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Resource Guide 11 - NHS Planning


Who should read this?
  • Chief Executives
  • PEC Chairs
  • Commissioning & Finance Leads
Resource Guide 3
 Before you get started
  • Review the current LDP – where are you on the key targets?
  • Ensure the Board has a progress report on the current LDP
  • Agree process with other PCTs, Trusts and stakeholders

 Resources/Key Questions

  • How extensively does the current LDP need revising in light of progress?
  • Information – progress, updated demand & capacity models
  • New issues e.g. Practitioners with a Special Interest to resolve more care needs in a primary setting; new independent sector Treatment Centres

 How to do it?

  • Involve the Board and wider stakeholders in setting the direction
  • Summarise the key issues from the detail  of demand and capacity models and options for decision makers
  • Work closely with other PCTs and trusts to ensure plans are robust and jointly owned

 

 

A Framework for translating national strategic objectives into local objectives and key tasks

The Planning Framework

 Ensuring capacity to meet needs  
 Raising Standards  
 Involvement processes for service change  
 Resourcing the plan  
 Specialised Services  
 Plurality, diversity and choice  
 Updating and reviewing plans  

The Planning Framework

Strategic Objective

Local objectives

Key tasks

Each PCT has a Local Delivery Plan to clearly identify how national and local priorities will be met over a three year period.

(i) PCTs need to ensure that national priorities are linked to local priorities and that there are clear processes and timescales to ensure a meaningful and affordable medium term plan for local services.

The Board of the PCT remains responsible for agreeing the 3 year Local Delivery Plan for the organisation and must ensure that the PCT has:

  • Management capacity within the organisation’s planning and commissioning functions to enable an effective plan to be developed
  • Clear arrangements and processes are in place ensuring the involvement of key stakeholders including local people and patients, key provider trusts, clinician engagement, social services, the voluntary sector
  • Planning processes and timescales should enable sufficient time for an appropriate engagement and involvement process to support and direct planning activity
  • The PCT should ensure that supporting strategies (for example, communications) are in place throughout the planning process
  • Interfaces to strategic development and detailed development of Service Level Agreements should be clear and systematic.

Where a PCT acts on behalf of others as lead commissioner, lead commissioners are responsible for ensuring involvement of other PCTs as appropriate in key planning proposals, which could affect service delivery (either service quantity or quality). 

Responsibilities of lead commissioners should be clear, formally agreed by all relevant PCTs and should cover roles across the planning and service level agreement activities.

 

Ensure that clear programmes are identified.  In order to structure the planning process, in most cases it is helpful to ensure that the commissioning of health care is structured according to care groups or programmes which best reflect involvement processes and match strategic development.

Identify appropriate programmes (for example, Services for Older People), and identify the baseline parameters for planning purposes.  Medium term planning builds on this existing framework, which would typically include: -

  • Strategic direction
  • Stakeholders
  • Resources
  • Scope, quantity and quality of services commissioned

 

When establishing programmes for planning purposes, PCTs should take account of current structural arrangements, which reflect the nature of services provided (for example networks of care, and joint budgets or partnership agreements), and should therefore form a sound platform for service planning (this is already working effectively in many parts of the country)

 

 

Ensuring capacity to meet needs

 

Strategic Objective

Local objectives

Key tasks

The NHS plan identified clear objectives for the expansion of services and improvements in patient access through reduced waiting times.

 

The key elements of this expansion are:-

  • Additional acute facilities
  • Intermediate care
  • Critical care
  • Secondary workforce
  • Primary workforce
  • Improved modern facilities
  • Equipment
  • Information technology

 

 

PCTs will need to develop 3-5 year capacity plans agreed with local providers, taking into account forecast supply and demand, capacity constraints and medium term changes to population needs.  PCTs should understand population access rates for key interventions (at HRG level) and use comparative analysis to set thresholds that deliver changes to access rates as appropriate. 

Under Payment by Results PCTs will pay at full tariff for additional activity (rather than current marginal cost for much of the activity). They will therefore need to place significant emphasis on managing the interface with the acute sector both at point of referral, and point of discharge from the secondary/tertiary sectors in particular.

