NHS England and NHS Improvement Board Meeting in Common – 26 September 2019


>>Dido Harding: – sitting to my right – ought
to be paired with a David.>>David Roberts: Absolutely. We’re common
as muck.>>Dido Harding: Lord Prior is – well, you
are; he isn’t.>>David Roberts: That’s probably true, actually.
I’ll certainly agree with you on the – for me, absolutely. I’m quite happy to be called
that.>>Dido Harding: So, Lord Prior is unable to
be with us today, so I’m going to physically chair the meeting, but David in his capacity
as the Deputy Chair of NHS England is chairing the NHS England part of our committee in common,
if that makes – or board meeting in common, sorry.
>>David Roberts: Indeed.>>Dido Harding: Okay, so thank you for doing
that.>>David Roberts: Good. I’m hoping not to
do very much. It’s in your tender mercies.>>Dido Harding: Well, should you be needed,
you’re here. The other apologies we’ve had are Andrew Morris, David Behan, and, just
at the last minute, Lord Darzi has had to go to a clinic to see some patients this afternoon.
And we should also acknowledge this being Amanda Pritchard’s first meeting, so very
much welcome Amanda as the Chief Operating Officer and Chief Executive of NHS Improvement,
so welcome to the team.>>Amanda Pritchard: Thank you very much.
>>Dido Harding: Have we got any declarations of interest that need to be added to the register?
Everyone happy? Okay. I can hear – there’s an interesting television programme going
on in the background.>>Amanda Pritchard: I think it’s you.
>>Dido Harding: Is it me? That’s even more disturbing. Are there any comments on the
minutes and matters arising from the last meeting? Any issues there, we should just
pull out? Jessica, anything on the matters arising that we need to bring up?
>>Jessica Dahlstrom: No, it’s all in hand.>>Dido Harding: Okay, excellent. I know there
was one that was a meeting that – for Noel and I, with NHS Resolution, that is in the
diary, if that’s not clear. Excellent. In which case, we’ll just quickly move on
to my update. Couple of things that I wanted to reference. The first thing I’d like to
do is to thank Jeremy Hughes and the Alzheimer’s Society, who have just run a fantastic Dementia
Friends training session for the non-execs, which has been a really brilliant break between
board meetings to help us learn, bring us back to really why we do this. You see a number
of us wearing our badges – but also, just helping us really raise our awareness of what
it feels like to have dementia and how all of us can play a role in making our environments
both in the NHS and at home more dementia friendly. So, thank you to Jeremy and his
team; we are now all Dementia Friends, which is excellent. So, that’s the first thing.
Second thing: since our last board meeting, as ever, I have been out and about a fair
bit. So, for example, I spent an absolutely eye-opening morning shadowing Dr Clare Gerada
in her clinic, which treats doctors, provides mental-health support for doctors, which was
a great combination for me of getting closer to our mental-health clinicians, but also
with our people plan agenda on what we need to do to support our clinicians working in
the NHS. What Clare and her team in Vauxhall and across the country are doing is just that,
so that was hugely helpful for me. But I’ve also been out and about looking at AI at Moorfields,
at what Milton Keynes are doing in terms of engagement and becoming a great place to work.
Been to East Surrey with the trusts that are working with Virginia Mason on continuous
improvement. And to Bolton two weeks ago to open their urology unit. So, I’ve been trying
to get out and about as much as usual. I used to write that down, but I like people to know
where I’ve been going. And tomorrow, a number of us are off to Worthing to spend some time
with Marianne Griffiths and her team understanding the patient-first approach to improvement
that they have in Worthing and in Brighton. So, those are my travels.
And then, the final thing I wanted to just put on the record: we will be writing out
today to all provider chairs and lead governors of foundation trusts with some work that’s
been underway for the last 18 months setting out a development framework for NHS chairs,
an appraisal framework that underpins that development and competency framework, and
a remuneration framework for chairs and non-executive directors. It was – came to our people committee
quite a while ago and has been working its way through the various levels of approval
that remuneration does require, and so that will be heading out to the service writ large
this afternoon. So, that’s my update. Any questions, comments?
Excellent. In which case, we will hand over to Simon.
>>Simon Stevens: So, I think most of the substantial items we need to talk about are elsewhere
on the agenda. Let me just mention five things briefly, before we get into that. The first
is that, as we previously discussed, the single biggest thing the Health Service has got to
get right, right now, is better support for our frontline staff. We will next week therefore
be allocating the £150 million of professional development funding which, since our last
meeting, Ruth and colleagues, we’ve been able to secure, which will mean that our frontline
nurses and other health professionals will have that earmarked training and development
support for the next three years and beyond. There’s obviously a lot of other work going
on in terms of how to expand training pipelines and better support for retention of staff
currently at work, but that’s a concrete set of progress that’s been made since our
last meeting. Secondly, we have long argued that, despite
the fact that we’ve got a five-year revenue funding settlement, the fact is that too much
of our buildings and equipment is out of date, and we have bottlenecks for diagnostics as
a result of that lack of capital investment. Since we last met, we have seen the improvements
in the availability of capital funding for the current year, £1 billion extra of permission
to fund capital investment across the NHS, and the beginnings of a hospital replacement
programme, with the first set of schemes announced. And we are hopeful that that is just the beginning
of what will be a bigger process of hospital upgrades, but also mental-health services,
community health services, and primary care, as well.
Thirdly, if you talk to anybody across the frontline of the NHS right now, they would
say that the NHS is under real operational pressure. Somebody put it in terms of, the
NHS feels full at the moment. And so part of what we’re going to be discussing this
afternoon is the work underway not only to try and deal with that in the here and now,
but the broader service redesign agenda to relieve some of those pressures in the different
parts of the system, of which the work with GPs, the work on same-day emergency care,
many other things, are all of a part. But frankly, that is the key focus of leaders
across the NHS right now. Fourthly, that is in the context then of the
run-up to October 31st, and the exit from the European Union. And so you’re going
to have a direct briefing from Keith Willett this afternoon around the NHS’s preparations,
in conjunction with the Department of Health and Social Care, and other parts of government.
Fifthly, all of this is happening at a time when we are now in the final stages over the
next two months or so, in the bringing together of NHS England and NHS Improvement, and we
have to record the fact that that means it’s a time of quite considerable uncertainty for
many hundreds of our staff across both organisations, having had a big consultation and discussion
over the summer as to the shape that that should look like. And so I just want to place
on record I think my thanks and our thanks as an entire board for the people who are
continuing to work so diligently on those first four items, while nevertheless personally
experiencing the fifth.>>Dido Harding: Yeah, absolutely. Excellent.
Any questions? Ruth?>>Ruth May: It was more of a comment rather
than a question. So, Dido, you and I were at the Queen’s Nursing Institute one day
this week, and both of us were given speeches. And yesterday, I had the opportunity to speak
with a number of DONs from across England, Directors of Nursing from across England.
And the overwhelming positive feeling about the CPD announcement of nurses receiving investment
in their continuing professional development, not only is it appreciated about their own
career progression, about more likely to stay within the NHS, but also for patient safety,
so they’d be safer practitioners. So, it’s a great downpayment, and I know people are
very much appreciative of that.>>Dido Harding: No, I agree. David?
>>David Roberts: Simon, your comments about the NHS feeling full I think resonates with
the – all the conversations that we’re having. I think when we come into the section
later on, on the performance report and so on, it would be really helpful to know what
we’re going to try to do to change that, given that we are running into winter, in
particular, with whatever pressures that will bring.
>>Simon Stevens: Absolutely. And both Amanda and Pauline, I think, will use the time to
get into that. There are some things that are in the gift of the NHS locally, there
are some things we’ve got to get right nationally, there are some wider questions that frankly
are still not properly resolved, of which the single biggest item is the pensions effect
on the availability of A&E doctors, surgeons, anaesthetists, and that does need a definitive
resolution, because what the Royal Colleges, what clinical directors locally, individual
doctors, our trust leaders are telling us, is that that is having a material effect on
the availability of staff to look after our patients.
>>David Roberts: And you’re confident that that’s understood in the appropriate parts
of government?>>Simon Stevens: I think it’s understood
that there is an issue, and now we need to move that understanding to a set of conclusions
that would resolve the matter.>>David Roberts: Okay.
>>Dido Harding: Okay. Any other comments? Okay. In which case, we should move onto our
next item, which is EU-exit readiness. Keith, can you come and join us?
>>Keith Willett: Thank you. Thank you very much. My role in this is, I was appointed
as the Strategic Commander for EU Exit for the NHS, and with responsibility for taking
the NHS and its structures out of the European Union, if indeed, that is the case, on 31st
October. And I would just remind everybody at this point in time that the legal default
is that we – the UK does leave the European Union on 31st October.
So, just to put things into context for everybody, the Department of Health and Social Care does
lead the response on EU exit, and is responsible for the planning and the preparation of the
health and care sector, so NHS England and NHS Improvement’s roles are to support that
process, to prepare and plan for any issues or adverse incidents that may arise as a result,
and take the opportunity for benefits that could also accrue by the work that we’re
doing. I’m pleased to report that the NHS is in a good position of readiness at this
point in time, but we must recognise that the potential scale and scope of a no-deal
exit means that there undoubtedly will be some issues, and that there are elements that
are outside the control of NHS England or NHS Improvement, and that we are dependent
on government action in departments, and also on industry. There is a paper that’s laid
before you which lays out the relationship with the Department of Health and Social Care,
and the Government, and it also explains the operational response structure that we have
put in place, which includes a national coordination centre, regional coordination centre, a commercial
and procurement cell, as well as structures within every NHS organisation to support an
EU exit. And that will – and they have been given advice and support to make ready. The
make-ready process has been very individual. We have gone round the country and helped
the 400 NHS organisations, so that includes the clinical commissioning groups, the acute
trusts, the ambulance services, mental-health trusts, community trusts, and as well as the
key stakeholders, to help them understand what a no-deal exit impact means to them in
terms of their workforce, the supply of medicines, medical devices, what it means around data
and information flows, what it means around the patients who are EU nationals living in
the UK, and indeed, UK nationals living overseas. They’ve had – so, an extensive exchange
has gone on, and they – those organisations have been tasked to go back and to make the
changes and readiness within themselves in anticipation of a no-deal exit.
