Posts Tagged ‘Integrated care’

Introducing integrated personal commissioning

By Luke O’Shea, NHS England’s Head of Patient Participation - 21st March 2015 4:00 pm

We’re at the start of a radical integration programme, the first of its kind in the world, called Integrated Personal Commissioning (IPC).

The most radical part of IPC isn’t the integration of health and social care, or the entirely new financial incentives, or the central role of the voluntary sector. These elements of the programme are vital, but are being tried at scale in programmes around the world. The really radical part, the controversial part, the uncomfortable part, is to hand real power over to people and, if they choose to take it, to allow them spend their own budgets according to their needs and priorities – ‘what matters most’.

The publication of the Five Year Forward View signalled a resounding consensus on the need for greater integration of services. Vanguard sites implementing new models of care are being announced this week which will attempt to bridge three great divides: between mental and physical health services, between social care and health services, and between hospitals and primary care.

The IPC programme, as an integrated care model, will look to address these divides. But it is also attempting to bridge a fourth great divide. This is the often invisible divide between services and the people they were created to serve.

Many policy debates focus on service structures and manage to overlook the people who have the biggest interest in getting things right; the people and communities they serve. We fail to harness their energy, expertise and motivation at our peril.

Growing evidence shows that a failure to involve people in their care and treatment leads to far poorer outcomes and higher cost. Services themselves have a bias towards the status quo, even when the needs of the population change beyond recognition. And the population is changing – with dramatically rising numbers of people with multiple long-term conditions – so a very different health and care system is needed.

If we want to create a safe, sustainable and relevant 21st century health and care system, we will need to involve patients in their care and share power with them as equal partners.

So today we are announcing the names of the areas that will go forward as IPC demonstrators. They have a very hard task for the many thousands of people they serve, but a vital one. They are working to transform the lives of some of the most disadvantaged and intensive users of NHS and local authority services.

Different demonstrators are focusing on different groups, which include children with complex needs, mental health service users, people with complex learning disabilities and people with multiple long term conditions.

People in these groups will be supported to take a far greater role in their care, with increased peer and community support, and with the option of taking their annual budget for care and support as an integrated personal budget. Fortunately, there is strong evidence to say that, with the right support, people are surprisingly good at shaping their care. They are typically prudent and thoughtful commissioners, listening to professionals, and with a huge personal interest in getting things right.

But for me this is about much more than arguments about service quality and value for money. It’s also about a basic right to self-determination.

For many intensive health and care users, routine health and care services severely constrain how they live their lives.

I spoke to the mum of a young woman with complex disabilities about the care she was getting before she took up a personal health budget. She said that she was not prepared to accept an ingrained poverty of aspiration for her daughter just because she had very complex health needs, so she decided to write her daughter’s care plan and a detailed budget alongside.

She deliberately wrote the plan in her daughter’s voice, and, to give them credit, the health professionals were supportive and signed it off. The opening sentence in her daughter’s plan said “I am waiting for you to start my life”, because she says that up until now previously her daughter had not been able to live her life to the full. That has all changed now. Her daughter is confounding professionals and doing things they said could never be done.

As the IPC programme begins, we face some big challenges and we will certainly make mistakes. But we have a duty to raise our aspirations and try to make this work.

After all, there are many thousands of people waiting for us to start their lives.

Hospitals should be system leaders not ‘islands’

By Mike Broad - 19th March 2015 10:33 am

Acute hospitals will need to play a fundamentally different role within local health economies if the vision described in the NHS Five Year Forward View is to be achieved, a report argues.

The Forward View, which sets out how NHS services will have to change in order to deliver new models of care to meet the needs of the future, provides an opportunity for hospitals to lead the development of integrated care and improve the health of the population.

But to do so, says the King’s Fund report, hospitals must avoid developing a ‘fortress mentality’ in response to mounting service and financial pressures.

There is a danger that hospital leaders focus on safeguarding their organisations rather than the sustainability of local health systems more widely.

The report argues that acute hospital leaders need to look outwards to their local communities and work more closely with primary care, social care and community services to improve the health of the populations they serve.

This will need to include a bigger role for them in prevention and public health and greater collaboration with neighbouring hospitals to improve services for patients.

The report reveals that there are some parts of England where these developments are already under way, but others where significant changes are needed. In areas where more substantial progress has been made, acute hospital leaders have invested considerable time and energy in building relationships with community partners, often over several years, and in particular have needed to make sustained efforts at improving the relationship with local general practices.

