Editor’s blog Monday 21 June 2010: Revised OF 2010-11 - reports of the death of targets have been greatly exaggerated

Whoever drafted the revision to the NHS Operating Framework 2010-11 deserves a sharp clip round the ear for inventing the word “re-ablement”. (Unless there’s a DH sweepstake to see who can come up with the most hideous policy neologism – if that were happening, I would quietly respect “re-ablement” as a worthy challenger to “polyclinic”.)

Connoisseurs of DH documents know that the controversial bit is always stuck in an Annex or Appendix (think of The NHS Plan’s ‘sod off’ response to the recommendations of the Royal Commission on Long-Term Care).

And so it is here: the long-trailed Bonfire Of The Targets. Except of course it isn't any such thing, as you will discover below.

The revised OF abolishes “guaranteed access to a primary care professional within 24 hours and to a primary care doctor within 48 hours”, and the threshold on the “four-hour maximum wait in A&E from arrival to admission, transfer or discharge” is lowered from 98% to 95%.

In addition, two Tier 1 Vital Signs are removed. The one whose abolition everybody noticed was the “percentage of patients seen within 18 weeks for admitted and non-admitted pathways (and supporting measures)”

Abolished measurement: patient experience of GP access
More interestingly, people seem not to have noticed the second abolition: “patient experience of access to primary care (and supporting measures)”.

On first sight, this appears to herald the abolition of the GP patient survey, which if it were the case, would please BMA’s GP chair Dr Laurence Buckman no end. The GP patient survey costs £13 million: neither a huge management cost, nor a tiny one.

A cynic might suggest that cancelling this survey would be an effective means to defer the point at which worsening access in primary care would become obvious, let alone demonstrable.

However, consulting the DH suggests that this is not the case, and that this refers to the original OF’s specific commitment on widening access to primary care via 50% of practices offering extended opening. A DH spokesman said that “the GP patients’ survey is linked to GP pay under parts 7 and 8 of the current contract. No decision has been made on the future of the GP patient survey”.

Target practice
We have previously considered what targets are good and bad for, and pointed out that experience in much-cited deficit-reducing Sweden of abolishing healthcare targets was of an increase in waiting.

Lowering the threshold by 3% in 4-hour A&E is probably sensible. Abolishing the 18-week elective target and 24/48 primary care target entirely may not be.

Time will tell. Tick-tock, tick-tock.

The main document
The introduction, by NHS chief executive Sir David Nichiolson (and counting), highlights five areas for the revision:
• revisions to Vital Signs and Existing Commitments;
• new rules on reconfiguration;
• future direction and next steps on transforming community services;
• finance and efficiencies; and
• accelerating development of the payment system

We have already had Andrew Lansley’s odd new rules on reconfigurations.

Nicholson (and counting) adds in a sly line that “patients would not expect a return to long waiting times for operations”. The language is well-chosen: indeed they “would not expect a return to long waiting times for operations”, but the document offers no evidence that they may not get them.

Radicalism tomorrow
The document proper promises Coalition health policy is one which “puts patients at the heart of decision-making, which focuses on quality and outcomes not processes and with more devolved responsibilities … The NHS Operating Framework for 2011/12 will include substantive systemic changes and in developing it, we shall review the clinical relevance of all existing indicators with the removal of those that have little or no clinical relevance".

Existing operational and QIPP plans remain in place, and PCTs are to work jointly with social services on joint planning. It’s a pity that PCTs are going to lose functions and staff and likely be merged (organically and bottom-up, of course!), and that social services budgets will be cut to protect NHS funding, but as we will be learning again and again, you can’t have everything.

Being told that “PCTs must put a stronger emphasis on using Secondary Uses Services as their data source, which requires providers to improve the quality and completeness of data, in line with the information transparency agenda“ is a bit odd. They were meant to be doing that anyway.

On access and the intent to remove process targets, the revision opens a can of worms by characterising this as “not a signal that clinically unjustified waits are acceptable”. In practice, the difference between a clinically unjustified wait and a clinically justified one is likely to depend on whether a commissioner is overspent. It’s going to be a brave new world.

Just kidding! We’re not abolishing process targets; just central performance management of process targets
You’ve got to laugh – it’s in the commissioning plan.

No sooner are we abolishing process targets, then we find that their guarantee in the NHS constitution means that they are not actually abolished at all. All that is being abolished is “performance management of the 18 weeks waiting times target by the Department of Health … commissioners should maintain the contractual position and GPs and commissioners will want to ensure that any flexibility to improve access reflects local clinical priorities; and referral to treatment data will continue to be published and monitored. Commissioners will want to use the median wait as an additional measure for performance managing providers”.

In other words, targets are not going, and remain codified in the patient right and legal requirements on providers in the NHS constitution.

The NHS constitution isn’t legally enforceable, but it is there, and primary legislation would be needed to repeal it. Moreover, moves to repeal it would promote a fight in which Labour could win some easy glory.

Waiting times will still be measured, and it will be a commissioners’ thing to worry about waiting.

The revision notes that policymakers “are considering to what extent amendments are required, and if so, we shall carry out a full consultation in due course”. A full consultation is wonderful Whitehall-speak for ‘the long grass’. Let’s hope the THC content isn’t too strong.

There is to be greater emphasis on the dementia strategy and on care access and priority in treatment for military veterans.

Reconfiguration – all over the shop
On the one hand, “A moratorium is in place for future and ongoing reconfiguration proposals“.