The particular issues that I raise in the paper are around, obviously, we have taken
the NHS through this in the end of March and in mid-April, but this time, there are some
differences, is that we are going into winter rather than coming out of winter, and it’s
already been alluded to that there are – will be significant pressures within the system,
and we have aligned our winter operational response and our EU exit response, and ensured
that one isn’t surging into the other, as it were, so that we are capable of managing
a heightened level of demand. The other issue I have highlighted in the
paper is around our reliance on social care, a sector we know that is actually very fragile
in many ways, has had more cuts over recent years, and also, has a different employment
and provider model, which makes it more difficult to have perhaps the same national grasp that
we have in the NHS, and how we have encouraged the local health and care economies to come
together so that the NHS, indeed, can support social care where that will be of benefit,
particularly if they start to get into difficulty. And the third aspect I’ve raised is that,
clearly, at the moment, we don’t know what the outcome and impact will be of a no-deal
exit. We have the government planning assumptions and we have worked to those, but there could
be issues going on for a lengthy period of time, and we will need to address the resilience
within NHS England and NHS Improvement to manage what could be a lengthy period of multiple
issues. So, that’s perhaps a brief update, and I’m
very happy, of course, to take any questions.>>Dido Harding: Any comments or questions?
Thank you, Michelle.>>Michelle Mitchell: Thank you. We had the
pleasure, really, of hearing the full briefing in the audit committee. I mean, is it possible
just to expand on some of the risks around the social care workforce and what you think
they may need for the NHS? And perhaps describe to us whether you have the team in place and
the resources to fulfil this programme.>>Keith Willett: So, on the social care workforce,
yes, absolutely, and that would be one of our indirect risks, certainly in terms of
the NHS. So, the NHS workforce, about 6.5% of our workforce are EU nationals, and they
will all be working under the terms and conditions of the NHS, particularly agenda for change,
which covers care staff and nursing staff. In the social care sector, it’s about 8%
are EU nationals, but like the NHS, there is a significant variation across the country.
So, in London and the South East in particular, there are very high numbers of EU nationals
working in social care. Many of them will be on an unstructured pay scale, and many
on relatively low pay scales within that. Clearly, the NHS is very dependent on social
care. We have about 100,000 beds in the NHS. In the care home sector alone, there are 450,000
beds, and about 1 million in total looked after in the community. So, any impact on
the social care workforce, to either domiciliary care or to the care home provision, would
have significant knock-on effects, hence why I think we have been asking the NHS at the
health and local – and the social care community locally, particularly through the local resilience
fora, to focus on this, to understand each’s business continuity plans, to a level that
we haven’t done before. The other issue I think in the social care
workforce is, the provider sector is very fragmented; something like 85% of the care
home provision are small or medium enterprises, they’re not large corporate organisations.
And therefore, we don’t have either the same level of information about how prepared
they are, or, indeed, what their plans are for resilience. Now, the Department of Health
and Social Care has that responsibility and are working down through the directors of
adult social care and MCHLG to get assurance in that sector, but clearly, it is an area
that remains vulnerable. And within government planning assumptions, which are public, there
is a risk of the – of sterling value changing, and clearly, that would have potentially another
significant impact. I don’t see the social care workforce issue as being a day-one issue,
but it could certainly become an issue over time.
>>Dido Harding: Thank you. Any other questions?>>David Roberts: What help do you need?
>>Keith Willett: So, I think for me, the greatest help I could have in the lead-up to 31st October
is to ensure that events like this, we do get the information out to the public, to
the NHS staff and to our patients, just how much preparation has gone on. And it is extensive
across health, in particular, and they should be reassured that that has gone on. Also,
we have put in extensive response models in order to deal with any incidents or issues
that do arise. Now, that confidence needs to get to the public and to the patients,
because what would really hurt the NHS, and therefore hurt patients, would be if behaviour
started to change unreasonably leading up to that, so people started to do things differently,
ask for more medicines, that sort of thing, which would clearly make – create difficulties
within the system which need not be there, because all of that has been managed well
upstream. And we’re very used to it; the NHS and our staff in the NHS in particular
are used to managing risk day in, day out. That’s what we do, whether you’re the
bed manager in a hospital allocating patients, whether you’re the nurse in A&E or the GP
in the surgery, or the paramedic at an accident scene. Managing risk and prioritising is what
we do, so I think the public and our patients can trust that we will do that through whatever
is presented to us.>>Dido Harding: Thank you, Keith. Steve?
>>Stephen Powis: Keith, I was just going to expand on that point, because as you just
alluded to, the NHS, both nationally/regionally and frontline staff are very used to dealing
with issues that arise, often with short notice, where we need to, of course, correct, or we
need to put in support for supply chain disruption, etc. So, I wondered if you could expand a
little bit on the sense of where the planning is building on expertise that we already have,
and where there may be some new risks, what you have done to mitigate those new risks.
>>Keith Willett: So – thank you. So, I’ll use medicines as the example, because that’s
probably easier. So, there are a shortage of medicines all the time, and have been for
years. At any one time, there are dozens if not up to 100 medicines that the NHS will
be aware that are in – have some shortage. That’s business of usual for us. Most of
those are managed well upstream with the suppliers, with the manufacturers, and very rarely do
they come to – even to the notice of the public or patients. So, that system is all
in place. We’ve had that established across government and across the NHS for many years.
What we’ve done is, throughout the EU exit planning, we have enhanced all the elements
in the normal pathways that we use. So, we’re not asking people to do anything different
within the organisations; we’re following the business-as-usual functions, how they
identify problems, how they escalate problems to make us aware nationally, and then we’ve
increased the capacity to manage those nationally. So, that’s why I’m saying we’re confidently
well prepared in that regard.>>Dido Harding: Wol?
>>Wol Kolade: Thank you. Could you say a bit more about how you’re working with the other
departments within government? Because of course, it’s not working in isolation; you
have to interface with other people.>>Keith Willett: No, I’m pleased to say
that, having taken on this role, one of the first things was that the Department of Health
and Social Care very much adopted the NHS into their structures. So, we are represented
on all their boards, their assurance boards, their supply boards, and their operational
boards, working very closely. They obviously have the direct access to government departments,
but I have been confident that they have given me all the information I need for the NHS
to make the necessary responses, and indeed, where appropriate, I’ve actually joined
them to meet with other departments, particularly perhaps, the Department for Transport, which
are key in terms of the freight capacity and the supply chain to the NHS. And indeed, I’m
working with the Cabinet Office, as well. So, in that regard, we’ve had a very good
relationship.>>Wol Kolade: Thank you.
>>Dido Harding: Keith, is there anything else that you need from us? Mindful particularly,
as Simon said earlier, the degree of additional workload that people are feeling within NHS
England and NHS Improvement as we bring our two organisations together, that extra stress.
Is there anything you need from us as two combined boards to help you?
>>Keith Willett: So, I think that is keeping this very much on the agenda and recognising
the pressures in the system at all levels in the NHS: across NHS England and Improvement
staff, but also very much down to the frontline staff and across the community, and including
social care. I think we need to keep that very high on our agenda, monitor it very carefully
and be prepared to respond as and when issues arise. I think it – we’re always good
for managing incidents and problems over a period of a few weeks and into a few months,
but there is a risk of exhaustion there, and I think that will coincide with the winter,
and therefore, we will need to be particularly sensitive to that risk.
>>Dido Harding: Yeah. Wise words, wise words. Any further questions or comments? In which
case, can we just formally thank you and your team, and your growing body of full-time and
reservists who are working on this? You give us great confidence with the professionalism
with which you’re leading this.>>Keith Willett: Thank you.
>>Dido Harding: Thank you.>>Speaker: Excuse me, Chair?
>>Dido Harding: I’m terribly sorry, but we don’t take questions in the middle of
the meeting.>>Speaker: I’ve had an email to say that
I’ve been asked an informal question before the meeting started.
>>Dido Harding: I’m afraid the meeting has started. I will come and see you as soon as
the meeting finishes. If we could proceed, please.
>>Speaker: What time does the meeting finish?>>Dido Harding: When we get to the end of
the agenda.>>Speaker: Right, I’m –
>>Dido Harding: I’m really sorry, but we do need –
[BREAK IN AUDIO]>>Speaker: – not having had any response
whatsoever. We’ve come in person. We merely want to hand you a copy of the email that
we sent you in July, so that we know that you’ve all seen it. And that is really it.
I mean, it’s just –>>Simon Stevens: So, I’m happy to take it
– [BREAK IN AUDIO]
>>Speaker: Why did I receive – [BREAK IN AUDIO]
>>Dido Harding: Send the email to me. We’ll review it, but we –
[BREAK IN AUDIO]>>Dido Harding: – people who – sorry –
[BREAK IN AUDIO]>>Speaker: – asked me to just – I was
told at the beginning of the meeting I – [BREAK IN AUDIO]
>>Dido Harding: Could we move on to Digital First? Oh, sorry, I’ve stepped – missed
one. To legislation. Ian?>>Ian Dodge: Thank you very much, Chair. In
February, we published our draft proposals. We struck a chord, generating 192,806 written
responses. In parallel, the Health and Social Care Select Committee conducted an enquiry.
In June, it published its conclusions and recommendations welcoming our approach, albeit
with important caveats. Since then, my team and I have worked intensively with many organisations
to shape our final proposals and reflect the advice of the Select Committee. And today,
I’m pleased to report that we have achieved a clear consensus. This morning, a broad coalition
wrote to the Secretary of State, and I quote, ‘With unanimous support for a focused NHS
bill within the forthcoming Queen’s Speech’, and they welcomed our recommendations and
encouraged the government to continue the process of co-production. And the organisations
are the NHS Confederation, NHS Providers, NHS Employers, NHS Clinical Commissioners,
the Community Provider Network, the King’s Fund, the Royal College of Nursing, the Academy
of Medical Royal Colleges, the Royal College of General Practitioners, the Local Government
Association, the Patients Association, Healthwatch England, the Richmond Group of 14 major health
charities, National Voices, Unison, ICS Leaders, and the NHS Assembly co-chairs.
Turning to our recommendations. We continue to say: scrap Section 75 of the Health and
Social Care Act 2012. Remove the 2012 Act role of the Competition and Mergers Authority,
and remove the NHS from jurisdiction of the Public Contract Regulations 2015. Our proposed
best value regime should be renamed, co-produced with the NHS Assembly, and published in draft
alongside a bill. Patient choice should be protected. The triple aim duty should include
wellbeing as well as health. It should include a new duty to engage local communities. The
government should also explore establishing the principle of community co-production within
the NHS constitution. We drop the proposal to force provider mergers. The proposal to
set capital controls for foundation trusts has been heavily circumscribed as a reserve
power only, with numerous safeguards. Only NHS providers should be able to hold integrated
care provider contracts. Integrated care systems should be further supported and strengthened
by the ability to create joint committees across multiple providers and commissioners,
and the transparency of their decision-making improved. As the boards have previously discussed,
we recommend the full legal merger of NHS England and NHS Improvement, which is, of
course, actually Monitor and the Trust Development Authority. Given the three have different
accountability arrangements, that will have to be reviewed and clarified in a bill. The
proposal to allow the Secretary of State to change arm’s-length-body functions should
be dropped. The government should revisit national accountabilities for workforce functions,
as advocated by the Royal College of Nursing and others. In order to make integrated care
a reality, other changes are needed that don’t need legislation, and there may be a case
for the department additionally to consider whether a bill could help by providing a clear
and transparent underpinning for information sharing and IT interoperability within the
NHS. So, we were asked by government to make recommendations.
