CHIEF OPERATING OFFICERS & DIRECTOR OF OPERATIONS NETWORK POLICY UPDATE

19 July 2016

Siva Anandaciva Head of analysis

What we will cover

01 BREXIT AND POLITICS

02 FINANCES

03 PLANNING

04 QUALITY

05 REGULATION

06 WORKFORCE

07 NEW CARE MODELS

08 CONCLUSION

A major league hitter can time a jet plane

Johnny Bench, Cincinnati Reds

What we will cover

01 BREXIT AND POLITICS

02 FINANCES

03 PLANNING

04 QUALITY

05 REGULATION

06 WORKFORCE

07 NEW CARE MODELS

08 CONCLUSION

Brexit

No brexit budget EWTD

NHS Providers Chairs/CEOs survey, April 2016 (n = 45) • 75% see negative impact

from Brexit on NHS • 40% think positive impact

on procurement and competition

• 40% think no impact on funding NHS as a whole

• 80% see negative impact on access to funding for research and innovation, and recruitment of the health and care workforce

Source: image from The Spectator

Homerton surgical team

Brexit

Impact on current and future workforce

Fall in the pound affecting procurement

prices c£900m

Delay to announcements e.g.

financial reset

Competition & procurement law

European Working Time Directive in contracts

but can revisit if not in internal market

Same SofS, same Department but

new/old priorities and new/old relationships?

All bets are off e.g. who runs NHS

Another General Election?

Wider impact on GDP and fiscal policy but first

dibs from social care

What we will cover

01 BREXIT AND POLITICS

02 FINANCES

03 PLANNING

04 QUALITY

05 REGULATION

06 WORKFORCE

07 NEW CARE MODELS

08 CONCLUSION

Struggle through 16/17… but 2017-21 U-Bend is coming

It looks like we will just struggle through 2016/17, the

supposed year of plenty…

…but current profile of additional NHS funding, increasing activity and new policy

commitments leads to crunch period in 2017/18 – 2020/21

% in

cre

ase

in N

HS

Bu

dge

t

The chart of financial doom

Source: NHS Improvement

1. The underlying deficit is far worse once prudential accounting and underinvestment in capital are factored in

2. This makes 2016/17 incredibly difficult with additional provider stretch needed 3. Puts us off track for the 22bn 4. Financial sustainability will eat new policy commitments and transformation for

breakfast

“It’s not creative accounting, it’s witchcraft”

What does good look like anymore?

Source:

How are things going? Well demand is up to our eyeballs,

we are nowhere near our financial control total, and we have a Requires Improvement from the CQC. So we feel we

are upper quartile at the moment.

NHS FT NED

And the corners of the triangle are nailed to the floor

Conflicting views on what’s the problem and what to do

1. Individual providers responsible for provider deficit

2. Must eliminate deficits and recover performance in 2016/17 year of plenty

3. Top-down individual control totals and performance trajectories right mechanisms

4. Provider Boards must be held to hard account, up to and including removal, if they miss a quarterly milestone

1. Provider deficits are a system issue

2. Realistically no chance of financial or operational balance by 2016/17

3. Control totals must be credible and owned by provider boards

4. Support and accountability in balance are needed, recognising where factors are beyond board control due to system impact and overall context

MUST. TRY. HARDER IT’S THE SYSTEM STUPID

And pressure to be part of the solution not the problem

How will you

explain to your

neighbouring

trusts that you

have not signed

up to a control

total?

Ask not what

your STP can do

for you, ask what

you can do for

your STP

20161//17 Sustainability and Transformation Funding

£5.5bn cash uplift (£3.8bn real)

£0.1bn Central policy initiatives e.g. MH, Cancer, Diabetes, IT

£0.2bn Targeted (for everyone)

£1.6bn General (for emergency care

providers)

£3.5bn commissioning budgets inc. pass through pension costs

£1.8bn Sustainability funding

• 70% released based on financial control total delivery • 30% released where operational trajectories achieved with tolerance and control total delivered

(assumed you play ball in the STP) • Better than binary pass/fail on everything, not handed back to HMT, not gummed up in system,

maintains incentive to hit your YTD even if you miss a month as you can earn missed payments • But still lots of financial uncertainty, working capital , appeals process, control total primacy,

ratcheting up of cumulative ask

2016/17 finances

Source: Kings Fund QMR April 2016

2016/17 is already falling apart. We closed 2015/16 with a £50 million deficit. Our control total for this year is a £15-20 million deficit. At the end of April we are already at - £10 million. NHS FT Director