On the other hand, “This does not necessarily mean that formal consultation and implementation plans should be unpicked”.

The Independent Reconfiguration Panel will sort it out, apparently.

No, me neither.

Transforming Community Services transformed
You’ll need to read all this gubbins: ”Separating PCT commissioning from the provision of services remains a priority. This must be achieved by April 2011, even if this means transferring services to other organisations while sustainable medium-term arrangements are identified and secured. PCTs should therefore continue to develop and review proposals for the divestment of their directly-provided community services, but in doing so ensure that:
• they have been tested with GP commissioners and local authorities;
• final proposals are consistent with the aims of the forthcoming NHS Strategy in strengthening the delivery of public health services and health services for children;
• they consider the implications for choice and competition;
• they consider a wide range of options, including the development and early delivery of Community Foundation Trusts and Social Enterprises, providing employee leadership and ownership;
• there has been effective engagement of staff and their representatives when considering options;
• previous proposals for continued direct provision are reviewed and alternative options developed which secure separation; and
• proposals should be capable of being implemented, or substantial progress made towards implementation, by April 2011.

“Guidance on the approval process and timescale will follow publication of the forthcoming NHS Strategy. This may include an additional option of a staff membership Foundation Trust model for community services, where viable. Existing approved
applicants for Community Foundation Trusts, however, should continue to prepare for the first step of being established as NHS Trusts.

“Looking forward, we shall develop proposals for a phased move towards an ‘Any Willing Provider’ model for community services, addressing barriers to entry to greater participation by the independent and voluntary sector”.

This is confusing at a lot of levels. PCTs are meant to plan for a future community provision landscape in which they won’t commission? What of the integration deals already agreed with secondary care which have “implications for choice and competition”?

Finance and efficiencies
The key messages are:
“In setting capital allocations for 2011/12 particular consideration will need to be given to reducing the high levels of Backlog Maintenance"

“The overall ceiling for Management Costs in PCTs and SHAs will now be set at two thirds of the 2008/09 Management Costs (£1,509 million), the ceiling will therefore be £1,006 million. It will be for SHAs to determine how this is managed across PCTs and the SHAs, but the expectation is that most of the reductions need to be realised in 2010/11 and 2011/12. SHAs should ensure that plans are not limited to simply achieving the ceiling and should aim to go further to ensure all possible efficiencies are realised”.

“The Management Costs reduction plans for 2010/11 and 2011/12 will need to be revisited. In aggregate, PCTs and SHAs will need to save at least £222 million in 2010/11 and a further £350 million by the end of 2011/12. Achieving these reductions will significantly narrow down the variation in per capita management costs between the SHA areas. For 2011/12, we will explore how to take this further to address the variation at PCT level. As part of the ongoing reduction in SHA and PCT Management Costs, the NHS Operating Framework for 2011/12 will set out how resources will be released from the infrastructure and running costs of SHAs and PCTs in order to provide a running cost allowance for the GP Commissioning Consortia”

“In order to deliver additional efficiencies in 2010/11, the Government has recently undertaken a review of capital spending and announced new spending controls, including a freeze on new consultancy, marketing and ICT spend, a freeze on civil service recruitment and centralised procurement for goods and services. This will be overseen by a new Efficiency and Reform Group. While these controls do not formally apply to the NHS, organisations should ensure that they can demonstrate similar discipline across these areas, and prepare for a period of capital constraint, particularly as they progress their quality and productivity plans”.

“These actions should be additional to the existing requirements for the SHA and PCT sector to end 2010/11 with £1bn of aggregate surplus and for SHAs to ensure that two per cent of recurrent funding is only committed non-recurrently at the aggregate regional level”.

Payment reforms
All will become clearer in the “forthcoming NHS Strategy”, apparently.

In the meantime, choice and competition and re-emphasised; and performance-related pay is full steam ahead: ”payments for performance must be structured around outcomes, be capable of aggregation along patient pathways, extend across service sectors, be benchmarked for quality and cost; and incentivise for quality. We are continuing to develop contractual quality requirements, expanding the number of best practice tariffs where payment is linked to best practice care, and expanding the list of never events so that no payment is made for services which compromise patient safety. These changes for 2011/12 will be detailed in the tariff guidance we issue later this year. In 2011/12, we intend to make available a number of pathway (or year of care) tariffs in appropriate areas. To support the development of pathway tariffs, a number of ‘commissioning packs’ are in production”.

“Re-ablement”-wise, ”for 2011/12, we are planning changes to the tariff to cover re-ablement and post-discharge support, including social care. Re-ablement services help people with poor physical or mental health accommodate their illness by learning or re-learning the skills necessary for daily living. Such an approach creates real opportunities for acute providers to work with GPs and Local Authorities and would require the full engagement of the wider health and care economy before discharging patients. It should encourage the use of services such as community health services; social care; home adaptations (including telecare), and extra-care housing. And the DH would love to hear from anyone who’s doing this successfully.

You already know about the ‘30-day-acute-discharge-if-readmit-no-pay’ gig, which will start on 1 December 2010. Generously, they “are leaving the exact method for determining how non-payment should occur up to health economies' discretion in consultation with GPs and local authorities - this will allow the local NHS to come up with a solution that fits its circumstances”.

It’s the new localism, innit? … and will be an interesting first test of GPs’ willingness to play hardball. December could be a lively month for news stories. Better get recruiting for plumbers now, because there are going to be a lot of leaks around then ….