Chris Naylor, Senior Fellow at The King’s Fund, said: “We are seeing an important shift in thinking in some acute trusts. Hospital leaders are telling us that they see their role increasingly in terms of system leadership, and that working closely with local partners is key to the survival of the services they provide.

“However, the picture varies across the country, and even in those areas where most progress has been made, there is still a long way to go before the new models of care described in the Forward View can become a reality. One critical area where rapid progress is needed is improving the relationship between hospitals and primary care – this has all too often held back successful integrated care.”

To ensure that these ways of working become widespread and support the vision set out in the NHS five year forward view, significant changes are also needed in how health services are paid for, regulated and commissioned.

The report recommends:

- developing a new regulatory model with greater emphasis on whole-system performance

- ensuring that competition law does not create barriers (real or perceived) to constructive dialogue and partnership working between commissioners and providers

- continuing to develop a range of alternative payment systems and support local commissioners in moving away from activity-based tariffs for hospital care

- introducing a transformation fund that ensures that all areas of the country are able to cover the costs of the transition to more integrated models of care

- creating more flexible job plans for acute care professionals that emphasise continuity across settings and joint working with other professionals

- developing more flexible contracting models for general practice to make it possible for acute hospital providers to take a greater role in primary care provision.

NHS Confederation director of policy, Dr Johnny Marshall, commented: “This welcome report reinforces what we have been saying for some time – that all NHS bodies, including acute trusts, need to look beyond the boundaries of their own organisation, and work with key partners, including local government, to improve the health and wellbeing of their local communities.

“There are many examples of this kind of leadership across the health service but we need Government to support this approach – stability is key to building these local partnerships. The next Government must avoid another top down reorganisation of NHS structures at all costs.”

‘Vanguard’ groups lead on new models of care

By Mike Broad - 11th March 2015 10:07 am

Twenty nine ‘vanguard’ groups have been chosen by NHS England to take the national lead on transforming care for patients.

269 groups of nurses, doctors and other health and social care staff from across the country put forward their ideas for how they want to redesign care in their areas, with the 29 most innovative being chosen.

Drawing on a new £200 million transformation fund and tailored national support, from April the vanguards will develop local health and care services to keep people well, and integrate home care, mental health and community nursing, GP services and hospital services.

NHS England hopes it will mean fewer trips to hospitals as cancer and dementia specialists and GPs work in new teams; a single point of access for family doctors, community nurses, social and mental health services; and access to tests, dialysis or chemotherapy much closer to home.

Speaking on NHS Change Day, Simon Stevens, the Chief Executive of NHS England, said: “The NHS now has its own long term plan, backed by just about everybody, and today we’re firing the starting gun. Instead of the usual top-down administrative tinkering, we’re backing radical care redesign by frontline nurses, doctors and other staff – in partnership with their patients and local communities. From Wakefield to Whitstable, and Yeovil to Harrogate, we’re going to see distinctive solutions to shared challenges, which the whole of the NHS will be able to learn from. ”

David Bennett, Chief Executive of Monitor, said: “The first wave of vanguard sites represents a practical start to transforming the NHS. We will use our expertise in areas such as pricing and system economics, alongside our oversight of foundation trusts, to help local areas develop the new models of care that are essential for the NHS and the people who use it.”

The vanguards will develop new models of care, including:

- multispecialty community providers (MCPs), moving specialist care out of hospitals into the community;

- integrated primary and acute care systems (PACS), joining up GP, hospital, community and mental health services, and;

- models of enhanced health in care homes, offering older people better, joined up health, care and rehabilitation services.

From April 2015, the national NHS will work with local vanguard sites to develop dedicated support packages to enable and accelerate change, and an intensive evaluation programme will seek evidence on what works so that this can be spread to other parts of the country.

Support will be tailored to the needs of each area, but could be a combination of peer learning and expertise in areas such as patient empowerment and community engagement, leadership, clinical workforce redesign, using digital technology to redesign care, devising new legal forms and new contractual models; and joined up procurement.

All areas will benefit from a wider support and learning package which will be rolled out later this year, based on the learning from the vanguard sites. Additionally, as a result of the many examples of excellent models up and down the country, a wider programme of support is being put in place for some of the health and social care systems that applied to be part of the programme.

Samantha Jones, Director of the New Care Models Programme at NHS England, said: “This is one of the most exciting opportunities to support change to how health and care services are delivered for patients for a long time. The health and social care systems that have been chosen to be vanguards in this cohort embody the forward-thinking and collaborative approach to improving patient care that the NHS Five Year Forward View called for last year. NHS England and partner national and local bodies will now work with those sites to accelerate the improvements that they are making and ensure this is replicated nationally.”