What we will cover

01 BREXIT AND POLITICS

02 FINANCES

03 PLANNING

04 QUALITY

05 REGULATION

06 WORKFORCE

07 NEW CARE MODELS

08 CONCLUSION

Emerging tension between different forces

CENTRIFUGAL

CENTRIPEDAL

• Control totals for providers

• 1% hold back for CCGs • Increased CCG

assurance • STPs

• Co-commissioning of primary care and specialised care

• Devolution / Delegation

• Earned autonomy • STPs

Does the city come before the citizen?

• Our future lies in networks and health systems; not individual go-it-alone institutions - Simon Stevens.

• An emerging Aristotelian view of planning through sustainability and transformation plans (STPs)

• Strategic, multi year, place based plan to set alongside single year, institution based, operational plans

• Come together with your local place, address the wicked issues and develop a long term plan to transform care and plot a path to long term sustainability

But several tricky issues to work through

Timelines too ambitious (we

have a vision not a plan)

Late entry of items e.g. specialised commissioning

Top-down baubles e.g. 7DS not

bottom-up wicked problems

Different patches going at different

speeds e.g. leaderless STPs

If you want to build a new

hospital, is that an STP issue?

No statutory basis, so what holds you

together?

Still regulated as institutions

System control totals and

performance proving tricky

Can not ignore the law, consultation,

judicial review

An informal initial categorisation

Good plan Addresses the key issues. Credible leadership. Credible finances. Acknowledges areas that need further work e.g. specialised commissioning

Wrong plan Does not address the wicked problems e.g. reconfiguration or service swaps, vertical integration, social care

Box 3

Do not pass go First time these people have been in a room together. A non-plan.

And multiple overlapping footprints

• 44 Sustainability and transformation plans

• Local education and training boards

• Academic Health Science Networks

• Ambulance services • Local Digital Roadmaps • Urgent and emergency

care networks / local delivery networks

• Maternity networks

Relationships are key but also hard

• Some STP planning meetings are turning into the conclave of the five families

• CCGs opting out from process you can not opt out of

• Little power to keep LAs at the table if they do not want to be there

And some STPs are a beautiful ship

It’s like going back to nursery school. NHS England and NHS Improvement have told us to

go an build the most beautiful ship we can. And our plan is beautiful. It’s got rigging and

masts and everything you could want.

The one thing they forgot to tell us is that the damn thing

has to float.

NHS Trust strategy director

It’s like going back to nursery school. NHS England and NHS Improvement have told us to

go an build the most beautiful ship we can. And our plan is beautiful. It’s got rigging and

masts and everything you could want.

NHS Trust strategy director

What we will cover

01 BREXIT AND POLITICS

02 FINANCES

03 PLANNING

04 QUALITY

05 REGULATION

06 WORKFORCE

07 NEW CARE MODELS

08 CONCLUSION

System under sustained operational pressure 98% 92% 91% 88% 86% 83% 82% 80% 77% 75% 73% 67%

97% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%

96% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%

95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%

95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%

94% 92% 90% 87% 84% 83% 81% 79% 77% 75% 72% 63%

94% 91% 89% 87% 84% 82% 81% 79% 77% 74% 72%

94% 91% 89% 87% 84% 82% 81% 78% 77% 74% 71%

94% 91% 89% 87% 84% 82% 81% 78% 76% 74% 70%

92% 91% 89% 86% 84% 82% 80% 78% 76% 74% 69%

92% 91% 88% 86% 84% 82% 80% 77% 76% 74% 68%

92% 91% 88% 86% 84% 82% 80% 77% 76% 73% 67%

%

seen

in 4

hours

Type 1

A&Es

Q4

2015/

16

Source: NHS England

Worst A&E performance figures since the standard was introduced – 4Q 87%

Ambulance services under sustained demand and performance pressure

Elective operations cancelled

District nursing and health visiting

caseloads increasing just as contracts come up for tender

Mental health referrals increasing

TLAs not always the answer

Interviewer: What is your level of change fatigue, on a scale of 1-10?

