Why is financial stability important to the ICS?
As spenders of public money, all our ICS partners have a duty to taxpayers and the Treasury to use the funding available as efficiently and effectively as possible, maximising the improvement in health and care which can be gained from each pound spent. Public Sector organisations, including the NHS, have a statutory duty to break-even and are held to account for failure to deliver that target. In recent years the NHS has managed to operate within its allocated budget at a national level. However, most provider organisations and many commissioners have failed to balance their books, with the resultant shortfalls being offset by nationally held reserves, deferral of investments, and the use of various national support funding schemes. In summary the NHS system needs to move towards sustainable financial balance as any deficits built up will need to be repaid, which in itself is a brake on health investment and a reduction in future health outcomes. To help restore financial balance in this period of organisational deficits, NHS England and Improvement has set ’financial control totals’: maximum amounts by which organisations may overspend.
What difference does the ICS make?
In 2019/20 for the first time, the NHS partners in the ICS System were accountable for the delivery of a NHS system financial control total, which aggregates the control totals of individual NHS organisations set by Regulators. Over time, it is planned that the proportion of support funding that will be reliant on delivery of the whole system control total will increase, although the rate of that increase has not yet been specified.
|NHS Ipswich and East Suffolk CCG||100.0|
|NHS North East Essex CCG||100.0|
|NHS West Suffolk CCG||100.0|
|East Suffolk and North Essex NHS FT||100.0|
|West Suffolk NHS FT||100.0|
In addition, East of England Ambulance Service Trust which covers six ICS/STP footprints is wholly reflected in the Suffolk and North East Essex ICS financial plans, but does not count for the purposes of system financial control management. The tables and charts that follow reflect the five core organisations noted above.
Five Financial Tests
In line with the aspirations in long term plan, providers within the system should be in balance during 2020/21, with the whole system being in balance in 2023/24.
2) Providers must deliver 1.1% cash releasing efficiency, unless they are in deficit (1.6% applies).
NHS organisations within Suffolk and North East Essex are aiming to deliver minimum levels of efficiency as follows:
- Organisations in recurrent balance – 1.1% plus 0.5% to contribute to the regional reserve (minimum 1.6%)
- Organisations in deficit – as above plus an additional 0.5% to move towards balance (minimum 2.1%)
3) Plans must include measures to maximise efficiencies and support appropriate reductions in the growth in demand for care.
System financial plans reflect the developments noted throughout this strategic plan, including measures to moderate the growth in non-elective activity. Our ICS non-elective admission/A+E attendance rate growth is currently 2.1%/0.4% respectively below the regional average.
4) Reduced variation across the system (quality, access and outcomes).
The efficiency element of the plan draws on local and national benchmarking work to show where further efficiencies are available through reducing variation on quality, access and outcomes.
Over the period of the long term plan, we will be making progress on the implementation of population health management which will be a key enabler for this work, assisting with effective decision making.
5) Make better use of capital investments, with a baseline of investments and a prioritised list of discretionary expenditure items.
There is a well developed ICS estates strategy and supporting workbook which set out the current baseline of assets and the prioritised list of future developments. In addition to this work, which focusses largely on NHS assets, our local alliances will be looking at the wider public sector estate with the aim of maximising efficiency and effectiveness.
Although we have been able to make significant efficiencies by working as our constituent parts, we know that generating further savings year on year becomes increasingly challenging. We also know we need to do more to meet the challenges of continued increasing demand for services and the increasing health inequalities caused by local deprivation. Local government also continues to face huge financial pressures, and our system can learn from the successful strategies that have enabled our local councils to continue providing high quality services despite major cuts in funding in recent years. Our workforce is our most important resource, and we must ensure the skill mix of staff meets peoples’ needs, fill vacancies and reduce reliance on agency staff, improve staff experience and reduce sickness rates. Going forward, we know we need a whole system approach to integration and transformation that takes into account these challenges and builds on our strengths.
We have agreed the following principles that will underpin our approach to achieving system efficiency:
- We will differentiate between areas where activity directly drives costs from opportunities to release costs, and we will tailor our approach to system efficiency accordingly.
- We will avoid shifting activity and costs from one area of the system to another – instead identify and support a range of different options to achieve savings.
- We will seek to avoid making the mistake of spending new money in ‘old ways’ – we will instead explore ways to use money differently in the future.
- We will listen to the ideas of frontline staff, test out their ideas and scale up what works.
- We will help frontline staff to better understand how what they do impacts on budgets and resources.
- We will use technology to operate more efficiently and effectively.
- We will use buildings more effectively, sharing spaces and resources.
- We will take a regional approach where appropriate, achieving alignment and consistency across borders.
Scheme 1: Agency standardisation: system-wide agreement and implementation
- Collaborating at a regional level to align our approaches to agency staffing and drive up standards, building on best practice locally and elsewhere.
- Exploring in more detail where agency spend is highest and develop the workforce in these areas to reduce the need for agency staff.