We have now demonstrably channelled what the NHS and its wider partners in local government
and the voluntary and community sector want and do not want from NHS legislation, and
I commend these proposals to our boards, to government and to Parliament.
>>Dido Harding: Questions or comments?>>Speaker: Thank you, Chair. First of all,
I think it was a remarkable response, 192,000. I think it does show the depth of commitment
to the service out there, and their wish to be involved, and the fact we’ve listened.
I just – on a specific, I just wonder if you’d expand a bit upon the Select Committee’s
airless room, and what the thinking is there about ensuring choice.
>>Ian Dodge: So, on the Select Committee, we’re quoting David Hare, who represents
NHS – a particular set of providers. And their view was that it’s very important
that, in the best interests of patients and the public, the core principles of patient
choice which have been enshrined in the NHS since its inception in 1948 – very first
line, first choose your GP – actually are maintained. So, how do we make sure that that
happens alongside the increased collaboration?>>Dido Harding: Ruth?
>>Ruth May: Thank you very much, Chair. Thank you, Ian, for all of the work you’ve done
on a wide range of these issues. But referring particularly to the recommendation number
26, I’m grateful and I support wholeheartedly the recommendation that the government does
now revisit with partners – RCN, Royal College of Midwives, Unison, and others, as well – how
we look at the responsibility nationally for duties in terms of workforce functions and
accountability, and having more clarity on that, I certainly would welcome as Chief Nursing
Officer, so thank you.>>Dido Harding: Other questions or comments?
Simon, is there anything that you’d like to add?
>>Simon Stevens: Well, I mean, as Ian implies, we are actually building on a big consensus
that has emerged across the NHS about some of the changes that people would like to see;
rightly so, in order to accelerate our joined-up care and the long-term plan implementation.
I don’t think anybody’s naïve about the particular parliamentary circumstances facing
the nation right now, so this is not just a question for the immediate here and now;
this is actually, whenever that time comes for Parliament to address these matters, here
is a very solid and consensus-based set of practical proposals, and whether that time
is imminent or a little way off, these proposals will be ready for that moment.
>>Dido Harding: Wol?>>Wol Kolade: Just one quick question. Ian,
are you able to estimate the benefit, the cost saving perspective, of the duplication
that’s been present in the system, to the benefit of actually implementing this?
>>Ian Dodge: I don’t have a particular number I can quote, but one of the things that the
NHS has been saying, particularly in relation to procurement, is that there’s an automatic
requirement now under the existing legislation, the combination of Section 75 and then the
Public Procurement Regulations, that when you hit a trigger point, there has to be a
procurement for those services. And we hear not just from commissioners and NHS providers,
but also other providers, including in the independent sector, that say, ‘Look, it’s
nuts to have to go through this procurement process’. And what we’re trying to do
is to make sure that we can reduce avoidable bureaucracy associated with that. And what
the proposals overall are mainly doing is, they’re removing barriers, so restrictions
that make it hard for people to work with each other, and that’s really the essence
of almost everything in this set of propositions.>>Wol Kolade: Thank you.
>>Dido Harding: So, on that basis, are both boards happy to approve these recommendations?
Excellent. Great piece of work. So, now we will move onto Digital First primary care.
If Dr Nikki Kanani and Ed Waller can join us? I think there’s chairs for both of you,
just.>>Nikki Kanani: We’re used to getting cosy
on this side of the table, so thank you for having us, and we’re asking you to formally
agree the publication of our Digital First primary care consultation, which you’ll
all have in your packs today. And a huge thank-you to the teams who pulled this together; it
was a truly heroic effort, and I hope that it answers a lot of the questions that you
have been asking over the past few months. To set the scene: I’m Nikki, I’m a GP
in London and director of primary care here at NHS E&I.
>>Ed Waller: And I’m Ed Waller; I’m the director responsible for primary care strategy
in our NHS contracting machines.>>Nikki Kanani: And this is part, I think,
of a wider narrative. You’ve all got examples of places round the country where general
practice particularly can offer really good digital services for their patients. And actually,
I think for decades, general practice have been digital pioneers, and we can see those
examples in some spaces round the country. And what we want to do is offer that to all
of our patients around the country. I still struggle sometimes to log on in my own practice,
and I want to make sure that that isn’t the case for my colleagues. Because actually,
we’ve got far more to focus on. And actually, more so for our patients. Recently, I had
a patient tell me that as a nomadic boat-dweller, she’s unable to get the care that she really
needs. What that meant for her was that she was diagnosed with breast cancer at stage
IV. We can avoid that, and what this paper does is begin to set out that story and those
first steps. This story actually started last year, when
we began to negotiate the GP contract, and when we came to – in January to set out
that we will offer Digital First care across primary care by 2020/2021. And what that really
means is making sure that all our practices can digitise their offer. So, actually, we
don’t talk about Digital First primary care, but primary care offering all manners of ways
to access your appropriate primary care professional. Because that’s not always going to be the
GP, and in fact, over the next five years, as we see more staff coming into general practice
and primary care, it could be and it will be the right person for the care needs that
you have. So, we’ve set out a framework and we’ve
set out a timeframe, and this framework and timeframe will need time and capacity to embed
in general practice, because it is a change that will be taking our practices on, but
one that we must necessarily do. As we’ve gone through this journey, we’ve realised
that there are a number of key questions that we need to answer in order to really get us
effectively on that journey, this being very much the beginning. And I’m going to ask
Ed to set out some of those key additional requirements that are in the pack, AND then
we can open up to questions.>>Ed Waller: Thanks, Nikki. So, the consultation
itself focused on some of the changes we think – thought were required to the commissioning
contracting machines to take account of the fact that new models of primary care were
expanding, and expanding in a way that wasn’t foreseen when the commissioning/contracting
arrangements were designed. So, effectively, we had providers who were registering patients
as out-of-area patients, i.e., outside their GP practices’ catchment, and providing to
them a Digital First offer: a Digital First offer we think patients should have the choice
of, and as Nikki described, by 2021, all patients will have that type of service. But we need
to reconcile some of the way that is currently working, with the rules. And we can break
that down into three categories. So, on the first, we propose that where a
provider registers lots of patients out of their practice catchment area, there should
be a threshold at which that list is broken up to return patients to a practice list that
is – registers them in their own CCG and allows those patients to be delivered integrated
care with other providers. So, above 1,000 patients, we’re going to take forward a
proposal to disaggregate large contracts that have registered out-of-area patients, and
new APMS lists will be established in the CCGs where more than 1,000 patients are residing,
and those new APMS providers will be required to join local primary care networks.
In the first instance, that means a single list operating in Hammersmith and Fulham will
turn into 17 lists, one in Hammersmith and Fulham, and one in 16 other CCGs where more
than 1,000 patients are registered. There are than a set of financial questions.
One of them is the speed at which the financial allocation process reconciles large-scale
movements of patients. We are taking forward on the back of the consultation a mechanism
that would speed up the reconciliation process, so that between financial years, a quarterly
mechanism would reconcile the movement of large numbers of patients between CCGs. And
that will take account of the demography of those patients, their age and their gender,
and it’ll take account of the practice’s position from whence they came and the deprivation
of the original practice. We also asked questions around the way in
which we fund practices, and whether Digital First models should ask us – cause us to
ask questions about whether that was right. One of those questions was around whether
out-of-area patients – and these are patients who register away from their home – should
be – should count – should have less value in the general practice funding formula than
patients who are in-area patients, and the reason for that would be, the obligation on
the GP to provide home visits disappears. We’re very clear that the proportionality
of rejigging the entire NHS primary care allocation systems, trying to account for what are a
very small number of patients, most of whom don’t actually receive home visits because
of their demographics, would be totally disproportionate. We propose to leave that as it is. And we
also asked about whether the 46% that a practice received for a new patient to take account
of the extra work involved in registering a new patient, should be changed to take account
of digital models. We’ve heard very strong feedback through the consultation that to
try and make changes to that mechanism also runs the risk of destabilising practices who
have a naturally high turnover, and again, the proportionality of the number of people
we’re talking about on the Digital First models doesn’t warrant changing that system.
The final thing the consultation asked, and which we’re now proposing to take forward,
is a mechanism by which under-doctored parts of England would become places where new lists
could be established under a nationally run procurement regime. We would nationally certify
providers who were suitable to take up opportunities automatically in the places where – the
20% most under-doctored CCGs, and that builds on the fact that in the early evaluations
of the Digital First models, there is some emerging evidence that you can bring in GP
capacity through Digital First provision that isn’t available if you try and force people
to work in a face-to-face model, and we want to make sure, if that is going to happen,
it happens in places that need doctors most. In terms of next steps, the requirement to
disaggregate lists that are large and based on out-of-area registration requires changes
to the law. It requires the Department to change the regulations governing the GP contract.
We will need to discuss the details of that with the BMA, and hope to implement it as
soon as changes can be made, which might well be as soon as April.
>>Nikki Kanani: So, thank you. I hope this offers a balance between digital innovation
and how to futureproof ourselves, but continues to value continuity of area, which we – I
know we highly value within current models of general practice. Happy to take questions.
>>Dido Harding: Munir?>>Munir Pirmohamed: Thanks very much, Dido.
Can you explain how you came up with the number of 1,000 as your threshold?
>>Ed Waller: So, the original consultation proposed that the number should be between
1,000 and 2,000. We’re trying to balance two things, really. We’re trying to balance
the fact that we’re trying to return patients to a practice that is based locally and is
able to integrate the care it offers with other local services, as soon as it is practical
to manage the implications of running a practice, i.e., have enough patients to make running
a practice sustainable. We got a lot of consultation feedback about where that boundary was, and
settled on 1,000 as a sort of practical midpoint in some of the considerations we had to take
account of on that.>>Dido Harding: Okay. Noel?