The NHS Five Year Forward View, published in October 2014 by NHS England, set out the health, quality of care, and funding gaps that will open up if the NHS does not change.

GPs not consulted on Manchester health devolution

- 3rd March 2015 3:51 pm

GP leaders in Manchester have slammed the lack of involvement of general practice in plans to hand £6bn NHS funding to a new devolved local authority body.

The plans are backed by 12 CCGs, 10 local councils, NHS England and other NHS bodies.

But chairwoman of greater Manchester LMCs Dr Tracey Vell said she was ‘disappointed’ the agreement had been signed.

‘The objectives involve general practice but general practice as a provider has not been given a stake so far in the process,’ she said.

CCGs, she added, cannot represent GPs as providers.

Read more at GP Online.

Reaction to Manchester’s devolved health spending

By Mike Broad - 25th February 2015 8:24 pm

Dr Mark Porter, BMA council chair

“There is no doubt that patients would benefit from more joined-up health and social care. However, any plans to do so would have to be underpinned by clear funding to ensure that an already dangerously over-stretched NHS budget isn’t used to prop up a woefully underfunded social care budget.

“These wide sweeping changes will affect millions of people. We need to look carefully at exactly how they will affect the commissioning and delivery of services, and what the impact on patient care will be. We must also ensure clinicians have a central role in decisions over health care, something which was undermined by the Health and Social Care Act 2012.

“We need assurances on who is responsible if these changes go wrong. Doctors believe the secretary of state for health should have the duty to provide a universal and comprehensive health service, and must take responsibility for guaranteeing national standards in the of quality care across the country, especially if the delivery of care is to be devolved to local authorities.

“The NHS has just undergone unprecedented upheaval, there must be no more games with our health service and we need to avoid a situation where the NHS moves from being a national to a local political football.”

Richard Humphries, Assistant Director of Policy at The King’s Fund

“The news that Greater Manchester’s local authorities and NHS are close to agreeing a deal with NHS England to establish a new partnership for health and social care across the Manchester region is very significant.

“If implemented effectively, this could be a step towards a big prize - a single, seamless health and social care system delivering integrated care for people in Greater Manchester. It also provides an opportunity for councils and the NHS to work together to improve health and well -being in the region.

“While the ambition is welcome, more details are needed about how the partnership will work in practice and who will be accountable for £6 billion of NHS resources involved in the deal. It will be important to avoid the distraction of further organisational change and to clarify the accountability of the Health Secretary for the NHS as a whole alongside a greater role for local government.

“Manchester has been chosen to test out this new way of working because of the strength of local relationships. It is unlikely that many other areas are yet in a position to follow its lead.”

Rob Webster, chief executive of the NHS Confederation

“If we are to tackle the challenges that face the health and care system then local organisations will need to work in different ways. Leaders need to look beyond the boundaries of their individual organisations, instead developing shared priorities for their area and working collaboratively with other organisations to improve the health outcomes of their local community. The focus of politicians and arms length bodies must be to create the right environment to allow this sort of approach, offering support and looking to remove any barriers to new ways of working which improve patient care.

“What this example does demonstrate is the role CCGs are playing, working with partners in local government to drive improvements in care. It’s also positive that providers of healthcare have been engaged in this work. It’s vital that all sorts of providers, including community, mental health, acute, and ambulance, are fully involved in these plans.

“We are pleased to see that the changes in Manchester are being locally driven, rather than a centrally imposed initiative. Manchester’s plan is an example of changes resulting from good partnership working and strong relationships between health and care leaders, who are showing they can put the interest of the local population ahead of their own organisations.

“All political parties need to learn a lesson from this – as we set out in the 2015 Challenge, what’s needed is the space and stability to let these cultures develop. That means avoiding another top down reorganisation of structure at all costs. This model won’t be right for all parts of England – local areas need the freedom to develop solutions which are right for their individual situation.”

Manchester to gain health spending control

By Mike Broad - 8:10 pm

Greater Manchester is to gain full control of its health spending and trail-blaze new models of care, as part of an extension of devolved powers.

Chancellor George Osborne said the £6bn health and social care budget would be taken over by the region’s councils and health groups and come into force in April 2016.

The plan would see local leaders, and ultimately Greater Manchester’s new directly elected mayor, control how budgets are allocated.

The government hopes integrating health and social care services will ease pressure on hospitals and improve community services.