- Ensuring all partners adhere to agreed standard agency payment rates.
- Developing consistent and efficient approaches to flexible working and a shared bank to attract staff to take up these options.
- Exploring annualised rostering to ensure gaps are filled and to improve consistency for staff and service providers
These measures can enable us to improve activity and efficiency; lower vacancy rates and spend on agency staff; achieve consistency in the agency offer and payment rates; align our approach locally and regionally; and provide a stepping-stone to permanent work for our staff.
Scheme 2: Effective use of estates and support services
- Making better use of space in buildings, in particular for administrative staff, by stocktaking to identify gaps and opportunities both now and as contracts expire, building on One Public Estate initiatives.
- Making better use and spreading the costs of providing core hours or 24/7 coverage in, for example, maintenance, estates, HR, finance, or legal specialist services.
- Reducing duplication in governance areas such as serious incidents and complaints.
- Joining up areas such as procurement and contracts, and approach the market as an ICS where possible, to ensure we do things only once.
- Joining up business intelligence teams to improve quality and consistency of data.
- Reducing waiting times for patients by identifying gaps and opportunities across the system and joining up on clinical outsourcing.
- Review how services are paid for by CCGs, including the needs of our Primary Care Networks.
- Compare data on waiting times across specialities in the ICS to find opportunities for efficiencies.
In this way we can share resources more effectively, make better use of the resources we have, and improve consistency and quality of care for people using services. .
Scheme 3: Effective use of estates and support services
- Using data to review the gaps across the system, understand the causes, challenge issues of concern, and share best practice in recruitment and staff skill mix.
- Continuous advertising, promoting our area as a good place to work with a positive culture and good health and wellbeing, effective leadership and best use of technology
- Working with higher education to ensure pre- and post-qualification learning meets employers’ needs.
- Considering an ICS-wide recruitment hub, and make the bank a more attractive option.
- Taking a consistent approach to using recruitment incentives across our area, and reviewing opportunities for bursaries to attract staff.
- Proactively attracting newly qualified professionals back into our area, and taking a consistent approach to international recruitment.
- Developing a workforce passport that can be used across the ICS area to simplify and speed up recruitment.
These measures can improve system-wide collaboration and integration; increase workforce supply; achieve ‘one’ system-wide workforce where partners trust each other’s training and standards; create an agile workforce; increase the attractiveness of substantive positions and retention of staff; reduce workloads through better skill mix; and reduce agency spend.
Scheme 4: Developing the model for urgent and emergency care
- Ensuring that people are directed to the right place and type of care for their needs; ambulances should take fewer people to emergency departments, as more people’s needs can be met within the community. Enabling ambulance services to access mental health care records will support this strategy.
- Creating a less risk-averse culture in care settings and in primary care, by training and supporting staff to recognise better when and where people need care and treatment. Reducing reliance on agency staff in care settings will mean staff know the people they care for better, helping them to make the right decisions for their needs.
- Achieving a common approach across the ICS to providing integrated support when patients return home from hospital that builds on existing best practice.
- Reviewing the functions and available space in community hospitals, to maximise the opportunities to use their resources effectively.
- Developing seven-day therapy services to better support people in the community and avoid hospital admissions.
- Explore creative opportunities to reduce ‘stranded’ patients, for example extra voluntary sector support, or short-term accommodation where people can wait for adaptations to their own home.
- Explore why care homes can be reluctant to admit new residents over weekends, and ensure the right resources are available to support homes in the first days of the person’s stay.
These strategies can enable us to achieve better health outcomes for patients, reduce the need for hospital stays, cut agency staff costs, and reduce the risks of cancelling elective surgery due to high demand for unplanned care.
- Triaging referrals from GPs at a central point to reduce inappropriate demand for outpatients.
- Improving access to online consultations and virtual clinics.
- Simplifying care pathways by centralising outpatients, providing a one-stop diagnostic hub to reduce the need for people to travel to multiple appointments.
- Improving systems for cancelling appointments to reduce the number of non-attendances.
- Reducing the need for locum doctors and agency staff, so that people experience more continuity of care and more efficient support.
- Moving further to paperless recording systems to reduce costs of transferring paper records to online.