>>Noel Gordon: Yeah, I think this is a very positive step forward overall, and thank you
very much for pulling it all together. With respect to paragraph 12 on how you’re targeting
new opportunities on areas of greatest need – and some of those areas of greatest need
are in deprived areas – in NHS Digital, we spend a lot of time testing digital products
on the spectrum of inequalities and the spectrum of needs, particularly in areas which are
not digitally adept. When you certify nationally some of the providers for Digital First services,
what kind of assurance mechanisms do you think you’ll have in place to ensure they adopt
the same standards of testing suitability of digital products in deprived areas as we
do today?>>Ed Waller: So, the next phase of this work
is actually to design precisely what APMS contractual arrangement those new market entrants
would be offered, and the processes by which we would do – we’d make such assurances
as that. I think one of the important things on accessibility is that we want to put a
requirement on any provider that enters the market in one of these areas to make an effort
to register with their – in their provider model a cross section of the population. So,
this shouldn’t be about putting providers into under-doctored parts of England and then
providing services preferentially to people who might well be, even in that CCG, receiving
better healthcare than others.>>Dido Harding: Joanne?
>>Joanne Shaw: Like Noel, I think this is a really positive step forward, so thank you
for that. I wanted to just sort of ask about the broadening the lens of it. I think when
we talk about Digital First primary care, we can sometimes get a bit overfocused on
video consultations between patients and professionals, which I would sort of call remote doctoring.
It’s a great thing to have. But actually, if you ask patients in a more sort of market
researchy sort of way what do they want, you’ll hear a lot about, ‘I want to be able to
monitor my long-term condition using an app, I want to be able to ask clinicians a question,
I want to be able to sort out my appointments, I want to be able to sort out my medicines,
I want to be able to see my record. So, I just wondered if you could tell us a bit more
about how you see the staff beyond the – if you like, the remote doctoring and the appointments;
how that might develop as a result of the proposals that you’re putting forward.
>>Nikki Kanani: Great, so I’ll kick off, if that’s all right. This is something we’ve
been considering really closely through the national review of access, which I’m currently
chairing. A big part of this is exactly what you describe. What patients talk about is
much more about controlling and re-empowering themselves with their own healthcare. So,
actually, what they want to be able to do is not phone 200 times to get hold of their
GP, and not have to almost fight to get their information uploaded or to pull down their
own information. So, I think this is just the beginning of setting out what the – sort
of what the basic offer is across general practice, but particularly through primary
care networks, we’ll be able to offer a much wider array of services. So, working
with colleagues in NHSX, we’re talking about tech banks, so people can then get their iPads
to do their remote monitoring of their long-term condition, to make sure that apps are fully
interoperable and can sit behind the NHS apps so that they can – people can look after
their own healthcare. I mean, as I say, my children are seven and 11, and they’re not
going to sit in the GP surgery waiting for pretty much any aspect of their healthcare.
We need to be really mindful of that as we develop. So, I think the implications are
huge in terms of how we can support practices to broaden their offer, but with the support
and resilience of other practices through the network.
>>Ed Waller: I guess the only other thing to add is that the GP contract deal that the
board saw in January also set out a series of milestones on the provision of services
in a digital manner. So, for example, this year will see 25% of practice appointments
available to book online, and the same sort of requirement is in place around online access
to your patient record, prescription ordering, etc. So, slowly, the whole system moves towards
a whole gamut of things being provided in a digital way.
>>Joanne Shaw: That’s going to be really essential in closing what will otherwise be
an ever-widening gap between the workforce that we have available and the – people’s
increasing health needs. So, that focus on using technology to improve people’s ability
to look after themselves and to, as you say, kind of take power and control back, is just
really encouraging. Thank you.>>Nikki Kanani: And just an aside, the – I
think it’s the second or third paragraph here, we talk about the change management
capacity that general practice needs, and primary care, and it’s almost, we need to
just set aside the text slightly, because once we get that right and we get people feeling
more comfortable with their tech and, you know, the fax machines that definitely aren’t
in my surgery are moved away from, we will be on a different journey with developing
tech and embedding it in the way that you describe.
>>Joanne Shaw: Thank you.>>Dido Harding: Any further questions or comments?
In which case, are we happy to approve the recommendations? Well done. Thank you.
>>Nikki Kanani: Thanks.>>Dido Harding: So, we move on now to the
clinically led review of NHS access standards. Steve, are you going to kick us off?
>>Stephen Powis: Yes, thank you, Dido. So, as the board will recall, in June of last
year, the Prime Minister asked NHS England as part of the development of the long-term
plan to review the key access standards used within the NHS in England. And specifically,
the ask was to ensure that in developing a service plan for the next five to ten years,
we ensured that those access standards were up to date and were fit for purpose for the
service developments that we would be proposing. And I guess you can think about that in two
ways, and we approached it in two ways. Firstly, for some of these standards which have been
in place for up to 15 years, what have we learned, what are their strengths, what are
their weaknesses? In essence, how could we improve upon the current standards? And secondly,
as I have alluded to in terms of the service models that have developed during that period,
and in our work set out in the long-term plan to develop them further, are those standards
supportive of the direction of travel that those services models are taking, i.e., do
they support the service and support patients in delivering the service models that we have
developed and we are proposing? So, the long-term plan was published in January,
and in that, we promised that we would publish an interim report in the spring, and we did
so in March publish an interim report, which set out a proposed set of updated and improved
standards. I’m not going to go through those in detail; they are summarised in the paper,
and of course, in more detail in the already-published interim report. But I will remind the board
that they’re in four key areas. The first is urgent and emergency care, where there
have been standards, the A&E four-hour standard, for around 15 years. In elective care, where
key standard is around 18 weeks, standard for treatment from referral. In care, where
key standard is a 62-day standard from referral to first treatment, and some two-week access
standards. And in mental health, and I think particularly important in mental health; this
is an area where we have had very few access standards, and I think the importance of proposing
a set of standards in mental health that will bring mental health parity in terms of access
standards with physical health is extremely important.
So, as part of that report, we emphasise the importance of testing the proposed standards
to ensure that we learned how they might work in the real world rather than on – in a
report. And therefore, in the next phase of the work, we have moved into a testing process
with NHS organisations. We commenced the testing in the early summer, so urgent and emergency
care went first at the end of May. And we have been rolling out our testing over the
last few months, and will continue to roll that.
By nature of these standards and by nature of the patient pathways and journeys that
they encompass, the testing periods will be different for each of the standards, and therefore,
the timelines are not unified into one single timeline. So, as I’ve said, urgent and emergency
care we rolled out first, and probably some of the mental-health standards we will be
rolling out towards the end of the testing period.
So, at this point, I should pause to say that I’m extremely grateful, as I think we all
are, to those NHS organisations that have joined with us and agreed to be test sites.
I don’t underestimate the work involved in doing that, and for the around a dozen
or so – depending on the testing area that we have used in each of these protocols, testing
protocols – I’m really grateful to the organisations, the boards, and indeed, the
front-line staff who have joined us on this journey to test a set of new, improved standards.
I’m not going to comment in detail on them. We may comment a bit more on urgent and emergency
care, because that has been going the longest, and I’m really grateful to Pauline Philip
and the team – Pauline is over there, who’s been leading this. And Pauline might want
to comment on some of the high-level learning from that initial phase. But I would say that
our experience has been that the sites that we have recruited have enjoyed working on
this. They want to be part of the journey of improving standards, and they have worked
very closely with us, and they have found it useful, interesting and helpful to be able
to revisit some of the aspects of their operational performance. So, in urgent and emergency care,
where we have suggested a standard that encompasses total time that a patient spends in an A&E
department rather than focusing just on a four-hour period, has allowed organisations
to really think about every minute that a patient spends in an A&E department. It’s
too early to discuss data in detail, but as I say, Pauline may want to give some more
high-level information. The third point I would make in introducing
the paper is that we have always involved partners in the development of this, and since
March, we have expanded the stakeholders and partners that we have worked with. So, we
have, in addition to an oversight group that has looked at the work as a whole, we have
introduced specific expert groups in all of the four areas – in cancer and mental health,
using groups that we already have as part of the long-term plan – and that has been
invaluable in giving us particular expert advice. And again, I’m very grateful to
those organisations and those individuals who’ve worked with us on this, and that
includes the variety of professional groups such as colleges, both colleges – doctors
and colleges and nurses, and others, to patient groups and to charities. And their ongoing
help in this is really important. And finally, I would say something about next
steps, which is, again, in the paper. So, firstly, we will be continuing testing. As
I said at the start, we are still relatively in the early phases of some of the testing,
so we have more to do. Secondly, we have committed to evaluation, so we are evaluating in a number
of ways, and some of our patient groups have very kindly stepped up to undertake a valuation
in terms of patient experience, and I’m very grateful to Healthwatch and others. And
then we are commissioning academic partners, or an academic partner, for some of the evaluation,
as well. We also wish to consult. The point at which we do is contingent, of course, on
the testing and a number of other things, but that is something that we committed to
do, and we remain committed to do. So, I think I will pause there to take questions.
Pauline, do you want to add anything additional at high level on the urgent and emergency
care, because I know that’s something that you’re very involved in.
>>Pauline Philip: I think, Steve, just to reinforce what you’ve said – and, you
know, I think by working with the 14 departments, there is a real atmosphere in those departments
that every minute counts for every patient, and I think that’s why we’ve had a significant
level of clinical interest in this. And if by counting other metrics, will it support
our transformation journey better than the metrics we have at the moment, clearly, it’s
still very early days, and we need for those departments to collect more data. At the moment,
the focus has been on the mean, but also, time to initial assessment, and now, increasingly,
on the critical conditions, the patients that we would expect to be seen in a very short
time. But I think an awful lot of cooperation from the 14 departments, so we’re really
pleased about that.>>Stephen Powis: Thank you.
>>Dido Harding: Joanne?>>Joanne Shaw: Thank you, Steve. I think this
is tremendously interesting. And I guess the question I would ask is that, it sounds like
you’re taking this to a really good level of sophistication and testing it extremely
thoroughly. From the point of view of the kind of member of the public, the existing
standards – I mean, they may be crude, and they may be subject – susceptible to some
gaming, and they might be being imposed in some – in ways that some people might consider
a bit sort of crude and brutal. But they have a couple of real merits, don’t they? One
is that they are very easy to understand, and the second thing is that they have had
a dramatic effect on waiting – it is argued that they had a dramatic effect on waiting
time. So can you help us understand how – whether you see those advantages as being somehow
maintained in the new system? What are the trade-offs between the sort of simple, brutal
effective, versus something which sounds as if it might be a little bit more technocratic
and a bit more difficult to kind of get one’s mind around?