Manchester City Council confirmed 10 local authorities, 12 clinical commissioning groups, 14 NHS partners, NHS England and the government are in discussions on a “groundbreaking agreement for health and social care”.

A Greater Manchester Strategic Health and Social Care Partnership Board - effectively a glorified Health and Wellbeing Board - will be put on a statutory footing by the end of 2015-16.

It would set region wide strategies and priorities, with a joint commissioning board – made up of NHS England, the CCGs and councils – reporting into it.

Mr Osborne said: “This is what the NHS wants to see as part of its own future.

“And it’s also about giving people in Manchester greater control over their own affairs in that city, which is central to our vision of the ‘northern powerhouse’- so it’s a very exciting development.”

According a memorandum of understanding, the model will be built on the “principle of subsidiarity…ensuring that decisions are made at the lowest level possible”.

This suggests that while some commissioning decisions would be taken at a Greater Manchester-wide level, others would remain at the level of individual “localities”.

The document states that pooled budgets “at the locality level” – between individual CCGs and borough councils – would be in place from 1 April 2016.

Local health and wellbeing boards would agree strategies and priorities for delivery of integrated health and social care within their districts and in the context of the Greater Manchester-wide strategy and local priorities.

Local plans would be submitted to partnership board to ensure strategic coherence and consistency across Greater Manchester.

NHS England, CCGs and districts would pool relevant health and social care funds to a local joint commissioning board building from existing arrangements such as the Better Care Fund.

A Local Joint Commissioning Board will commission services in line with locality plan.

Richard Humphries, Assistant Director of Policy at The King’s Fund, said: “The news that Greater Manchester’s local authorities and NHS are close to agreeing a deal with NHS England to establish a new partnership for health and social care across the Manchester region is very significant.

“If implemented effectively, this could be a step towards a big prize - a single, seamless health and social care system delivering integrated care for people in Greater Manchester. It also provides an opportunity for councils and the NHS to work together to improve health and wellbeing in the region.”

Dr Mark Porter, BMA council chair, commented: “There is no doubt that patients would benefit from more joined-up health and social care. However, any plans to do so would have to be underpinned by clear funding to ensure that an already dangerously over-stretched NHS budget isn’t used to prop up a woefully underfunded social care budget.

“These wide sweeping changes will affect millions of people. We need to look carefully at exactly how they will affect the commissioning and delivery of services, and what the impact on patient care will be. We must also ensure clinicians have a central role in decisions over health care, something which was undermined by the Health and Social Care Act 2012.”

Labour’s plan to better integrate health and care

By Mike Broad - 28th January 2015 11:44 am

The Labour Party has unveiled its 10-year plan for the NHS saying that while there would be no top-down, major reorganisations, they will develop a more integrated health and care system.

Labour leader Ed Miliband said the implementation of his national vision of integrated health and social care will be evolutionary.

Improving home care services is a key thrust of the plan. Health and Wellbeing Boards would become accountable for ‘year of care budgets’ which would cover the health and social care needs of those at the greatest risk of hospitalisation.

Providers would bear the costs if the health of patients under the budget deteriorated and they needed expensive hospital care. It’s aimed at tackling the problem of 15 minute social care visits.

Andy Burnham, shadow health secretary, said: “If social care in England is allowed to collapse, it will drag down the rest of the NHS. [It] is a root cause of the crisis in [accident and emergency]. For the want of spending a few pounds in people’s homes on decent home care, we are spending thousands of pounds keeping older people in hospital, even when they are able to leave. The increasing hospitalisation of older people is no vision for the ageing society.”

Burnham confirmed his desire to “work towards the notion of a single [health and social care] budget; a single budget for children and then a single budget for adults”.

Labour would also repeal key elements of the coalition’s Health and Social Care Act. Statutorily enforceable rules on NHS competition would be unpicked, with Labour claiming that £100m in savings could be generated by scrapping the competition rules.

Miliband endorsed the ‘NHS preferred provider’ policy saying the private sector has a role but as a supplement rather than a substitute.

Miliband said: “We can only join up the services when we have the right values at the heart of our NHS: care, compassion and cooperation, not competition, fragmentation and privatisation. These aren’t the values of our National Health Service. These aren’t the values of the Labour Party. These aren’t the values of the British people.”

Much of the detail in the 10 year plan has already been announced, particularly plans to recruit extra GPs and nurses. However, the announcement of a “new arm of the NHS” comprised of 5,000 home care workers employed within the health service is significant.

The home care workers would focus on “those with the greatest needs, including the terminally ill so they can stay with their family at the end of life, and those who are leaving hospital who need extra help if they are to move back into their homes”.

