COVID19 20(20) and beyond...• Staffing shortages ... Sir Simon Stevens: It is a separate agency....

COVID19 ...20(20) and beyond

Siva Anandaciva, The King’s Fund

© The King's Fund 2018

The national picture

June 2020

Siva AnandacivaChief Analyst


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2010 20252020

Increased focus on

integrated care, but finances

and waiting

times get worse

Global financial crisis & Health

and Social

Care Act

Stormy waters

Growing pressure

A narrowing Covid Future

Workforce crisis, Central control & system working

Same plan at different pace vs

different plan

The strategic environment





• Staffing shortages• Waiting time performance deteriorating• Stubborn provider financial deficits• Deteriorating physical estate

• Delayed social care funding reform• Diffuse accountability across national bodies• Unclear subsidiarity• Wider macro economic environment inc. Brexit

• Short-term focus• Unrealistic expectations of what is possible• A health and care system designed for a different purpose• Wider societal trends eg changing attitudes to work

C2015 to Jan 2020

What’s the problem to address?





Sir Bernard Jenkin: NHS England cannot justbe responsible for delivering frontline careif it does not also integrate planning ofthe workforce. The NHS people plan camefrom another body. How can you run anorganisation if you are not responsible forplanning your own workforce?

Sir Simon Stevens: That may be a questionfor higher powers than me.

Sir Bernard Jenkin: That comes down to theproblem of the lack of accountability inthis

Sir Simon Stevens: It is a separate agency. Ifwhat you are getting at is about HealthEducation England and its separateresponsibilities, that is certainly true. Thereality is that everybody is pitching intogether on this and we have acompletely aligned view as to what now isneeded on workforce support and growth.

May 2020 Public Accounts CommitteeCultural change as well as technical change





What’s was the solution?

A system that is clearer about where it is headed, where more elements are aligned in the same direction, and where

expectations are more realistic

C2015 to Jan 2020

NHS long-term plan, and people plan

Legislation, 5-year NHS funding deal, Powis review, ‘Fix social care’

Fewer moving pieces with CCG and NHSEI mergers, return of regional management

Structures

Resets

Plans





What were the expectations?C2015 to Jan 2020

Eliminate 52 week waits for planned care and avoid growth in waiting lists

Over 11,000 people waiting over a year for care, compared to

1,600 a few months ago





C2015 to Jan 2020

Improve A&E performance, while waiting for Powis review

What were the expectations?





C2015 to Jan 2020

Financially balance NHS public provider sector and prepare for every org balancing

What were the expectations?





C2015 to Jan 2020 What were the expectations?

“System by default”

• System transformation and collective management of system performance

• Bind financial fates together with system control totals and capital funding

• Change how services delivered eg 1/3 outpatients moved from face-to-face

• Expand primary and community services inc. through Primary Care Networks

• Anchor institutions and wider determinants

The expectations were still high. Too high.





What’s happened?Covid-19






“It is the current generation, the

previous generation and the next

generation who have all come together.”

Sir Simon StevensMay 2020 PAC






Lockdown begins






Eg elective activity

Eg virtual appointments, call before you

go





Capture what you’re doing and have a framework





Some parameters still to be defined

• The political environment: A government with a large majority but not much time to get on with its plans before 2023/24, must-dos and nice-to-haves

• The public finances: attitudes to spending, trading within TME

• Workforce: international recruitment, attitudes to the NHS, morale and energy of existing workforce

• Physical logistics: hot and cold, green/amber/red

The future





The future Some options on where to go and how to get there

(2) A new plan characterised by need to respond to coronavirus – more centrally directed (inc. regions), leadership cells, provider-led, acute expansion inc. ICU

(1) Same NHS long-term plan, but deadlines pushed back, some elements emphasised more than others

(3) A new plan characterised by local direction, public engagement, prioritise investment in primary and community services, system-led





The future The national view

Sir Bernard Jenkin: There has been a certain amount of reference to the NHS long-term plan. Sir Simon, how much would you like to rewrite that plan in the light of the COVID experience?

Sir Simon Stevens: The fundamental analysis that underpins the long-term plan is, frankly, as true today as it was a year ago. As a country, we have clearly seen the benefit of joined-up services in responding. It goes under the title of integrated care, but actually that is what people have been doing in the heat of battle in the coronavirus response. We have seen the impact that obesity, heart disease and other chronic health conditions have on the susceptibility of people to this terrible infection. We want to tackle that. We know that we need to build our capacity, including strengthening the staffing support across the health service. We also know, as set out in the long-term plan, that doing it in the same old way is not the answer. We have to use technology to drive improvement. For example, just look at what GPs have done in the course of a few weeks. That points the way to what the future needs to look like. All that is unchanged and, if anything, the impetus to accelerate it is greater. There are some things that are now different in the light of that. We have seen that we have the ability to tap into very strong public support through volunteering. There has been an uptick in interest in joining the health professions. At a time when the rest of the economy is going to be so severely disrupted, I think we are going to need to think much more flexibly and creatively about new routes into nursing and other health disciplines. I am sure we are going to take stock, in the light of the new circumstances, but, fundamentally, the prospectus for the health service continues to enjoy substantial support.





#1 We retained resilience to deal with on-going Covid19 and pandemic needs

#2 We did everything we could to minimise excess mortality and morbidity from non Covid causes

#3 We returned to the right level of access performance for elective cases prioritised by clinical need

#4 We put in place an effective response to the other effects on public health of the pandemic

#5 We helped our people recover and established a new compact with them

#6 The positive innovations we made during the pandemic were retained, improved and generalised

#7 The new health and social care system that emerged was fundamentally better at addressing inequalities

#8 The new health and social care system that emerged was materially higher quality, more productive and better governed

The future The regional view

Albeit with some nuances eg retaining intensive care capacity at far higher levels





Some predictions

1. Nationally, there will be a reprofiling of the long-term plan, some deals on technology to retain digital capability, but no fundamental change of course. Workforce will remain the key challenge to delivery.

2. We will move slightly from ‘just in time’ to ‘just in case’ on balance between supply and demand, but will be constrained by workforce pressures

3. There will be contention over what decisions are related to Covid or not, though in some cases they will be hard to undo anyway eg hot/cold, centralisation of specialised services

4. Social care will be given additional funding to keep the system from collapse, but fundamental reform will prove elusive in this parliament.

5. Regions will take clear differences to how they discharge their duties, with London feeling the most like the old Strategic Health Authorities in its approach

6. The fissure between providers and commissioners will heal, but undesired rifts between secondary care and primary care may emerge

7. Manchester and Yorkshire will continue to be one of the pace-setters for what the system could look like if it was focused on integration and population health

8. Trust was built or lost during Covid – this will have a legacy eg discharges to care homes, staff break rooms, working from home, twitter restrictions

The future





Two final reflections

Most decision-makers have never lived through something like Coronavirus.

There is a danger that it distorts decision making eg rather than investing in community services, you invest in community lung rehabilitation; the

problems with social care are reframed as problems of grip and control; we

design a virtual consultation system that is more resilient to covid, but less

resilient to a cyber attack

A health care system can probably do one big “visible from space”

thing well at any given time.

But it will have to deal and recover from Covid-19; reverse the

HSCA2012; transform to system-working; recover operational

performance; Brexit…

Resist the urge to over-specify We’ve done our big thing?

© The King's Fund 2018© The King's Fund 2018

www.kingsfund.org.uk

Thank you

Siva AnandacivaChief Analyst

[email protected]

COVID19 20(20) and beyond...• Staffing shortages ... Sir Simon Stevens: It is a separate agency....

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