NED: 15

Interviewer: It’s a scale of 1-10

NED: I’m too fatigued to stick to scales

• Exec level • New focus on

U&EC • Segmentation of

areas

Newsflash

Other key new national initiatives

New Health and safety investigations branch (HSIB) • Hosted by NHS Improvement, but impartial • New chief investigator Keith Conradi from airline industry • One of the primary purposes of the investigations will be

working out where safety could be improved through greater standardisation and incorporation of human factors into clinical systems and processes

National and local “freedom to speak up” guardians • Dr. Henrietta Hughes appointed as National Guardian,

hosted by the CQC • Leads cultural change within NHS trusts and FTs so staff

feel confident and supported to raise concerns about patient care

• Learning events, training for guardians and good practice documents

Review of deaths

By April 2018 NHS will have medical experts independent review every death

Standard method developed by NHS England and Royal College of Physicians

Will cover all deaths so 300 doctors trained by April 2018 to administer

Expected to uncover more poor care that will lead to more referrals to coroners and a different caseload to what they normally see

Understood that there is variation in how coroners operate, and relationships with the NHS…

But what is the strategy?

Responsibility for quality is too diffusely distributed across the national leadership,

making pursuit of a common agenda difficult

Compounded by inconsistencies in local

accountability that lose something in translation from national level

Between June 2011 and the end of 2015

there were 179 quality-related policy measures announced by government.

Nearly one a week.

Control and improvement are out of balance

What we will cover

01 BREXIT AND POLITICS

02 FINANCES

03 PLANNING

04 QUALITY

05 REGULATION

06 WORKFORCE

07 NEW CARE MODELS

08 CONCLUSION

NHS Provider Sector - regulation

All data correct as of June 2016

16 Trusts are in quality

special measures

68%

Of rated trusts are rated ‘requires improvement’ or ‘inadequate’ by the Care Quality Commission (CQC)

13 Trusts are in success regime

areas

6ish Trusts are in financial

special measures

Frimley (27) Salford (15)

West Sussex () Northumbria (18)

Newcastle (39)

Clear Jim Mackey narrative emerging

We're here to support, we're here to support, but there has to be accountability

• Trying to build headroom for leaders.

• Interventions on the contracting round (CCGs

but not LAs) and tendering already.

• Agency out of control sends out wrong signal. Need to get others off the pitch but we can’t do that until we prove we can handle performance and finance. Don’t put in unreasonable plans.

• As legislation intended NHSE and NHSI balancing each other.

NHSI changing the landscape

It feels like the Trust and CCG are caught in the cross-fire between NHSI and NHSE.

NHSI say we cannot sign a contract unless we can hit the control

total.

The CCG are told they MUST submit a break-even plan and the only way they can do and fund us for activity is to access the 1%

transformation fund, but NHS England will not give them permission to do that.

We are close to our control total, but do not have a realistic and

achievable plan to go that further mile. So it is getting to the point where we and the CCG either flip a coin to see where the financial

risk sits, or we ask NHSI and NHSE to slug it out and tell us what our local contract value is.

NHS FT Finance Director

A new oversight framework

QUALITY CQC rating, patient

& staff surveys

MONEY Old metrics

Use of resources Carter

OPERATIONAL PERFORMANCE

Small set of constitutional

standards

LEADERSHIP Well led framework

Organisational health

STRATEGIC CHANGE

In progress, likely to include STPs & NCM

Earned autonomy

More autonomy

Limited autonomy

Essentially special

measures

• Local decision making free of constraints

• Fewer data and monitoring requirements

• Simpler processes for transactions

• Recognition and opportunity to spread success

A new single oversight framework for FTs and Trusts, which establishes a single definition of success and a new relationship between the regulator and the regulated

Some issues with the NHSI oversight framework

• One approach for an FT and trust provider sector facing similar challenges

• Potential to align far better with CQC • CQC rating slots into NHSI quality

rating • NHSI develops use of resources

methodology to slot into CQC rating

• Takes some relativity into account

through performance trajectories

• Provides some implicit clarity on the FT pipeline, authorisation process and sequence with earned autonomy

• Familiar first three domains

• Subjectivity of leadership and strategic change

• Alignment with special measures

• Institution vs system not resolved

• Overlap between CQC and NHSI rather than one framework e.g. CQC rating is not the only thing that determines NHSI quality rating