>>Steve Powis: Yes. So of course, as I said at the start in the introduction, we have
existing standards and they have in many ways served us well in the years that we have used
them, but they have strengths and weaknesses. It is not actually the case that they are
always as well understood as we think and there is often confusion over the four-hour
standard, for example. And a recent, I think, Times article was corrected in a letter from,
I think, a retired doctor, who pointed out the four-hour standard is from arrival through
to the completion of treatment rather than initial treatment. So we still see confusion
in the minds even of those August people who write in newspapers, over these standards,
so I don’t think it is universally the case that every standard is as well understood
as we might like to think. But nevertheless, what we are trying to do
is to introduce, as I say, a set of standards, or propose a set, that will move us on and
build on what we have already. And very much a set of standards that is understandable
to staff and patients is one of those criteria which is exactly why we have asked Healthwatch
and others to help us in assessing that. And Healthwatch have been use – very helpful
in not only helping us understand what patients currently think, but they will be assessing
what patients think as we start to develop new standards.
And I should say personally I have tried to very much approach this as a patient rather
than a doctor because I’m a patient as well as a doctor and I think in setting any set
of standards, it’s important that there is a narrative that is as simple as possible
for the patient but also for staff. And of course, those are not always the same, but
I think it is important to get the balance right.
So in cancer for instance where we are really moving towards early diagnosis because we
wish – we know that early diagnosis of cancer means that diagnosis is picked – the cancer
is picked up at an earlier stage and that means that treatment is more effective and
that outcomes are better. So moving to a standard that focuses on faster diagnosis in other
words says to the citizen of England that from the point of referral to an urgent cancer
service you will have a diagnosis within 28 days, most of the time of which is that you
don’t have cancer, but you will get that diagnosis in 28 days begins to shift the emphasis
of what we do onto picking up cancer and diagnosing quickly. So, there is merit not only in what
we wish these standards to support operationally but the message that they convey around what
our intent is.>>Richard Douglas: Mine’s actually on the
– a little about the timescales of this. Because we’re field testing at the moment.
We’d said that we wouldn’t be looking to introduce new standards from April 2020.
We’ve got evaluation and then consultation and then approval to go through, and what
I guess I wanted to get my head around on this is – is when as a board do we start
to see the evaluation and to think then about how we consult the next steps on this? Because
they are so critical these standards.>>Steve Powis: Yes. So as I said, there are
a number – the various standards or the various testing is being approached on different
timelines. So, there are a number of things that we need to consider in the overall timeline.
One is the individual timeline, so mental health will take us longer because of the
deployment of resource into the system as part of the long-term plan and indeed the
five-year forward view in mental health, which will allow those standards to be introduced.
The outcome of testing: so obviously we want the testing to support recommendations and
introduction of standards. That’s what we choose to do, or choose to recommend, and
of course we’re still in that testing phase. There are a number of obviously key points
in the NHS rhythm of the year. 1st April is a very important point not just because it’s
our financial year: because it is the point at which the mandate for the year from the
government takes effect. So, we are working towards if everything goes as we would wish
possibly a 1st April implementation for urgent and emergency care, but on the others and
very possibly for the cancer 28-day standard. But we will need to work and see where we
are over the next month or two in terms of the pilots. The consultation is also important
and we need to work that in and of course some of these, in particular on elective care
and on cancer, are in the NHS constitution, and we are working closely with the department
of health and social care over the approach to legislative changes, if they are required
in order to progress those. So a number of moving parts, but some indicative
thoughts in our minds.>>Richard Douglas: I think you answered the
second part of the question I asked. Do these automatically then – if we have new standards
they automatically roll into the constitution as replacements for existing ones?
>>Steve Powis: So it depends. I’m not going to give you a complex answer –
>>Richard Douglas: No, keep it simple.>>Steve Powis: – because it’s a complex
answer, which is why I think I chose my words carefully and said potentially, because it
rather depends what we recommend and how we recommend it and the approach we’re taking.
But yes, it may require possibly secondary legislation, but that is still to be arrived
at.>>Dido Harding: Quite a lot of conditional….
>>Steve Powis: I am absolutely conditioning that with a lot of conditions until we know
what we’re recommending, I can’t give you the answer.
>>Dido Harding: That is fair enough. Other questions or comments on this. So, this is
going to be coming back several times I expect, so good to have an update, and thank you to
everyone who’s working so hard out in the trusts testing and trialling this. Okay. Thank
you. So we move on. It flows nicely to current operational quality and financial performance.
I thought we might start on the sort of operational and quality side and just start by welcoming
Amanda and having you just give us your sort of first impressions, and then I’m sure you’ll
hand over to Pauline and then Julian.>>Amanda Pritchard: I will. Thank you very
much. Thank you very much indeed. I think – I think we discussed this sort of at the
very outset of the meeting, that what we see in operational performance at the moment actually
is the NHS doing largely an extraordinary job despite really quite significant pressure.
So, I think it’s really – we are very aware of just quite how hard colleagues from
across the whole of the NHS are working every day to provide the best possible care for
patients, to do that as quickly as possible, and as efficiently as possible. And in the
paper, there are some real things to celebrate. So we’ve got not only the increase in activity,
the year on year improvements that are set out, but also I think crucially some of the
developments around the transformation agenda, so the new services that we’re introducing,
so we can see in the paper we talk about – Pauline will say more about this – increasing same
day emergency care, the acute frailty provision that’s being rolled out, the about to roll
out targeted health checks for patients who may have lung cancer, the HPV vaccination
for year 8 boys which is about to start, again, rollout. And I think the other thing that’s
just another thing to celebrate really is that year on year increase in mental health
funding which again we’re seeing translate into reduced waiting times for treatment.
So setting all of that as the context – and we talked about it earlier – I think there
is very real pressure in the system. We talked about pensions; I think it is worth probably
coming back to that because there’s no doubt that that is having a material impact on capacity,
at exactly the same time as we’re seeing, of course, increasing demand particularly
around non-elective care. What can we do? I think David that was your specific question.
So I wont try and answer that comprehensively, but actually I think there is something important
about just recognising and thanking people for what they do now, and celebrating that
great stuff, because that is the everyday reality of what’s happening in the health
service. Not that everybody gets it right every single time, but the aspiration is absolutely
there. So I think I’d start with that. I think
the second thing is really focusing on then where are some of our biggest challenges.
And clearly, it’s linked partly to pensions but not exclusively to that. There is a question
about how we can best support the workforce in the NHS; how we can ensure that we are
doing everything the people plan sets out – the interim plan sets out around making
it – the NHS a great place to work, making sure that we’re retaining the talented and
committed staff we have. The investment in CPD I think will be a part of that, but that’s
clearly again not the whole answer. And then I think there is something for me about just
practically – third thing really. It is working with our regional colleagues, our
front line colleagues – and Pauline will say more about this, I think – which we’re
now doing to undertake a stock take, to make sure we are really clear about, I guess, where
our biggest pressure points are heading into winter and that we’ve then marshalled our
collective resources to give the best possible support to those organisations that need it
over these coming – over these coming months, alongside making sure, I guess, that we are
rolling out and supporting systems and organisations to implement what we already know works and
is effective. So I think those are just a few thoughts on
the kind of what can we – what can we do about it. But I know Pauline and other colleagues
will want to add.>>Dido Harding:. Thanks. Pauline?
>>Pauline Philip:. So yes. Just adding a little bit of detail as far as emergency care is
concerned and elective care. Starting off with emergency care, I think it’s set out
in the paper, our performance for the month of August was 86.3%, and clearly we would
like it to be higher than that. However I think the really important thing to say is
that for the month of August, within four hours, we treated an additional 37,000 patients.
So that really goes back to the point Amanda was making about how hard our staff are working
at a time when demand continues to increase. In August alone we saw demand growth of 3.9%.
Now, a small amount of that was down to how we have changed our services, but essentially
we are seeing an ongoing growth in demand month on month and the services have been
seeing this for a number of years. And against that picture as Amanda rightly highlighted,
we’ve got significant workforce issues. Some of which we were very much aware that we would
be dealing with, and that we’ve been working very hard to recruit staff, etc., but I think
in particular the pension issue is something that a year ago, sitting in this meeting,
we would not have been talking about. So I think at the front door of the emergency
departments, yes, our overall performance is not at the level that we would like to
be able to say. We’d like to be able to say it’s 95%, but I think the really strong
message is, our staff are seeing more patients within four hours, and working very, very
hard to do that. Just moving on a little bit for the picture
outside the very front of the department and looking at admissions to hospital. And I think
there you start to see the impact of our transformation work, and the reform agenda. And you know,
just drawing people’s attention to the fact that if you look at zero length of stay around
same day emergency care, year on year, an 8% increase as far as the admissions are concerned.
Whereas for overnight admissions it was only 2.1% and I think that’s testament to the
amount of work that’s been done to completely transform the model about how we are going
to care for patients in the future. Ultimately the idea being – and I think everybody in
this room would support it – that if you don’t need to spend a night in hospital,
well, nobody wants to be in hospital. And we’ve got clinicians right across the country
working with us every day of the week to further develop those services. At the moment we’ve
got 100 diagnostic pathways agreed, so there’s 100 different types of ambulatory care pathways
being used right across all of the NHS. Moving from same-day emergency care, just
drawing people’s attention to the ongoing work around the ambulance reform agenda, and
you know, when we look at performance of the ambulance service, they – the 999 service
itself has seen 141 more calls during the period of January to August. And when you
look at the performance against the categories – cat 1, cat 2 and cat 4 – higher, better
response times for all of those than when you compare them to last year.
If we move to 111 for the same period they have seen an additional – or they have experienced
– an additional 123,000 calls and the really interesting stat which I think very much links
to the ambition around the reform agenda, is that we have now reached a stage when you
look at August information where we are having twice as many 111 calls as 999 calls. So the
whole landscape is changing, and changing significantly.
Linked to that, 111 online – now 100% coverage across the country, and when we look at the
type of coverage it’s at the phase III phase, which means that a patient can receive a clinical
call-back. And looking at the conversion rate of people who actually go online to actually
ending up in an emergency department, that being less than 10%. So these services being
really the forefront of what we will be doing now and in the years to come. Behind that
a whole range of services being further developed, on a day to day basis. For example, urgent
treatment centres. And I think we talked about that at the previous meeting.
So that’s a bit of an insight into where we are with performance, but I think going
back to the point that was made earlier about what can we do to do even better, which clearly
is where we want to be, I think it’s the ongoing drive of the transformation agenda.
We are developing greater and greater confidence in that, and I think it is very satisfying
for the people who are experienced in delivering care within those very different services
than existed five, ten years ago. But also we’ve obviously identified a number of priorities
that we want to focus on, now and in the coming months, to better prepare us for winter. Again,
the board won’t be very surprised about what they are, because they’re things that
we’ve been talking about for a long time, but services like reducing length of stay,
better for patients who are in hospital and need to go home, but also freeing up capacity
for the winter period; GP streaming; focusing on weekend discharges; etc.
So if it’s okay, I’ll move maybe from emergency care straight to elective care.