 

Having identified capacity requirements, further work will be required with providers to understand the constraints to delivery of additional capacity, modernisation of care pathways, and taking account of:-

  • Capital infrastructure requirements 
  • Workforce expansion

 

  • Understand the quantity of care required, and develop capacity plans
  • Identify historic activity levels for specialties, and key HRGs within specialties (e.g. primary hip replacement)
  • Forecast future required activity levels to meet access standards, taking account of changing demographics (e.g. population growth changes by 5 year age band)
  • Use comparative analysis to review current access rates (by key HRG) and identify outliers
  • Using public health needs assessment, identify planned changes to access rates, and revised care pathways where appropriate.
  • Ensure that thresholds, and guidelines are used effectively to implement changes to access rates, and ensure that clinical audit as appropriate is in place to review changes.
  • Review ‘quantity of activity’ requirements against local capacity with key stakeholders ensuring that robust plans are in place to increase capacity where appropriate, and that plans take account of planned provider diversity, reflecting patient choice.  The PCT should ensure that a commissioning policy is in place, which takes account of the role of the independent sector in the delivery of care for local people
  • Primary responsibility for the development of business cases lies with providers, however PCTs should work with providers to ensure that business cases are consistent with the strategic direction and are supported by agreed infrastructure policies (for example, workforce planning)

 

 

 

Raising Standards

 

Strategic Objective

Local objectives

Key tasks

The National Plan signalled further development of national quality standards.  These are delivered primarily through the following:

 

  • National service frameworks (web link)
  • NICE recommendations (web link)
  • CHI recommendations
  • Priorities and planning targets (including the Public Service Agreement).

 

 

 

 

 

Raising Standards – Improving Performance in the NHS, published by the Department of Health in May 2003 outlined the next steps towards achieving the NHS Plan vision and improving performance across the NHS through targeted programmes, and where necessary targeted support in organisations to achieve consistently high performance across the country.

 

 

 

 

 

 

 

 

NICE guidelines support commissioners and providers, offering expert guidance to ensure that new drugs and technologies are cost-effective, and that implementation ensures consistent application on a national basis.

 

Meeting quality standards and modernising services

 

PCTs should ensure that they have plans in place to meet as a minimum the national quality standards set out through the Priorities and Planning targets, National Service Frameworks and from the National Institute for Clinical Excellence (NICE).

 

In addition to these, Primary Care Trusts, from their involvement with local people and needs assessment should identify local quality standards.  PCT commissioners in many areas are working towards measuring health outcomes rather than specifying inputs to services.

 

 

 

The Commission for Healthcare Audit and Inspection will independently inspect NHS organisations, and from their work, PCTs should outline local objectives to improve performance where necessary.

 

 

 

 

 

 

 

 

 

The introduction of new technologies and drugs (or new uses of existing technologies) has been a significant driver to increasing the outcomes and quality of care. However costs are also significant, and PCTs will need effective structures to manage this (although increasingly, a range of drugs/technologies are covered by NICE guidance).

PCTs should ensure arrangements are in place for the effective implementation of National Service Frameworks, ensuring strong processes for involvement and clinical engagement.  Improving standards and quality of care should take account of the total care pathway in the various care settings, with particular focus on the interfaces between different care providers.

 

 

The Department of Health through the Modernisation Agency has established a range of programmes working towards the modernisation of services, including the raising of standards, and the effective use of resources.  These programmes include (for example):

  • Access Booking and Choice
  • Critical Care
  • Cancer Services Collaborative
  • CHD Collaborative
  • Emergency Services
  • Action On Programmes (Cataracts, ENT, Orthopaedics, Dermatology)
  • Day Surgery programme
  • TC programme
  • Operating theatre and pre-assessment
  • Endoscopy
  • Collaboratives (for example the Primary Care Collaborative, Orthopaedic Collaborative)

 

See Find Out more for Details of these programmes, including methodology to support health economies in the modernisation of services is to be found on the following links

 

PCTs should ensure sound processes are in place when new drugs/technologies are under consideration, involving clinicians from primary and secondary care, with clear criteria and approval processes.  Where NICE guidelines are available, PCTs should ensure a clear strategy for resourcing and implementing changes.

 

 

Involvement processes for service change

 

Strategic objectives

Local objectives

Key tasks

National policy on the regulatory framework for changes to services.

 

 

 

With the introduction of Foundation Trusts in particular, changes have been made to the Regulatory Framework, which PCTs will need to take account of when considering changes to services.  These include:

 

  • The Independent Regulator for Foundation Trusts who will need to agree changes to protected NHS services and assets
  • The Reconfiguration Panel
  • The role of the local Oversight and Scrutiny Committees.

 

The requirement to consult the above bodies does not replace the need for statutory consultation in the event of proposals for major strategic service changes.

Involvement and consultation strategies will need to be reviewed to take account of changes to the Regulatory Framework,  which affect the way in which the local health economy must involve stakeholders in order to make changes to services.

 

 

Where significant service changes are possible, the processes to define and deliver these changes should include key stakeholders within the local health economy, including local patient/public involvement, clinician engagement, provider involvement, social services, the voluntary sector etc.