• No substantive move to outcome indicators or whole system metrics

• No explicit recognition of trajectory and there is a difference

Some performance issues in new framework

• Look at classic constitutional standards (e.g. Red1, A&E 4 hours) • Use STF trajectories if you have them, use national standards if you don’t • Trigger potential concern if you fail for two consecutive months • Can come in before two months of failing, if other factors in play e.g.

significant deterioration in a single month or multiple concerns across other standards

WHAT DO YOU THINK? • Still output rather than outcome • Still institution not whole system (e.g. emergency beddays per 1000

population, survival to discharge) • Two months pretty quick • Two-tier economy with STFs • What’s the alternative e.g. whole system metrics you would feel confident in

being regulated

CQC new strategy to 2020

Encourage improvement, innovation and sustainability in care • More flexible registration e.g.

NCMs • Assessing use of resources • Views of quality across

populations and local areas

Intelligence-based approach • Development of CQC Insight • Targeted and risk-based

inspection where comprehensive inspection is exception to the norm

Promote a singly shared view of quality

Improve CQC efficiency • Focus on CQC VfM and changes

to fees

1. Horizontal integration at

national level i.e. NHSE, NHSI, CQC

agree on what good quality care looks like

2. Vertical integration

e.g. boards and CQC can speak in same

currencies (e.g. Frimley and Barking) and CCGs on same

page

But how long will we continue this approach?

Source: Don Berwick

The goal

The reality

What we will cover

01 BREXIT AND POLITICS

02 FINANCES

03 PLANNING

04 QUALITY

05 REGULATION

06 WORKFORCE

07 NEW CARE MODELS

08 CONCLUSION

Supply of staff

• Significant variation in vacancy rates from 15% in London to 3% in parts of the North

• Expectation that by 2019/20 ‘we will have it right’ in terms of supply and demand for nurses and that in the meantime, agency staff and overseas recruitment must plugged the gap

• Open to over-supply planning

Agency and locum caps

Source: HSJ, Liaison

• Zero-sum game • Unintended

consequences e.g. therapists

• Additional levels of management sign-off on bookings

• Review of job planning • Sharing capacity across

wards • E-rostering • New posts e.g. physician

associates, associate nurses

So a workforce squeeze regardless of contracts

Pressure on rotas and

performance and CQC

requirements

20% vacancies in specialties even

in some attractive deaneries

Exiting training Locum & Agency

caps

New limits on consecutive long

days

“ We need more nurses and junior doctors than we have at present to run these rotas. The posts we need are not being allocated, and even if they were allocated in sufficient numbers we do not have enough people in the right parts of the country and the right specialties to fill the posts. ” NHS Foundation Trust CEO

Some other workforce developments

• Still a question of how it will be implemented not if (for now) • Growing concern though that nursing is different and

bursaries will have an impact on supply e.g. Entry age, part-time work

Move to bursaries for healthcare

education funding

• Growing focus on clinical productivity and output per WTE • Extend Prof Tim Briggs GIRFT to new specialties including

paediatric surgery • Still planned roll-out to mental health by end of calendar year • Quick on metrics & regulation but not support

Lord Carter - Mark II

• Attempt by NHSI to rebalance and move from agency being used to meet 1:8 and fear of CQC at all costs:

• Flexibility in skill mix • Focus on outcomes not inputs

• Concern from Royal Colleges that this does not learn mistakes from Mid-Staffs

• Concern if CQC on same page

Safe and sustainable staffing

Safe & sustainable staffing

There will be times of course when the safety of patients requires agency staff to be brought in and nothing being announced

will prevent you from doing that

Ruth May,

NHSI Nursing Director

But may be more complicated than that

• NHSI “Ok, yes we know you need nurses, but they cost too much so

try not to get them from agencies unless absolutely necessary in which case you’re welcome to do so.”

• Provider “Ok fine, what constitutes ‘absolutely necessary’ – is it still the same as what currently constitutes ‘absolutely necessary’?”

• NHSI “That’s your call”

• Provider “Ok fine, what’s CQC’s call on that going to be, given I’m supposed to be making the most efficient use of resources but not compromising patient safety?”

• NHSI “We’ll know the answer to that next time CQC does a CQC inspection.”

