Monitor, the government regulator for health services in England, requires NHS foundation trusts to submit various reports and plans. One of the key submissions for every trust will be its strategic plan and 5-year financial return, due to be submitted to Monitor by 30th June. I wondered how a member of the 2gether Trust might go about evaluating such a strategic plan, although all this is a little theoretical because only a brief summary of the plan is likely to be published.
Monitor’s planning and reporting requirements page outlines what has to be submitted. It says of the plan and the financial return that:
They should set out how your board intends to ensure appropriate, high quality and cost-effective services for patients on a sustainable basis.
It goes on to list eight ways in which Monitor will assess sustainability:
- the outcome of the first phase of the review and your trust’s response
- how robust your strategic planning process is
- your trust’s understanding of its local health economy and any likely financial gap based on its current configuration
- how well commissioner and provider activity and revenue assumptions for the coming 5 years match up
- the strategic options you believe are available to ensure the sustainability of high quality services for patients
- the schemes and initiatives your trust plans to use to secure its long term sustainability
- your trust’s level of engagement and alignment with key stakeholders in your local health economy
- your board’s self-assessment of your trust’s longer term sustainability and the key points supporting its conclusions
None of this is easy for a member of the Trust to interpret.
The national picture is an obvious place to start to get an idea of how the NHS might change over the coming years. NHS England has published a business plan for 2014/15 to 2016/17 called Putting Patients First. It goes into a lot of detail, but on the last page there’s a useful summary of eleven key measurables:
- Satisfied patients
- Motivated, positive NHS staff
- Preventing people from dying prematurely
- Enhancing quality of life for people with long term conditions
- Helping to recover from episodes of ill-health or following injury
- Ensuring that people have a positive experience of care
- Treating and caring for people in a safe environment and protecting them from avoidable harm
- Promoting equality and reducing inequalities in health outcomes
- NHS Constitution rights and pledges, including delivery of key service standards
- Becoming an excellent organisation
- High quality financial management
NHS England highlights 1 and 2, which it will measure using the Friends & Family Test. Measurement of 3 to 7 is through parts of the NHS Outcomes Framework. Measurement of 8 and 9 is a bit woolly, it seems to me. Measurement of 10 is through staff survey results and 360-degree feedback. And 11 is simply comparing actual spend with budget.
As a start, I’d want a strategic plan that is clearly and demonstrably compatible with NHS England’s key measureables.
Locally in 2gether’s home county of Gloucestershire the clinical commissioning group has published a draft 5-year strategy called Joining Up Your Care. It’s written in a way that makes it hard to pin down what the intention really is, as if all the nice ideas that anyone could think of were thrown into a large bucket and poured into the document without anyone having taken the trouble to join them up.
There’s a nice list of six approaches in the introduction, but whether this one is more significant than any of the many other nice lists is anybody’s guess:
- Clinical Programme Approach – taking the budget for a specific condition and reviewing the whole clinical and care pathway from prevention to end of life, working out how we can get the best possible outcomes within the resources available;
- Care Pathways – focus will be placed on agreeing and delivering care pathways across our entire community;
- Integration – we believe that if we work better together as a community, in a more joined up way, we can transform the quality of peoples care; adopting a “one system, one budget” approach;
- Effective Change Management – a sustainable model to drive innovation, service redesign and development;
- Focus on outcomes and the fundamentals of Quality;
- Ensuring best use of our resources.
Floating around in the bucket there are some ambitious ideas whose potential unintended consequences and costs are not acknowledged. For example, there’s an idea for integrated community teams (ICTs) consisting of many different types of professionals, and for which “substantial investment has been committed”, but there’s no sign of any detailed model behind the idea that would predict costs and clinical outcomes. The upshot may simply be that you won’t be able to see a doctor in many circumstances, as both diagnosis and prescribing will be performed by cheaper professionals, but it’s guesswork whether this will really be more cost-effective.
I’d want to see a strategic plan for 2gether that presents a realistic interpretation of what Gloucestershire CCG’s plan actually means (even though the CCG itself probably doesn’t know what it means), and that is clearly and demonstrably compatible with the interpretation, on the assumption that Gloucestershire CCG will remain the Trust’s most important commissioner.
Some consideration of other commissioners would also be good, and in particular an analysis of the bids recently lost for drug and alcohol services in Gloucestershire and for services in Bristol. Will a future 2gether win those contracts when they come up for renewal, and why?
Within the 2gether Trust there are some known strengths and weaknesses in comparison to other mental health trusts. For example, last year’s NHS Staff Survey seemed to suggest these strengths:
- Team working
- Equal opportunities for career progression
- Little pressure to attend work when unwell
A strategy that builds on these strengths, keeping teams together, continuing to ensure opportunities for career progression and continuing to respect staff as people, might be better than a strategy that undermines these strengths.
On the other hand, the survey seemed to suggest these weaknesses:
- Communication with senior management
- Quality of work and patient care
- Job-relevant training
A good strategy can either work around these weaknesses, taking them to be permanent characteristics of the Trust and designing a future in which they don’t matter so much, or it can tell a believable story about how the Trust is going to transform itself in these respects while safeguarding its strengths.
However the strategic plan turns out, it’s likely to be overtaken by events well within its 5-year time frame. In Gloucestershire, the CCG’s vagueness seems to me to be a weakness that will adversely affect the whole of the NHS locally, though I’m not sure that other commissioners are much better.
I’ve even heard it said that planning for as long as 5 years is pointless, because in that time you can expect a change of government, or at least a cabinet reshuffle or two, and your plans will have to change. I suspect, however, that there’s something to be said for planning that transcends the timescale of cabinet reshuffles and elections, even if not all one’s plans come to fruition.