>>Malcolm Grant: Thank you very much, and we will go on to NHS performance. Just on
this paper to note that we are on this occasion bringing a single paper to the Board, one
which deals with the performance over the NHS as a whole, but the second, the performance
of NHS England in supporting the performance of NHS overall. I am going to invite Barbara,
please, to kick off.
>>Barbara Hakin: Thank you, Chairman, and then I will hand over to Karen for the second
part. My report on NHS performance follows the standard format, and what I will not do
is repeat some of the things I have raised in previous meetings. However, I have a number
of issues that I particularly want to highlight out of this report.
First, I would like to just reiterate that it shows just across the board how busy the
NHS is, but how well staff in the front line of NHS are doing to deliver to patients the
services and the standards that we all want to see. Just a reminder that the standards
or targets are how we measure ourselves in the NHS to ensure that we are delivering to
patients their constitutional rights for those sections which are about the constitution.
I think it is always important to keep this in perspective. By constitutional rights,
if we look at A&E and the number of patients who are admitted or discharged within four
hours, in order to give ourselves assurance that we are meeting the standards, then we
look for 95 out of 100, or 950 out of 1,000 patients, to actually have their constitutional
rights delivered and be admitted or discharged within that four hours.
Whilst it is always disappointing when we do not meet the standard, I do think, in perspective,
what we need to realise is that whilst we are not meeting the 950, 925 out of 1,000
patients are getting their treatment within that time, and actually the vast majority
are well within that four hours: the vast majority of patients are only there for an
hour or so. I think on all of these it is important to keep a perspective for what is
a very important thing we do to measure our own success, but actually, I am making it
very clear that, for the most part, the vast majority of patients do get their treatments
in the times that have been set down within the constitutional standards.
I will also just highlight that, since we wrote the report and it was published on the
website, the September figures have been published. Disappointingly, across most of the standards
they show a small reduction, but for the most part the figures in here are a fair and true
reflection, because as I say, the changes in the September figures are small.
Then the third thing that the report highlights is just how much is in train, not only within
NHS England, but within NHSI, so that the national bodies can support the front line;
particularly working with local authorities and social care to try and reduce the number
of delayed discharges, which we know contribute to how well the NHS can deliver its services.
The report goes through the range of things we are doing with our partners at national
level in order to help support CCGs and NHS providers of care to be the best they can
be in delivering these standards.
Finally, Chairman, if I can, could I just update the Board, as Simon mentioned earlier?
In line with NHS England's statutory duty to manage emergencies and major incidents,
we are in NHS England - through the Emergency Planning Team - co ordinating the preparation
for any action which ensues by junior doctors, just in order to ensure that the best possible
services for patients and patient safety can be maintained.
>>Malcolm Grant: Thank you, Barbara, and of course that is something that the Board will
want to follow very closely indeed. We take your assurance, but we know that the current
circumstances are uncertain. May I invite questions or comments to Barbara, before we
turn to part two of the report? No? Well thank you very much, Barbara. Karen.
>>Karen Wheeler: On the NHS England Performance Report, the main element of this report is
the report of progress against business plan priorities, so this is essentially rating
us against our ability to deliver what we committed to deliver at the start of the year
through the business plan. The annex also, just in case it is not clear enough; the right-hand
side of that table, the dashboard table, reflects GMPP and IPMB, which are basically major programmes
and informatics programmes, in addition to those which are subsumed within our overall
priorities.
These programmes are effectively a subset, in many areas, of the Five-Year Forward View
delivery plan, but obviously do not include all of the Five-Year Forward View, and in
some areas concentrate on NHS England performance as well as wider NHS. They are big and complex.
It is also worth pointing out that some of these programmes, although we are monitoring
progress against our delivery for this financial year in here, some of these programmes are
of course three-, four- and five-year programmes, and will take that amount of time to fully
deliver.
They are in very different stages. For example, we talked about urgent and emergency care,
and learning disabilities. Some have been going like that for some time and are well
established and absolutely into delivery. Others are in relatively early stages - cancer,
mental health - where the programmes are at the stage of transforming strategic proposals
into a delivery plan, which will then be costed. Some of those, and the delivery of all this,
will obviously be impacted by spending review allocations as well, which we will doubtless
be taking into account. They are in very different positions.
I just wanted you to be aware that these ratings reflect both delivery to plan and what I tend
to call inherent risk. Some of these, where we have amber/red, does not necessarily mean
that they are failing against the delivery plan, but rather that there is a huge amount
of inherent risk associated with them, and so I think that is worth noting.
We are currently doing a stock take of all of our business plan priorities, and that
will refresh this dashboard and give us a more up-to-date view and a more in-depth view.
I think the stock take and the way that we are governing the priorities has actually
been really helpful, in terms of making sure that the whole organisation is pulling behind
each of these priorities; it is not just a directorate-owned piece of work.
The stock take is certainly identifying good governance and good process. In many areas,
the programmes are well established. Probably there are two areas where we are not as good
and need to do more. There are capability issues, both in programme management and aspects
like commercial procurement expertise. We are putting in place improvements to that
for a number of programmes. Secondly, costed delivery plans, which as we go into our business
planning process for the next year, we are asking all of the priorities to work out their
three year costed delivery plans for these programmes. That is something that more work
needs to be done on, to give us assurance around all of that.