And I think there, looking again at a similar theme emerging, whereby, whilst we may not
have hit the waiting list target from a percentage point of view, again, we’re seeing more
patients than ever before as far as OTT is concerned. If you look at the change in the
data from the month of June to July, you see the waiting list increase by 23,000. It’s
a small decrease but it’s significant that that is happening, and at the same time if
you look over the period that we are talking about, more patients being cared for through
our elective services. Sorry, elective care. Linked to that 52 weeks, we’ve talked about
the success that we had last year in reducing long waits, and we have now reached a point
where, if you compare the number of patients who are waiting more than 52 weeks in June
last year, to the number that are waiting now, we’ve been able to reduce that by 70.7%.
Clearly, still have some way to go: we want it to be zero. We’re working very, very
hard to achieve that. And again, just linking in the transformation agenda, working hard
to do things in a different way. The MSK service has been increasingly rolled out across the
country; we’d set ourselves an ambition for 15% by the end of the year. We believe
we’re going to be able to do better than that. And then other programmes as described
in the paper. You know, for example, the EyesWise programme, etc.
And then finally just to finish off with the point that Amanda made. We’re about to go
into a stocktake exercise similar to what we did last year. Working with our regions,
working with our front-line staff, our hospitals, our systems, to understand where they believe
delivery will be by the beginning of December and then by the end of March. And that’s
on a number of different metrics, right from ED performance through to cancer care, through
to the care of patients with learning disabilities, etc. why is that important? It’s important
so as we can support front line services to provide the maximum level of care possible
and to do it in a sensible way, understanding what work we can do during January, etc.,
etc. I think that’s it probably. Thank you everyone.
>>Dido Harding: If it’s okay I think we’ll stay on operational performance and take any
questions or comments on that before we move onto finance, assuming that there are some
questions and comments. David?>>David Roberts: So, Pauline, Amanda, first
of all, I think your core message which is that we have – we owe a huge debt of gratitude
to the people who are doing I think a phenomenal job in dealing with more patients and actually
as you said, 37,000 more people in A&E. But it’s reflective – we talked a lot about
the supply side; essentially, what we are doing to try and boost supply to deal with
higher numbers. I am intrigued about how much we understand about the demand side. So, you
know, some of the numbers, you know, it doesn’t sound much in percentage terms but it’s
a lot of people. And it won’t be uniform across the country either I would hesitate
to guess. So I’m interested in, is it demography, and
therefore this is just going to continue? Is it change in behaviour – people are more
willing and will go to A&E? Is it because they can’t get appointments elsewhere and
they think the only way – they’re not aware of the full panoply of options and availability
that’s around? Or is it something else? Because I think if we understand those, then
it’ll obviously be a bit of all; but if we understand the drivers, we can start to
think about how we can help patients get to the best place for them and choose the best
place for them, as well as tackling the supply side. So I’m just intrigued as to what we
know.>>Pauline Philip: So I think the first thing
to say that we’re focusing on demand all the time, to understand right across the country
what is happening, why people are coming to the front door of an emergency department.
And clearly, sometimes they are coming to the front door of an emergency department
because we have moved services around. We’ve collocated Urgent Treatment centres, etc.
But I think if from the evidence available to date, we are quite clear that it’s not
just that: that we are having a genuine increase in demand, probably in line with what we have
seen previous years. But I think the really important point to make is that the service
is pretty full at this point. We have maxed out the capacity we have. We have maxed it
out from a workforce point of view, from an estate point of view, etc.
So if you keep seeing this level of demand, you eventually reach a point where services
can’t deliver the way they want to. And clearly that’s why the reform agenda is
very important to do things in a different way.
I think going on to why are people turning up, if we park the reform agenda to one side
– so they’re not the people that we are sending to the departments etc. – yes, there
is an element of the ‘here and now’ society. You know, if a patient turns up at an emergency
department, they know what that offer is going to be, and I think that the challenge for
us is to make that offer better away from the emergency department, and that people
should be able to turn up at our other services, have diagnostics at the time of need, not
need to return to it three times, so as they’re not choosing to walk into the emergency department.
And I think we heard it earlier on being described as the sort of ‘Amazon generation’, and
you know, I think we’ve all changed our behaviours as to what we expect and when we
expect to see it. Clearly the important thing for us also is to understand on an ongoing
basis whether there is any changes from a population health point of view. We know about
our aging society but we’re constantly monitoring to see if there are any other issues. You
know, talking to colleagues across the border in Scotland, they talked about some of the
real impact they’re having around drug and alcohol – we’re watching all of those
things as well.>>David Roberts: So I’d encourage us to
really try and understand in some depth the drivers of demand, because winter will come
around every year. And therefore, I think we are in – we have done an astonishingly
good job at coping with increasing demand, but there are only so many levers that you
can pull. And therefore I think if we can understand that, you know, we can – the
demand side, we can start to think about how we can intervene higher up the chain, to make
sure that we can – we’ve got the right services for people who can choose in a sensible way
the right one for them, and hopefully then we can serve them better. Which is obviously
what we’re trying to do.>>Pauline Philip: And just to reassure you,
we are doing this all the time. And one of the really interesting things that we’re
doing at the moment is in a number of emergency departments actually sitting down and talking
to people when they come through the front door, asking them how they have used our services
or how they may not have used our services, before they’ve chosen to walk in, so we
can feed all that back.>>David Roberts: So maybe not for the board,
but I would love to see that. So maybe we could pick up outside, because I would be
really intrigued to understand those drivers.>>Dido Harding: Manir[?]?
>>Speaker: I would absolutely agree with David on understanding the drivers of demand, so
I was going to ask about that, but I’m going to change the question. I just wanted to now
understand about numbers and demand increase, year on year, and the trajectory of change.
Is that trajectory increasing or is it plateauing off? So at least that gives us some idea of
where we’re going to be in five years’ time. And the second question is, surely this
just can’t be a UK problem. Do we have any international comparators? So that we can
understand what’s going on in other countries and how they’re dealing with it as well,
so that we can learn from each other?>>Pauline Philip: Yes. So you know, if we
just reflect on some of the stats around attendance, or something, we can talk about admissions
as well if you wish. But if we look at the growth that has taken place over the last
ten years, around attendances to emergency departments, it’s about 2.4% when – this
is what we would expect to see. That’s what we have seen. That’s the trend. Last year
it was higher than that: it was 4.2%, and so far this year it’s 3.5%. Now, we do need
to subtract something from that around the reform agenda and the fact that we’re bringing
patients to emergency departments. But we are seeing consistent, if not increasing,
levels of growth as far as demand is concerned. And that’s all part of the picture of understanding
what that demand is.>>Speaker: And international comparators?
>>Pauline Philip: I haven’t got anything with me, but I think we are very much – we’re
looking at stats that we’ve had access. Looking at Scotland, looking at Northern Ireland.
And that everybody is seeing – or appear to be seeing a very similar picture to ourselves,
in particular looking at what’s happened over the course of the winter, and in April
onwards. And we have access to some of that information which we can share with you. But
unfortunately, I haven’t got it with me at the moment.
>>Dido Harding: That is a very important point in terms of all the countries in the union
seeing the same underlying trend through the summer.
>>Pauline Philip: Yes, yes. And I think, you know, even when we look at performance, we
have got some themes in common, in particular going back to the earlier conversation about
the pension issue and our ability to meet that demand. But happy to share that with
you.>>Dido Harding: I think it’d be great. I’ve
seen it but I think it’d be great if we could share it with the whole board.
>>Pauline Philip: Yes. Yes.>>Dido Harding: Joanne. You were keen to come
in.>>Joanne Shaw: This is obviously so important,
and when you think that a lot of what you do is about supporting local organisations
to do the best they can to manage the demand – but in the interests of also sort of focusing
on the things that only the centre can do, the stuff that’s very much in our responsibility,
it’s absolutely fantastic to see that 111 online is now available nationwide. And the
fact that only 10% of people who use it end up being directed into emergency care is incredibly
reassuring. So I suppose I have two questions around that. One is, now that we understand
what sort of impact it has, should we be promoting it more actively, vigorously and publicly,
given that for so many people now, the first place to go with any sort of problem is online?
And the second question I have is that, in a world where every percentage point or in
fact every basis point of demand makes a difference, continuously refining those algorithms and
understanding the patient journey through the questions, and tweaking them and refining
them so that we are deploying them in the most effective way to give people the right
answer who we unnecessarily send into care – can you tell us a bit about how that is
being done?>>Pauline Philip: Yeah. The first question
was around the whole issue of 111 and how we communicate. And clearly, we have been
careful in recent years to make sure that each of the services are sufficiently robust
before we communicate. You will be pleased to know that part of our winter campaign this
year is now around 111, because we feel that the service has developed sufficient resilience
that we really want to draw people’s attention both to 111 and 111 online. So that will increasingly
happen, and you will start to see the media around that in the coming weeks and months.
Sorry, your second question – I didn’t quite get it.
>>Joanne Shaw: How – what are we doing to refine the algorithms within 111 online and
also with phone, but particularly online, so we learn from patient journey through each
question, to refine and learn and make them more sophisticated, and reduce the number
of people whom we – who take a journey through the algorithm and end up being referred into
face to face care who might otherwise have been dealt with differently?
>>Pauline Philip: Yeah. So you may recall that as far as 111 itself is concerned and
111 online, that’s something that we’ve been very careful to do in the roll out, to
understand patient behaviour and how people are availing themselves of the service and
then what they are choosing to do thereafter. So for example, if we say to a patient, we
honestly believe the best thing is to go to the local pharmacy, but you turn up at the
hospital, etc., being able to capture that data. And you know through the emergency care
data set, etc., we are getting better and better information around population behaviour.
So there’s a significant focus on that, and again, happy to report it back in greater
detail for 111 and 111 online. But that’s how we know sort of the conversion
rate and who’s turning up in the departments, etc., and then we can compare that to who
we advise to turn up, etc.>>Dido Harding: I wonder whether, Noel, you
would attempt to answer – well, those of us who have been involved in sort of digital
service businesses that are much less important and much less sophisticated than 111 recognise
the question you’re asking, Joanna, the importance of continual optimisation. With your NHS Digital
hat on, could you maybe give us a bit more from that perspective?
>>Noel Gordon: Sure. And there’s an important link to the whole eChannel strategy and David’s
question of demand. So of our four major digital products, NHS online, the new NHS app, the
whole ePrescribing programme, and the eConsultation programme, the demand that we’re seeing
in all four new digital channels is exceeding our expectation which in one way is beginning
to show that the products we’re putting out there are well received and well tested.
