The latest planning guidance gets perilously close to being useful
30/09/2016by Rob Findlay
The gaping chasm between finance and waiting times is what grips our attention as we thumb through the latest English planning guidance.
The process is different too, with an earlier deadline and a two year plan. But underneath it is even more radical – it takes another decisive step away from feed-the-beast financially-led annual planning, towards genuinely useful operationally-led continuous planning.
Ideally, the trick is to anticipate where the regulators are going and leap confidently ahead of them, leaving a trail of ticked boxes in your wake. This guidance emphasises the waiting times standards, realistic activity plans, and demonstrating the capacity to deliver; in case you missed it the first time around, it says it again a couple of pages later. So that is our objective: an operationally deliverable plan.
Weekly or monthly trajectories?
But operational capacity works in weeks, whereas the guidance (with one foot firmly in the finance department) works in months. This is the first decision we need to make, and a lot of painful and confusing arithmetic awaits us if we get it wrong. (The technical guidance even gives us a preview, making heavy weather over how the weekends fall, and 2017-18 containing two Good Fridays.)
If operational life works in weeks then our plan should too. By using historical data that covers whole weeks and only one Easter we can take care of the working day effect in our baseline. We can then place Easter in our plans by adjusting activity in the right weeks. Then we only convert everything back into months at the last minute. The result: an operationally useful plan that is directly comparable with available weekly capacity.
Our second decision is how to phase activity through the year to make best use of capacity, and the guidance stresses that plans must be “reasonable and realistic” and yet “stretching from a financial perspective”. Although the simplest and most deliverable plan is whatever usually happens, that will not necessarily make the best use of the resources available nor deliver the A&E, cancer and 18 week access standards.
The real question here is, where is our capacity bottleneck? Is it beds, theatres, or staffing? Perhaps it moves around: beds in winter, staffing in the school holidays. Should we continue to approve mass annual leave in the school holidays, stranding bed capacity that could be used to shrink the waiting list? Or should we plan for more constant bed usage all year round, making better use of the holidays and reducing inpatient elective activity during the winter emergency peak?
Either way, we need to plan non-elective capacity alongside elective, so that we can see how our total requirements vary through the seasons. We need to know where capacity utilisation could improve. And we need to work out outpatient, diagnostic, and admitted capacity separately, which means taking into account the impact that each stage has on the next as patients pass along cancer and 18 week pathways.
Which brings us on to our third decision: how to deliver the better access trajectories required by the guidance. Much of A&E access is dealt with in the bed planning above. The consequence is elective waiting times that rise and fall through the seasons.
The traditional response to rising waiting times is to work harder, with waiting list initiatives and more vigorous efforts to book patients who are about to breach. But that is firefighting, not planning, and the financial squeeze makes this high-cost approach less viable.
Instead we need to plan for waiting times to peak safely without breaching, which means our waiting list needs to become smaller early on. This kills several birds with one stone: it’s cheaper, improves our access trajectories, and helps limit use of the independent sector to non-recurring work.
Up to date
So we come to our final decision. No matter how operationally realistic our planning may be, there is no way it will stay relevant for two whole years. We need to decide how to keep it up to date, for instance “monitor weekly, refresh monthly, revise quarterly”.
Now we can see how this journey ends. Genuine operational planning can come to the fore, with the national planning round as a mere by-product. That is how things ought to be.
But it could so easily go into reverse.
As we have seen, these calculations are not trivial. All it takes is for guidance to require one new thing, and all the carefully constructed planning models in the NHS will be torn up and replaced with ad hoc spreadsheets to address that specific requirement. Even that paragraph about weekends and Good Fridays will probably prompt this to happen somewhere.
If there is a planning round next year (and I didn’t see any promises that there wouldn’t be), NHS England will need to take great care not to destroy what it is now creating.
It’s hard enough coming up with monthly planning trajectories when you have several weeks to do it in. Now imagine having to do it for tomorrow.
Not only did one Scottish Health Board manage it, but their plans turned out to have pinpoint accuracy as the months unfolded. Read more in the case studyReturn to Post Index