Those are the priorities. I was not going to talk about the risks. Clearly the risks
are a mix of programme change and operational delivery. I was not going to talk about those
in particular. There is a third element of our corporate performance which is not reflected
in here but I wanted to assure you of, which is that we also of course scrutinise and look
at our own corporate performance of services. There was not anything to bring to your attention
there particularly today, but I want to assure you that we are all over that as well.
>>Malcolm Grant: Thank you for the report. Let me invite comments and questions from
the Board.
>>Noel Gordon: I think Karen's done a tremendous job to organise huge complexity into what
most people in the outside world would regard as a very structured transformation plan.
However, I note that in the stocktake, Karen, you are also pointing to evidence that there
is delivery risk, and potentially delivery delay as well. What is the best way for thinking
about how to manage progress of this huge complexity, given that we are only at the
start at the moment, and over the next couple of years it is going to get more complex as
we get into delivery? Would you anticipate the stock take coming up with recommendations
on how we are going to provide some sort of umbrella overview of progress performance?
>>Karen Wheeler: Very good questions. Yes, some of these programmes - we heard about
urgent emergency care and learning disabilities - are system changes that need to happen outwith
the system. They are not within our direct control. This is going to be very much a partnership,
working with local systems and so on. These are a subset of the Five-Year Forward View.
The Five-Year Forward View, of course, has a series of programmes as well which are the
responsibility of other arm's-length bodies - NHS Improvement, Health Education England
and so on.
Part of the challenge around this area is being really clear: what is NHS England? What
is Five-Year Forward View? How do those two dock together, and how can we work with our
colleagues in other arm's-length bodies to ensure that we are working on all of those
together? Obviously Ian leads on a large part of this on the Five-Year Forward View; Jo
Lenaghan works supporting the Five-Year Forward View overall governance as well, so that we
can try and create an overall delivery plan which takes account of our work in the context
of the Five-Year Forward View. I think that is really quite important. It is all part
of the same work, and we need to be clear how our progress is reporting under that.
So joining up the governance, sharing information and creating an overall delivery plan is a
key part of that.
Secondly, it is about capability. These programmes are all about the capability of the leadership
and the resources that you put into them, whether it is programme directors, SROs or
national implementation directors, which we are trying to recruit. Very specific capability,
as I said, around procurement expertise and so on. Some of those skills are quite scarce,
so we are trying to recruit and improve all of those as well.
There is a third docking, I suppose, with the Five-Year Forward View, making sure that
the work links into the business planning work for the wider system, so that local organisations
across the NHS and wider system are not being asked multiple times for different things,
but are building this work into their local plans. Again, we are trying to make sure that
our own work here docks into the planning guidance which we give out to the NHS, and
that that builds into three-year forward plans for local systems as well.
>>Noel Gordon: If I may just make an additional observation, Malcolm? One of the many lessons
learned from complex transformations in organisations outside NHS England is the risk of falling
into the trap that when we divide the world into silos, because silos are very good for
executing in this way, we actually kind of assume the silos will get on and do it. Actually,
when we divide the world into silos, we need to put as much emphasis on the horizontal,
cross cutting linkages between silos. In the past, that has been hugely forgotten, and
ended up tripping up the process of delivery much later on. It is purely an observation,
and one I know we will come back to. However, I think that is the other dimension of this
world, which is how we join up from the patient standpoint, the receiving entity of a local
health economy, right the way through to all of our organisational entities. In a way,
they need to see it as a joined-up delivery of outcome, as opposed to a series of 25 powerful
silos. You would agree with that, would you not?
>>Karen Wheeler: I completely agree with that. Much of this lands, of course, in the local
health economy. The local health economy needs to not see urgent and emergency care, mental
health, cancer and learning disabilities: they need to see a single plan for their local
health economy which is aiming to deliver the sorts of outcomes that we are looking
for here, but which is their plan and which is joined up. So our challenge right now is
making sure that we can articulate that well, in a helpful way for local health economies,
rather than confusing them with lots of different siloed plans. So we are on it. I am not sure
we have quite got the solution yet, but we are working on it.
>>Noel Gordon: It is a journey.
>>Moira Gibb: I just wanted to ask, given that child protection information-sharing
is showing as amber/red, whether that was a delay or, as Karen said earlier, inherent
risk?
>>Speaker: I think it might be an administrative issue.
>>Karen Wheeler: I think there is a risk there. There has been a risk associated with the
system.
>>Jane Cummings: It is the speed of rollout, as opposed to the system itself. We have only
just picked it up. We have a plan, and we are looking at it at the moment. We have just
taken it over, so we are looking at it at the moment. We have increased the level of
risk associated with it, having reviewed where we have got to. We have a plan, so we will
come back with a plan to let you know.
>>Malcolm Grant: Okay. Thank you. I think we have had a good review. Thank you, Karen,
for the report. As we know, the priorities and programmes will change as we go through
the next business planning round, and we expect to bring that back to the Board, either at
the next meeting or the following one.