But in the Amazon generation, the digital channels are generating new demand, and a
lot of that comes through in the triage process, the algorithms which drive the triage process,
and people checking more often about symptoms that they might have otherwise waited for
a physical consultation. So the benefits if you take them in the round
which hopefully come through in Pauline’s figures to some degree in being able to cope
with that steep curve of demand are also being seen in different ways. The benefits of patients
knowing more about their condition, knowing where to go, knowing how to access the right
solution, going to pharmacy – which we’re going to talk about the new pharmacy contract
which is a massive breakthrough in terms of activating a pharmacy channel as a new part
of the spectrum of offer – it is a demand-driven healthcare system that we have. And the more
we create new channels the more activity we get, but so we get new demand that might not
have otherwise been there. So it’s a helpful suite and there are more
roll outs in the NHS app with new functions coming on stream next year which will help
improve the offers progressively.>>Dido Harding: Any other questions or comments
on the operations? I have one, having just talked a lot about demand, I’d just like
to swing back to supply. Direct this maybe to Ruth, just to talk a bit more about what
we plan to do – this is with my People Plan hat on – to upweight the work on retention.
Because clearly, the single most sort of powerful immediate lever we can pull to increase supply,
is to make the NHS a better place to work, so that more of our fantastic staff want to
stay with us for longer or work a bit longer with us as a result. And I just wondered if
you could talk a bit more about what we’re doing now and what more we could do in the
near term.>>Ruth May: Absolutely. Thank you, Dido. So
the NHSI started the work on the retention and retention and collaborative using a quality
improvement methodology two years ago now. We started with a third of our community and
acute trusts and all of our vendor health trusts. And slowly by slowly, we’ve been working
with all of our trusts. And we’ve got some great people working on this: Professor Mark
Radford in my team has been leading it with a number of great individuals from all sorts
of backgrounds. HR backgrounds, clinical backgrounds, economic backgrounds. And they’ve been superb.
And what we’ve seen so far is that the trusts that have done the best are when they’ve
got the HR Director and the Director of Nursing working together and jointly owning it. Not
one or the other, and indeed not delegated to a deputy of a deputy of another deputy.
And I think what we’ve seen is the turnover rate has gone from 12.5% to 11.7% and in mental
health it’s even better than that. It’s 9.6% to 8.6%. So it’s working. It’s working
really well, but it needs to be scaled up. And that’s a recommendation that I’m working
very well with the Chief People Officer, Prerana, and we’re just currently working out how
we can scale up, what would be the return on investment. But we have nine or so – nine
individuals working extremely hard. But actually, it’s the trust themselves that are doing
that work. They’re the ones that are sharing the learning; they’re the ones that are focusing
down on what are the key things they need to do. What we’re seeing as well are the
trusts going, actually – it depends where they are. It depends what challenges they’ve
got: whether they need to focus on those people that are newly recruited in – not just newly
qualified but newly recruited in, where they need more nurturing, where they need more
care and career management. We’ve also seen that how do we extend those
people’s careers in terms of timeframe. So those people that are the over-50 mark:
how do we help them to have fulfilling careers in all sorts of different ways, right until
the very last day that they want to be with us?
So stretching both ends is really important. CPD is going to be critical. CPD is what people
tell us will make a difference to how they can have a career in the NHS. And I’m hopeful
that will be there and I’m hopeful now that we’ll work with trust Directors of Nursing,
university suppliers, trusts themselves that will be able to provide some of this training
that we’ll be able to keep people. So yes, it’s working well. But there’s much more
that we could do to industrialise it.>>Dido Harding: Thank you. Can we move onto
a verbal update on the month four financials, Julian, I think…
>>Julian Kelly: Sure. So at the end of month four, I mean, we’ve now got multiplied[?]
data then we had[?] at the end of month four, the NHS commissioners and providers out there
who spend the vast majority of the money, were off plan by £75 million on a £39.5
billion spend. So sort of more or less holding it there, and forecasting broadly speaking
to be on plan. What’s interesting when you sort of dig under the numbers is that somewhere
around 25%, 49 commissioners are showing a sort of an adverse variance to plan and broadly
the other 75% are absolutely on track. And for providers, probably roughly a third are
actually showing an adverse variance to plan, although the variance per trust is much smaller
than that for commissioners, and the vast bulk are actually showing just to be slightly
ahead of plan. Probably looking at the forecast numbers now is not worth too much money. What
we’re actually really trying to assess is, what’s the risk that we’re really sitting
on? And I guess the great advantage this year of bringing you and I together is the ability
to –>>Amanda Pritchard: To see it in the round.
>>Julian Kelly: To properly look at commissioners and providers in the round. Which I have to
say is probably – we’re also seeing real evidence of that and enabling much better
system conversations about how problems and financial problems and performance problems
together are being solved. But sat here today, we think we are sat on a kind of material
risk of sort of £5-600 million. Which in the scheme of about, you know, £120 billion
of spend might not sound a lot, but would be hugely problematic. And of course, different
this year to maybe last is that we really have put the money out into the system through
the increase in prices and allocations, and indeed then the additional support through
the provider sustainability fund and the financial recovery fund. So we absolutely do need the
system commissioners and providers to deliver against the plans that they have themselves
agreed through the planning process. So loads of work going on, largely through
our regional teams, with systems and then with individual organisations. I guess I sit
here and there are definitely some trusts we are bothered about. And probably the risk
we are looking at is split about equally between trust and commissioners. But probably this
year, compared to last, we are more materially worried about the commissioner position, and
we have seen certain groups of commissioners in the north west and in the midlands in particular,
showing material adverse – and so whilst across the whole country it’s how we’re
driving the improvement productivity programmes, on the commissioner side I think in particular,
how do we really drive better value, improved cost control, around prescribing – both
low value prescribing, the medicine reviews, the gearing up of GPs and pharmacists to really
get a grip of some of these issues with commissioners. And then we were having to think, at least
in a few places, is there a more structural intervention required, which is the sort of
ongoing conversation we are having with our regional directors at the moment.
That’s probably what is worth saying now.>>Dido Harding: Okay.
>>Julian Kelly: Actually, I will say, sorry, just two things. I think next time we come
back, we’ll have more to say on capital. Actually, more capital has got into the system,
but we have a real requirement, particularly from the provider sector, for taut capital
forecasts as we now are at the mid-year point. In large part, to work out, do we actually
have the capacity to release some more funding to begin to do catchup work in particular
around sort of critical maintenance backlogs. And we can only do that if we have taut forecasts.
So that’s the real plea to the whole of the – in particular the provider sector.
I was just thinking of the retention point. When you dig under the numbers, in particular
in the provider sector, basically we are running slightly over pace on pay, and under-pace
on sort of none-pay, year to date. And on pay, what’s particularly interesting is
the kind of agency number. It’s basically holding the same rate as last year. I think
people had planned that we would be seeing a decrease. I think it just goes to the point
of how do we improve not just recruitment, but retention, and how important that is if
we’re honestly going to get a grip of some of the cost drivers which are giving us problems.
>>Dido Harding: Yes. Yes. Agreed. Any questions for Julian? Or comments.
>>Andrew Morris: Dido, can I make a comment?>>Dido Harding: Andrew.
>>Andrew Morris: So much of our potential success going forward depends on system working
and getting a grip locally of the issues. How well do we feel that system working is
being developed? Because I think we’ve still got a range of approaches and you know, we
tend to look at the top-performing systems, but the big focus should be on the other end
of the scale really, about how we can support local leaders to actually get a grip on some
of the issues we’ve talked about, be it finance and performance – and I think you know,
anything we can do, and Amanda in particular, to encourage people to work together and actually
handle and tackle some of these issues going forward, will be our success or failure as
we get into the winter.>>Dido Harding: Amanda, do you want to pick
that up? I know you’ve spent quite a bit of time with system leaders in your first
few weeks in the job.>>Amanda Pritchard: Happy to. So I think really
important point, and it’s clearly a both/and at the moment, because we are both working
through a kind of well-established and well understood set of arrangements based around
sort of individual organisations within the system, and we’re working with systems and
that’s got to be right. But I think the work that certainly we’re trying to do – executive
team, but particularly working with Ian, with Julian, with other colleagues, is now to try
and really hone down over the next couple of months, what the ask is of systems. And
we’ve literally just had a conversation about it before this meeting. And yesterday we’re
out talking to ICS Leeds, and Chairs about their experiences. At another event last week
with a different group of people, talking about, you know, their different perspectives
on different parts of the system. And I think what comes through is a strong desire for
greater clarity; an equally strong desire for that to be co-created with the NHs, which
I think we would all agree is absolutely right. And a sense of kind of getting the right balance
between recognising the very successful variation that exists at the moment which is good and
responsive to local needs, but providing sufficient clarity about direction of travel and about
expectations of systems, such that people are empowered to get on and do the stuff they
need to do. So I think that’s the bit that we’re just trying to crystallise and we’ll
be trying to do that over the next couple of months.
In parallel though, and I think kind of importantly because that could be a sort of theoretical
exercise, we’ve also agreed with regional colleagues some areas, now, that we will start
to work in practice to try and sort of prototype what that kind of, I suppose, genuine support
model could look like at system level that would touch on some of the kind of financial
realities of what needs to be delivered but very much alongside a focus on all of the
other things we’ve talked about around quality and constitutional standards as well.
>>Andrew Morris: Thank you. That was really helpful.
>>Dido Harding: And I think that’s probably a very good summary of the whole discussion
which is that we need to be able to focus both on the long-term direction of travel,
and consult and engage and bring people with us, but also act in the here and now, recognising
quite how hard staff are working across the NHS, and how important it is that we support
them and deploy resources to support them in the areas that most need it as we run in
towards winter. Okay. Any final comments on operational and financial performance? Shall
we move on? Okay. Thank you all. So Ian: back to you. Community pharmacy.
>>Ian Dodge: Thank you very much. Can I invite Ed to join us?
>>Dido Harding: Excellent.>>Ian Dodge: [Inaudible] on community pharmacy
it’s fantastic today to be talking about community pharmacy here at the boards. In
July this year we reached a landmark deal which marks a sea-change in our relationship
with the sector. And I want to pay tribute particularly to Simon Dukes, the Chief Executive
of the Pharmaceutical Services Negotiating Committee; Janette Howe in the Department
of Health and Social Care and her team, and Ed and Lisa here in NHS England and Improvement,
and their team, who have really brought an energy and a focus to our work on community
pharmacy. This is the first ever five-year settlement
in NHS history, and it provides really important financial certainty for pharmacies at a period
of profound change, because the traditional high street model is being interrupted by
the rapid growth of online dispensing. And to assist with reform of dispensing and help
confront some of those challenges this deal will now enable wider use of hub and spoke
automation for all pharmacies; small independents as well as the large multiples, as well as
changes to skill mix. Pharmacies will now under this deal do more for the NHS, delivering
new clinical services. They become a more integral part of the urgent care system, something,
Noel, Pauline, you’ve just been talking about. And this five-year deal isn’t just
for the medium term: it’s for now, because the new 111 referral service to community
pharmacy for consultations being booked directly starts this October in time to help with winter.