In addition to these there may be other requirements to deliver service change, depending on local circumstances (for example Oversight and Scrutiny Committees, the Independent Regulator for Foundation Trusts, statutory duties of consultation).  Planning arrangements will need to be reviewed to ensure that they take account of these changes.

PCTs who commission services from a Foundation Trust may have a role on the Board of Governors and would need to develop a process that enables the PCT to advise/act on behalf of other local PCTs.


 

 

Resourcing the plan.

 

Strategic objectives

Local objectives

Key tasks

Nationally, 3 year allocations have been issued to PCTs to enable effective 3 year planning and improve certainty for both commissioners and providers of services.

 

 

 

National tariffs ensure that PCT focus is towards the quantity and quality of services rather than detailed price negotiation.

Local PCTs will need to ensure that service strategies reconcile to a longer-term financial strategy, and that medium term plans move local services towards the longer-term vision.

Medium term plans must be supported by a robust financial plan, which reflects investment, to meet national and local priorities, in particular taking account of financial reforms outlined in Payment by Results. In the early years of transition towards full implementation, PCTs should be confident that investments in service comply with national tariffs.  Where a business case requires additional investment in the early years, there must be clear agreement about funding of those additional costs, and commissioners will need to be certain that in the longer term the tariff level will be reached.

 

With the implementation of Payment by Results, PCTs will no longer need to engage in detailed price negotiation, however they will need to ensure that:-

  • There is clear comparative information for the quantity of service provided (e.g. access rates) and quality, which drive affordability of total service provision
  • Detailed financial comparative information for those services not covered by Payment by Results (including prescribing in primary care).

 

Financial plans should be clear, robust and transparent, ensuring full engagement with stakeholders as necessary.


 

 

Specialised Services

 

Strategic Objective

Local objectives

Key tasks

 

Please see Commissioning – Specialised Services

 

 

 

Plurality, diversity and choice

 

Strategic objectives

Local objectives

Key tasks

The NHS Plan, National Service Frameworks move the NHS towards patient-focused services, ensuring that patients receive the right care, at the right time, in the right place.  In addition to this framework local systems are now working towards patient choice from the point of referral (Choice at 6 months will be introduced in April 2004 for most specialties).  By late 2005 all NHS patients should have a choice of the time and place of treatment.  Together with these policies, the introduction of NHS and independent sector Treatment Centres, overseas teams and overseas treatment have expanded total capacity and choices available to patients and commissioners.

 

PCTs should ensure that they have clear plans for:-

  • Offering choice to patients, initially at 6 months and by December 2005 at point of referral
  • The role of the independent sector (including independent sector TCs) within the local health economy
  • Keeping the NHS Local encourages PCTs to consider how best to deliver services close to home – including the provision of appropriate interventions within primary care settings.

By the end of September 2003 PCTs will have completed plans for offering choice to patients waiting longer than 6 months.  This initiative is an opportunity for PCTs to understand some of the mechanisms for offering choice at point of referral – although clearly choice at point of referral will initiate a much more significant change towards patient–focused care.  PCTs will need to ensure that plans developed take account of the choices of local people, implying in many areas agreements with a wider range of providers in the medium term. 

 

As part of the direction towards plurality, diversity and choice, PCTs should ensure that they have clear plans relating to the use of the independent sector

 

Services delivered in primary care (particularly those that were formerly delivered in an acute setting) should form a key element of the planning programmes as defined by the PCT and be subject to similar criteria and standards.  PCTs should recognise that further guidance may impact on the delivery of these services (for example, although unlikely, it is not yet clear whether there could be a separate tariff in primary care for those services transferred from another NHS organisation – e.g. endoscopy services)

 

 

Updating and reviewing plans

 

Strategic Objective

Local objectives

Key tasks

National guidance for the development of Local Delivery Plans does not anticipate detailed additional priorities for the period 2003-06 beyond those outlined within the Priorities and Planning Framework “Improvement, Expansion and Reform”.

However PCTs are expected to update and review plans on an ongoing basis.

Detailed performance management will take place through Service Level Agreements, however PCTs should have arrangements for regular updates to plans and planning processes to take account of new guidance and policy, and changing trends (for example, referral patterns).

PCT Boards should expect regular reports on the development and updates of plans to ensure that they are up to date and that when SLAs are managed with providers, key issues that affect future plans are systematically incorporated, for example:

  • Changes affecting demand, supply or capacity
  • New national policy requiring new improved standards to be met
  • Changes in referral patterns, including changes resulting from patient choice
  • Changes to the regulatory framework
  • Recommendations from the Commission for Healthcare Audit and Inspection.

 

 

 


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