Source: NHS Providers policy advisor

And that’s before we get to Junior Doctors

On course for phased introduction

Provisional agreement on new contract not ratified by referendum Plan is still to introduce in phases

Additional costs to providers including additional employer pension contributions Significant additional duties for monitoring safe working hours and breaks and rotas

Need to track impact on wobbly existing rotas

Still significant trust and morale issues

Source: Junior Doctor Blog

Is this contract safe? On paper yes – the new safeguards reduce runs of shifts and provide a system that could

both address individual overworked doctors and collect data on understaffed rotas for the first time.

But in practice? In practice there has been no

groundwork laid for the expanded roles of educational supervisors, no realistic investment in the Guardian role in many trusts, and the financial pressures on hospitals right now are mounting. I simply cannot see hospitals

having the will, the manpower or investing the resources to make this work.

The old banding system was difficult enough- some

trusts actively hid hours monitoring data, and flat out refused to sort out rotas that breached safe working. But

where it did function, speaking from personal experience, it worked very well and effectively.

What is our offer?

Source: Roy Lilley, NHS Managers

…flexible rotas; child friendly (a crèche); a culture that is kind, creative and fun;

whole person training and development; dump bully-bosses and staff who behave

badly; listen to people; realise your people have a life outside work; find out what inspires people and do more of it; show people what good looks like and help them achieve it; accept pay is a

'national thing' but figure out what you can do locally with access and discounts

to become the local employer of preference...

Consultant contract

Radical contract reform

All change is painful, so change in one go

Put forward joint position from as least worst option

available through negotiation

Less radical reform Negotiate a package that

achieves delivery of 7DS but at a cost

Defer reform

Avoid strike of juniors and consultants at same time

Scale back 7DS ambitions

Lack of a national workforce strategy

Given the size of the NHS, workforce planning

will never be an exact science, but we think it clearly could be better

than it is.

The current shortage of nurses is largely of the

health, care and independent sectors’

own making

Workforce is a relatively neglected area of policy which is often pursued

as an afterthought

Regional planning to solve the hitherto insolvable

NHS England, NHS Improvement, HEE, CQC, PHE, NICE new regional structure based on four areas

Create Local Workforce Action Boards. Aligned to STPs (albeit < 44). Lead on local workforce issues. Jointly chaired by HEE and local CEO

Baseline health & social care workforce and identify issues. Develop a high-level workforce strategy to meet STP ambitions and an action plan for required investment in workforce

What we will cover

01 BREXIT AND POLITICS

02 FINANCES

03 PLANNING

04 QUALITY

05 REGULATION

06 WORKFORCE

07 NEW CARE MODELS

08 CONCLUSION

5YFV New Care Models growing

Two further new care models proposed

Reinvention of the acute medical model in small district general hospitals

Differs from Acute Care Collaboration (ACC) vanguards by specific focus on small district general hospitals, and

interest in care pathways and clinical workforce, rather than organisational

forms and operating models

Tertiary mental health services

Secondary MH providers taking on tertiary MH services such as secure MH and forensic services, perinatal mental health, Tier 4 CAMHS, CAMHS eating disorders, Tier 4 personality disorder

services (six pilots with S.Firn)

x14

x9

x6

x8

x13

Five vanguards

losing funding in 2016/17

as risk appetite grows (or shrinks)

It’s easy to be cynical but 5YFV KPIs matter

1 Brave CCGs where the council will become the strategic commissioner, the operational commissioning will move to the provider, and the CCG remains as a shell for statutory purposes

2

Fundamental changes to how we do things. PACs that may not have outpatients in the future. Move from a position where high DNA rate in geriatric outpatients (booked 6 weeks out) due to confusion or admitted already, to an open access outpatient slot tomorrow, telehealth and primary care access

3 Emergency department consultants after telehealth support to care homes launched: fewer patients come to our department to die. They die where they chose to.

Greater respect for localism

The whole culture of Waterstones, which he says had become too top-down, is now in flux. Local managers must make choices to suit local custom. They have abandoned uniforms, they can choose their own sales items to prioritise, and stock more non-book goods such as stationery. In other words they must curate, much as the staff in Daunt Books do, helping shoppers find interesting titles and avoid the obvious. James Daunt

Source: Management today

Including development of healthy new towns

Nye Bevan was Minister of health and housing. Now back

to integrating health, home and environment.