And pharmacies will also do more to prevent ill health. For example, by helping to detect
the very high levels we know of undetected hypertension which exist in our communities.
So this is, I think, a good deal for the sector. It’s fair for the taxpayer, and it’s beneficial
for the NHS, and I really commend it to the board.
>>Dido Harding: Thank you. Any questions or comments? Richard.
>>Richard Douglas: I mean, this looks very good. So I’ll start off with that.
>>Dido Harding: Good start.>>Ian Dodge: Thank you for that Richard.
>>Dido Harding: There’s a but coming.>>Speaker: Because we have actually now agreed
it with the community [inaudible] it’s an interesting commentary but…
>>Richard Douglas: What we’ve got here, it would appear with the locals[?], is we’ve
got a deal with the pharmacies that will give us more from there. They’ve, yeah, coped
with – as the rest of the NHS already has coped with the increase in volume, and we’re
going to get that for about £200 million less in five years’ time than we paid two
years ago. So, eight year period, we’re going to pay them about £200 million less
and we’re given a shed load more stuff. Now that feels brilliant to me. So that’s
my bit about it. Brilliant. I guess my question is, how do I explain that? And the sort of
– there’s one of three possible explanations. And you might say it’s the first one of
them. And the first one is: we did a pretty rubbish job in the past on this. Hand up,
I was responsible for this – for this area.>>Dido Harding: Ah, now we’re getting to
it.>>Richard Douglas: Second possibility is,
yeah, here is a sector that really is transforming itself, that really is, has thought about
now how you do a lot more but actually spend less per unit of activity on it. Third bit
is, actually, we’re squeezing the margins too much on this, and we push them to the
point where that could create problems for us in the future. And I guess what I’m trying
to understand a bit is which of those three things?
>>Ian Dodge: I’ll offer a quick take and then Ed can come in and correct me when I
get it wrong. On your first point I’d say yes, community pharmacy has been, actually,
a bit of a neglected centre. And that’s I think both to the detriment of the NHS and
it’s also been to the detriment of community pharmacy itself. I’d say yes, it is transforming,
and there is huge scope for transformation. I mentioned dispensing reform. We’ve got a
– we spend a lot of money on a network of highly skilled professionals, primarily through
dispensing, and there’s a big set of opportunities I mentioned. Hub and spoke automation I mentioned;
online distribution rather than just physical and face to face; and skill mix changes as
we end up with more pharmacists increasingly working in primary care networks, doing increasingly
complex work, not least bearing in mind we can’t get as many GPs as we would like.
So secondly yes, there is a really big efficiency opportunity. And then third in terms of the
value, this deal does provide stability. It comes against a context where there have been
recent cash reductions. We have also seen an increase in recent years in the number
of community pharmacies in this country, which we haven’t seen in some of the other countries,
and that follows market liberalisation that happened 15 or so years ago. And I would mention
that some of those dispensing reforms will help the sector deal with efficiency. And
one of the nice things about having a five-year deal is that actually it becomes in the interest
of the sector to try and work out how it can deliver some of the cost efficiencies now.
And one of the reasons why we struggle to unlock those changes is the extent to which
if you’re just doing a one-year deal, it’s been less of an obvious reason for pursuing
that. And then I’d say what we’re currently
doing is rebalancing off spend. So community pharmacy can see a really important future,
more closely linked to the NHS, where the balance of spending between dispensing relatively
speaking goes down, bearing in mind the efficiencies, and we begin to work up more clearly spend
on sets of clinical services that properly connect with and support the NHS and indeed
the wider public health work we’re doing.>>Dido Harding: Excellent. Steve, you wanted
to come in?>>Steve Powis: Yeah, well Ian made a very
good point, which was the focus on the pharmacy workforce rather than the community pharmacies.
And the pharmacists are of course an incredibly skilled workforce and it’s really essential
both for their professional satisfaction and for the NHS and for patients that we – that
we use them and all the skills that they have. So I think it’s important to see this in
the context of the increasing value and work they do in secondary care, to assist our secondary
care clinicians; in primary care, which is one of the cornerstones of the GP contract,
and of course they’re not alone there, we include paramedics and others. But pharmacies
– pharmacists have much more they can bring to primary care. We’re supporting that and
GPs are supporting that. And then of course in community pharmacies.
So I think it’s a great example of how when it comes to the people plan we are ensuring
that we use the skills mix and all the great staff that we have in the NHS and other areas
that support the NHS to its fullest.>>Ian Dodge: Can I add one other thing on
the workforce which is, apart from clinical pharmacists, we also have a huge opportunity
with recent reform and recognition and support for pharmacy technicians. And I think we will
start to see a real growth in their numbers in the next few years and that will help a
variety of sectors. It will help the community pharmacy sector and it will also help primary
care.>>Dido Harding: Brilliant. Mindful of everyone’s
time – Manir. Briefly.>>Speaker: Brief question. Good step forward.
Just wondering about the training requirements if they’re going to look after minor illnesses
with urgent care, and the training requirements might be different for somebody who’s working
in a single isolated pharmacy compared to those who work in a chain pharmacy and the
standardisation of that training.>>Ian Dodge: So the way the service has been
designed for its roll out in October is that it effectively directs to pharmacy the sort
of conditions you’d expect to be walking off the street into a pharmacy anyway and in the
clinical scope of practice for a pharmacist in their training. So it may be more conservative
than in the long run with extra training and support you could support the workforce to
deliver. Nevertheless, we have to make sure that everyone delivering the service in the
pharmacy is competent to do so. So the service specification’s very clear about the obligations
on the owners of pharmacies, the contract holders, to make sure competent staff are
certified as competent and delivering in the pharmacy and we are going to make available
training courses to make sure that things like red flag symptoms for sepsis, etc., are
well recognised by the people delivering the service.
>>Speaker: So those training courses will be available online to the pharmacists so
they can access?>>Ian Dodge: Those training courses will be
available in face to face, in proper training packages as well as online, yeah.
>>Speaker: I think the point in the round which then goes into primary care as well
is ensuring that we support our staff in terms of the extra skills that they might need is
well made and in pharmacy in particular, the chief Pharmaceutical Officer if he was here
would make that point. And it is indeed something that we are considering as part of the people
plan as to how we address that.>>Dido Harding: [Inaudible] John?
>>John: Mine’s just an observation, which is I had the great privilege to be out with
the Coop in Lincolnshire, who have 48 pharmacists – community pharmacies – just after this.
And I have to say there is – A, they do a phenomenally good job, being rooted in the
local communities; secondly they are really keen to play a full role in the local health
service; and thirdly, the length of the contract gives them some planning horizons which is
critical for them to think. So I think you know, they feel – and Ed,
I need to put you in touch with them. They feel really well placed, I think. The question
is how to leverage those sort of groups. We always think of the very big and the very
small: actually, there’s a strong thing in the middle who potentially have huge leverage
for us. And one of the things that I would observe quite strongly is, the development
of the workforce we’ve got is, how do we link the pharmacists in GPs, the community pharmacists,
and the pharmacists in secondary to be able to give career development, career support,
etc., etc. Because actually I think it would be quite [inaudible] in a GP, on their own.
So I think we need to think about that as well as through the – I think we’re pushed
for time so I’d suggest you pick that up later but I think there’s a real opportunity
there.>>Dido Harding: Take the challenge, and work
it, and move on. That’s okay. Excellent. Ruth.
>>Ruth May: It’s been commented [inaudible] for information. My paper, Neil and Olivia
lead this piece of work. It’s an annual update of our public and participation work.
More things that we need to be doing, and we were having a discussion pre-board, but
it is for your information as a board.>>Dido Harding: Excellent. Are there any questions?
Clearly this is a very important part of our responsibilities in both boards. Okay. We
will take it as read if that is okay. Which takes us back to Ian again.
>>Ian Dodge: Thank you very much. I’ll be very brief, to note that the government has
given a positive assessment of performance against the NHS England mandate. 45 of 60
assessed objectives being green or amber/green. Secondly, we now have a clear new mandate
for 2019/20 which covers both NHS England and NHS Improvement. And thirdly, henceforth
we will have a single integrated assessment against that, including formal six-monthly
reporting following the model we currently adopt for NHS England and we expect there
to be public assessment against that joint mandate.
>>Dido Harding: Any questions or comments on that? Good. In which case, is there any
other business for anyone? No?>>Speaker: CIL report?
>>Dido Harding: CIL report is starred and that’s done. I’ve purposefully tried to
leave us a little bit of time at the end, because I am mindful that a number of members
of the public – and you’ve been very patient, sitting for a long time. I wanted to just
explain why we weren’t taking a question in the middle of the board meeting, but also
make sure that there is a bit of time for us to have an informal conversation with anyone
who does – who’s travelled to come to the board meeting who does want to. So just
so – and I probably should have said this at the beginning. Just so everyone is aware,
this is a – it’s two board meetings in common, in public; it is not a public meeting,
which is why we don’t take questions in the board meeting itself. And that is part
of the setup and constitutional arrangements for NHS England, that we’ve adopted as we
meet in common. But I think both Davids and I feel quite strongly that we do really want
to make sure that we’re accessible to members of the public; that we take questions wherever
we can both face to face and electronically. So I am hoping we have left ourselves an extra
15 or 20 minutes because the private meeting doesn’t need to start until five. So if
there is anyone who has been patient and stayed with us and is now in the rain who wants to
have some informal time with either David or I, we can free that time up now for the
next 15 minutes and we will do that going forward in each of our meetings. And I would
say David, who spent quite a long time – I don’t know if you want to take two minutes
to describe the conversation you had with the people from Swindon?
>>David Roberts: Yes, so I think first of all is, they’ve clearly had a pretty bad
experience both locally but also in the way that we’ve interacted with them. And I think
we need to ask ourselves two questions: one is what happened, but secondly, why was it
that they felt the only way that they could get heard was to actually travel from Swindon
to here. And I think we need to ask ourselves some questions on that.
I’ve committed to go back to the lady, Kate Lenehan, who was, I think, bringing the raising
of concerns, and I think Simon, it’s something that maybe you and I can speak after, because
I’ve put my name on the line to make sure they get an answer.
>>Dido Harding: Thank you for doing that on behalf of both boards. So the public board
is now closed: if I could ask all the directors to reconvene at 17.00 and David and I are
available if people want to talk to us. Okay. Thank you all.