Every year, NHS England and NHS Improvement publishes planning guidance setting out what the NHS is expected to deliver in the new financial year – for example, operational targets, workforce objectives and financial requirements.
In 2021/22, more than ever, the 'ask' of the NHS needs to be realistic. This means reprioritising multiple commitments arising from the NHS long term plan, Conservative manifesto (not all of which are funded) and ongoing response to COVID-19.
At the same time, NHS leaders and those on the frontline remain keen to drive longer-term transformation of services and outcomes. NHS England and NHS Improvement's new paper Integrating care, which describes its vision for system working, shows it is thinking big. Subject to ministerial backing, significant legislative change for the NHS may well be on the horizon.
How can the planning guidance set out a newly reprioritised 'ask' that strikes the right balance between realism and ambition? Based on daily engagement with trust leaders and two provider roundtables, we believe that NHS England and NHS Improvement needs to do six things to help providers start 2021/22 in the strongest possible position and deliver for patients:
- Look after its people. An NHS Providers survey found that 99% of trust leaders are extremely or moderately concerned about staff burnout. While COVID-19 has pushed wellbeing up the agenda, it is not a new issue – workforce gaps in health and care were already having a negative impact on workloads and work-life balance. Investment in local wellbeing schemes, action to recruit and retain staff in sufficient numbers, and realistic expectations are all vital. The pandemic also highlighted that much more work is needed to create a truly diverse and inclusive NHS. Warm words alone will not be enough. NHS England and NHS Improvement must lead from the front by outlining the specific steps it will take, and the support it will offer to providers, in 2021/22.
- Set deliverable operational targets. Providers have worked exceptionally hard to restore non-COVID services. They met NHS England and NHS Improvement's stretching phase 3 recovery targets in August and September. But now the country is battling a second wave and providers are striving to keep services running, while adhering to rigorous infection prevention and control measures that limit their capacity by up to 20%. Even before the pandemic, there was a lack of hospital beds, rising demand for mental health and community services, and over 100,000 vacancies. While the planning guidance should be ambitious, NHS England and NHS Improvement needs to acknowledge these circumstances and address existing pressures. Undeliverable targets will put undue pressure on an exhausted workforce only just emerging from a tough winter.
- Support systems. Providers are enthusiastic about the opportunity to improve health outcomes and reduce inequalities via system working. Many are already leading or co-leading collaborative working at integrated care system (ICS) level, place and across multiple geographies. However, such arrangements have developed from different starting points and speeds. NHS England and NHS Improvement should use the planning guidance to set out the support available to ICSs (and sustainability and transformation partnerships evolving into ICSs), for example as they firm up their governance and decision-making arrangements, and champion incremental, locally led change. This will help ensure that advances in system working are manageable, sustainable and do not pre-empt potential legislation. Our full response to Integrating care can be found in this briefing.
- Provide clarity on the financial framework. NHS England and NHS Improvement is proposing major changes to the financial framework in 2021/22. It is expected that funding will be allocated and distributed at ICS level, and that blended payment will be introduced across almost all secondary healthcare services. Providers are broadly supportive of the overall direction of travel, but want more information on how the new arrangements will work in practice. We urge NHS England and NHS Improvement to deliver on the recommendations contained in our new briefing.
- Respond to the whole NHS provider sector. Providers of acute, specialised, mental health, community and ambulance services – alongside their colleagues in primary and social care – are all central to the COVID-19 response. They are also experiencing unique challenges. For example, against a backdrop of historic underfunding, the ambulance sector is only meeting increased demand by redeploying operational staff to frontline duties, and calling on support from private and voluntary resources. Past planning guidance has tended to have an acute focus. In 2021/22, providers' specific roles and needs must be recognised to help them serve patients and populations effectively.
- Engage and listen. We welcome NHS England and NHS Improvement's early engagement with providers on the planning guidance. April cannot mark the end of the conversation, which needs to include the wider health and care service, the voluntary sector and patients. Early 2021/22 is likely to be dominated by the ongoing response to COVID-19. Vaccines, treatment advances and rapid turnaround mass testing will hopefully enable the country’s transition out of the pandemic, but we know that COVID-19 will have a long-term impact. NHS England and NHS Improvement should work with providers to keep the expectations placed on them under review, while specifying key milestones to aim for throughout the year.
NHS Providers will continue feeding trust leaders' views into NHS England and NHS Improvement's thinking for 2021/22. We also await more details of the additional NHS COVID-19 funding promised at the spending review – as always, funding and expectations must be aligned.
This piece was first published in Public Finance.