Comment / Doing the right thing

What is the secret of good planning? Timing. NHS sustainability and transformation plan (STP) footprints across England will all have submitted their system-wide plans for delivering sustainable services over the next five years. But with last-minute changes in national requirements – combined with the order of submissions – this has been a somewhat frustrating process.

We’ve all been working on system-wide STP five-year plans over the summer. It has been in most cases a rather top-down process using the best available assumptions and benchmarks, to support improvement in key areas. While numbers have been submitted at the STP level, a set of yearly organisational numbers are implicit in this.

Late on in this process, we have had NHSI control totals issued for each provider for 2017/18 and 2018/19, which have to be agreed by end of November. In how many cases will these control totals reflect the numbers included in the STP submissions?

To top this, there is a real issue of having a third set of organisational numbers for the next two years. These are based on the traditional organisational bottom-up approach, taking into account individual local nuances, contracts, costs pressures and savings. 

Regulators are making it clear that an organisation’s issued control total can only be amended if another organisation within the footprint is willing to make an equal and opposite amendment. I can’t see many volunteers stepping forward to take on another’s debt – especially in health economies, where providers and commissioners are facing extreme challenge or already in deficit.

We do, however, need to recognise that our system leaders face a similar headache. The relentless pressure to deliver financial balance within quality constraints has led to this hard-line approach.

It is clear though that professional ethics must prevail, where the right numbers will be the right numbers, and we need to do the right thing.

The challenge is, of course, to make all this align. No-one would disagree that all the plans should – must – be based on a shared understanding of activity flows. This must take account of recent demand trends and a realistic assessment of the impact of any mitigating actions or pathway changes.

The challenges we face in the NHS can only be met if we face up to them as whole systems.

The solutions are likely to mean the re-provision of existing services in different ways, the involvement of different providers and some restructuring of services across broader geographies.

These are not quick wins and will involve several stakeholders, not least local politicians who are already demanding a role in this.

In the meantime, we need to get on with the day job. Our financial performance this year will also impact on the scale of the challenge next year. And while Q1 and early signs around Q2 are encouraging, we all know that much of the efficiency ask is back loaded in 2016/17. So the second half of the year presents the greater financial and operational challenge.

Many areas face rising pressure as a result of stretched social service budgets, adding further costs and affecting patient flow. My trust at the weekend had to admit two elderly people, not because they were ill but because they were physically unable to cope. Admitting was the safest and right thing to do – but there should have
been better, more cost-effective options.

There is more of this to come, so we cannot afford to put all our time into 2017-19 and beyond, thinking this year’s financial targets have been achieved. As ever, we must do the right thing.

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