10 pioneers areas building

dementia-friendly communities, new residential

care facilities, having fast-food-free zones near schools, walkable neighbourhoods etc.

But needs considerable commercial partnership

working

Source: Anna Kovecses

What we will cover

01 BREXIT AND POLITICS

02 FINANCES

03 PLANNING

04 QUALITY

05 REGULATION

06 WORKFORCE

07 NEW CARE MODELS

08 CONCLUSION

Things that have changed since we last met

2015/16 deficit,

2016/17 off track and a

reset

STPs submitted and a new spec comm framework

Junior docs agreement

rejected and new

safe staffing guidance

NCM funding, Estates review

New CQC strategy and

NHSI oversight

framework

Brexit, a new Prime Minister, a

new Cabinet

A lot going on across a range of different fronts

Success is now proof of concept/capability?

Source:

• 65% of sector in deficit, £2.5bn overall deficit, 11 trusts with

individual deficit > £50m • 4 providers meeting last quarter’s

A&E standard • 68% of providers requires improvement or inadequate. 16

providers in quality special measures

• 80% of providers in surplus & sector in aggregate surplus

• Meeting operational standards at aggregate national level • Bending CQC curve

• 20% of NCM delivering, 50% of population covered

• Four 7DS standards for U&EC

2015/16 2020/21

NHS Improvement 2020 objectives

Shared planning guidance must dos

Develop a high quality and agreed STP

Return the system to aggregate financial

balance

Sort out general practice

Deliver A&E and ambulance targets

Deliver RTT Deliver cancer

standards

Achieve and maintain the two new mental

health access standards

Deliver actions set out in local plans to

transform care for people with learning

disabilities

Improve quality, particularly for

organisations in special measures

And also deliver paperless NHS and seven day services and prevention

So what is the signal and what is the noise?

1. What do you get sacked for? A&E (or your equivalent) and finances

2. Safe and sustainable staffing – comply or explain. But explain proactively to CQC, NHSI, Healthwatch, MPs, everyone.

3. STP play nice but don’t forget the law and what you get sacked for

4. Is FT status the pot of gold at the end of the earned autonomy rainbow, not the rainbow that leads to the earned autonomy pot of gold

Welcome to Frimley

Wexham Park (our Prime Minister’s local hospital)

Oct 2015 Feb 2014

Clinical processes, management time, enthusing staff are all important. The hard and soft basics matter e.g. theatre utilisation

time, humility, cakes on the bus, long service awards

Welcome to Road House

• Guys, our core business is to run a hospital, and we’re not very good at it.

• Section 28 coroner referrals on preventing future deaths. You need to not just burn their house, but key their car and insult their partner to get one. They are that bad. We had 5 on the books.

• Serious incident lead and clinical audit lead in same room but not on the same planet

• Clinical director prep for CQC – what are your five key risks? Absolutely right. Now look at your risk registers which are three years old and don’t match what you just told me

• Flush out the bad apples. Managers and clinicians who have been cute and stayed below the radar being harmfully incompetent

NHS Trust Strategy Director

Welcome to Oxford

DTOC is an issue we will never solve. We are the worst in the country.

Perhaps the STP will solve it….Then new CEO said let’s buy capacity – we

can afford it, and we can’t afford not to. 60 care support workers directly

employed from career fairs aimed outside health & social care sector, who

provide social care in people’s homes after discharge from hospital. Bought

intermediate care beds. Reduced DTOC significantly.

Let’s find our 300 keenest people and ask for a 2 minute smartphone selfie

video on what their improvement idea is. 600 minutes of improvement. Lots

of popcorn.

Welcome to Croydon

• Not all good news

• ED rebuild with CAMHS paeds area

• Frailty Unit reducing length of stay and medical outliers

• Accountable care partnership • 10 year capitated

outcomes based contract • Under/over 65 incentives • Age UK a key member

and one member one vote

Thank you

From: It sounds like this

“COOs” person is going to be very important

moving forward – can I have their details?

To:

If we are going to take Carter to the next step it

is now clear to us we need a mix of COOs involved. Can you

get a group together?

THANK YOU • Sivakumar Anandaciva • Head of analysis | NHS Providers • One Birdcage Walk | London | SW1H 9JJ

• DDI: 020 7304 6819 • siva.anandaciva@nhsproviders.org

Q&A

Images from Googleimages & HSJ