Liverpool have our transformational programme, the Healthy Liverpool Programme. However we are working with our neighbouring CCGs to achieve the desired outcomes. Proposed committee in common is one mechanism that we could look at to address this. (In future blogs I will be able to describe how we address these boundary issues.)

Metrics are another issue.  We are developing local financial and operational metrics with providers focused on driving improved health outcomes as the national work seems to be still in the concept stage.  This really needs development on a war footing, because the planning process needs to be underpinned by this   There needs to be as much effort put into this as into designing and then trying to align different planning processes as this is how we will make big gains.

My future blogs will be about how we get on in Liverpool.

Dr Nadim Fazlani

Dr 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.