In this way we can improve patients’ experiences, reduce costs travel costs for staff and patients, make optimum use of available resources and reduce unnecessary follow- up appointments
|Productivity Area||Local Approach|
|Improving clinical productivity and releasing more time for patient care||Expansion of Consultant Connect scheme (new locations and specialties). Suffolk and North East Essex Implementation project for Local Health Care Records (Regional lead), and WiFi expansion (including GovRoam). Ambulance Electronic Patient Record being procured. Recruitment of new staff categories, to improve skills utilisation, and address shortages.|
|Maximising the buying power of the NHS, including Purchase Price Index and Benchmarking Tool, Getting It Right First Time clincally led procurement work and Support Supply Chain Coordination Limited||Key providers engaged with supply chain programme including standards of procurement accreditation Getting It Right First Time programme board in place. Product standardisation to deliver merger efficiencies.|
|Supporting the development of pathology networks and diagnostic imaging networks.||IT developments to pool diagnostic capacity and prevent duplication. Implementation of clinical decision support tools to reduce unnecessary referrals (target 3% reduction and 10% improved referrals).|
|Supporting pharmacy staff to take on increased patient facing clinical roles and, through the Medicines Value Programme, help the NHS deliver better value from the £16 billion annual spend on medicines||Pharmacy network development to enhance pharmacy in the community/neighbourhood services. Pharmacy support to primary care teams. Healthy living programmes. Medicines Optimised programmes (care homes). Clinical pharmacy, and social prescribing support to Primary Care Networks. Application for pilot status for PrescQIPP to identify system medicines management savings|
|Deliver an additional £700m savings in administration costs by 2023/24.||CCG management reconfiguration to complete by December 2019, to deliver 20% initial reduction East Suffolk and North Essex NHS Foundation Trust acute service reconfiguration to deliver a streamlined management structure.|
|Make better use of capital investment and its existing assets to drive transformation.||East Suffolk and North Essex NHS Foundation Trust acute reconfiguration, and West Suffolk NHS Foundation Trust Emergency Departments and Clacton Hospital cases to develop from existing estate, to improve utilisation, and drive efficiency agenda (West Suffolk NHS Foundation Trust admissions avoidance, and specialisation). GP surgery relocations to utilise existing sites (Oakfield, Kennedy Way) East of England Ambulance Service NHS Trust to rationalise estate to create Make Ready hubs, and to enhance Control room capacity, efficiency and resilience.|
|Implement the national Evidence Based Interventions programme to reduce harm and free up resources||Cancer plans (early diagnosis and personalised care programmes), to ensure appropriate and timely testing, improving outcomes and improving efficiency. Development of early intervention and crisis mental health services. Diabetes prevention and structured education. Implementation of maternity continuity of care projects.|
|Implement the National Patient Safety Strategy which will improve patient safety and prevent harm thus reduce costs||Roll out of Suffolk and North East Essex national pilot for Serious Incident investigation framework (expected to deliver improved patient outcomes rather than savings).|
|Reducing variation across the health system improving operational and financial performance||Full assessment of clinical directorates against NHS Efficiency Map. AI and digitisation assessment process in place; plans implemented to appropriate timescales. Alliance transformation programme to identify appropriate changes to care pathways and care settings using Rightcare, Getting It Right First Time and Model Hospital. Rightcare savings in urgent and emergency care opportunity estimated at £10.6m and elective care (GP referrals, other referrals, elective admissions and occupied bed days) estimated £13.9m|
In summary we have made the following cross system commitments to achieving system efficiency over the next five years:
- To develop an ICS wide policy for the use of agency and to seek a regional wide approach.
- To explore additional steps partner organisations can take to reduce sickness absence, provide more flexible working for our staff, and to develop a‘workforce passport’.
- To review opportunities for estates rationalisation with a particular immediate focus upon North East Essex where there are opportunities to achieve savings now.
- To move towards seven day working in community services across the ICS through a review in each Alliance of the relative merits of this and todevelop a costed plan.
- To work more closely together across the three Alliances on the Ageing Well Programme to develop a more consistent model across the ICS foradmissions avoidance and discharge support
- To develop an ICS wide outpatient programme which reviews and implements changes to enable a 33% reduction in face-to-face follow upappointments and, more widely, a reduction in demand.
- To renew discussions between partners to consolidate support services
New integrated contracting options
The NHS Long Term Plan notes that a new Integrated Care Provider (ICP) contract will be made available for use from 2019, following public and provider consultation. It allows for the first time the contractual integration of primary medical services with other services, and creates greater flexibility to achieve full integration of care.
Better Care Fund
The Better Care Fund and ‘Improved’ Better Care Fund is a joint budget between health and social care. The key features of the funds within Suffolk and North East Essex are the protection of adult social care, reablement services and out of hospital services. The combination of health and social care funding into a joint budget has enhanced the ability of commissioners to come together to improve efficiency and patient experience. For example, Emergency Vehicles have been commissioned which bring occupational therapy and paramedic care together. Joined up hospital discharge and reablement funding has enabled social care and health to jointly design services to improve efficiency and support our patients. The Better Care Fund continues to be a key feature of system integration and will develop further to include additional services over the planning round.
How will we know that we’re making a difference?
- Non-elective admissions will reduce – number of specific acute hospital admission rates
- Delayed Transfers of Care from hospital will reduce – rates per 100,000 adult population
- Better Care Fund plans are delivered successfully
- Provision of social services maintained – Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement or rehabilitation services, Long-term support needs of older people (aged 65 and over) met by admission to residential and nursing care homes, per 100,000 population.