There is as yet no detail on the training and qualifications these employees would have, what kinds of organisations would employ them, or how much they would be paid.

Labour has pledged to pay for these new employees with a previously announced mansion tax, a levy on tobacco firms and a crackdown on tax avoidance.

It would also cut bureaucracy, raising doubt over the continuance of arm’s length bodies created by coalition legislation, such as the NHS Trust Development Authority and NHS England. Other potential targets for savings could include NHS commissioning support units, or clinical commissioning groups.

Labour also said it would enter into a new ‘compact’ with the 1.3m NHS staff to “lift morale and improve patient care”.

This would include appointing a new ‘NHS staff champion’ responsible for improving workplace culture and reducing bullying, work-related stress and sickness absence.

It follows the pay dispute between unions and the coalition government over its decision to reject the NHS Pay Review Body recommendation of a 1% pay rise for all NHS staff.

If Labour wins the general election in May the party says it will “recommit to the Pay Review Body process and pledge not to renege irresponsibly on pay deals like current ministers”.

Miliband said: “What our 10 year plan is designed to do is give people a sense of direction – there is a sense of direction, there is a party with a plan for where the NHS goes. We’re not sort of chopping and changing, we’re not doing what this government has done in instigating, a top-down reorganisation, but are giving a clear sense of direction.”

The leadership, however, is facing a backlash by Tony Blair supporters who have warned that his plans for the NHS risk playing into Tory hands.

Former health secretary Alan Milburn said the party was running a pale imitation of its losing 1992 general election campaign, as it retreated to its comfort zone over the NHS rather than setting out a strong economic vision.

Royal colleges support integrated care drive

By Mike Broad - 17th December 2014 8:47 pm

New models of care should be based on the needs of patients, service users and communities, rather than buildings.

This is the view of the Royal College of Physicians and the Royal College of General Practitioners, which have released a joint statement on integrated care.

The statement, which is also supported by other medical royal colleges and faculties, sets out the values, vision and commitments of both colleges in working together at a national level to promote person-centred care, integrated care and collaboration.

The two colleges are committed to involve patients, carers, and service users across the breadth of their work, and to breaking down traditional organisational boundaries in order to coordinate care and meet people’s needs.

Professor Jane Dacre, RCP president said: “Primary care and acute care have always worked together for the wellbeing of today’s and tomorrow’s patients. It is vital that we remove the artificial barriers between us, and this statement opens the door for us to work ever more closely together, celebrating the care that we provide for patients.”

The £3.8bn Better Care Fund, announced in June 2013, is the government’s attempt to encourage the integration of health and social care.

Dr Maureen Baker, Chair of the Royal College of GPs, said: “More integration and better, constructive working between primary, secondary and community care will be beneficial for GPs, the health service and our patients.

“GPs, our teams, and colleagues across the NHS are currently under pressure to cope with increasing patient demand with the resources available to us – and it is essential that we look at how we use these scant resources, in the best interests of our patients.

“This statement is a welcome demonstration of the widespread support for closer working between healthcare professionals across the NHS in order to deliver truly patient-centred care.”

New figures from NHS England suggest the system is creaking under the strain of increased patient demand despite the mild weather.

Integrated care key to improving respiratory med

By Mike Broad - 8th December 2014 10:35 am

Multidisciplinary virtual clinics are an innovative way to bring together hospital lung specialists and primary care clinicians to improve the care of people with long term lung conditions like Chronic Obstructive Pulmonary Disease (COPD), according to a study.

COPD is a smoking-related condition affecting nearly one million people across the UK. There is wide variation in the management and outcomes of this condition.

Evidence suggests many patients do not always receive important support and treatment to help them stop smoking, nor exercise and education through a pulmonary rehabilitation programme.

Furthermore there is an over-reliance on inhaled corticosteroids (ICS) in their treatment. This is despite ICS only being effective with a small number of patients and amid increasing concerns about their side-effects (e.g. pneumonia) and costs to the NHS.

The study, developed by King’s Health Partners and Lambeth CCG, and presented at the British Thoracic Society’s Winter Meeting, shows that ‘virtual clinics’ that review individual COPD patient case-notes and agree treatment plans, including stepping down and stopping inappropriate ICS, reduced high dose ICS prescribing and a consequently saved £200,000 to the local healthcare economy.

In the study 94% of Lambeth GP practices hosted a virtual clinic, and the researchers believe that if the findings were applied across the NHS, thousands of patients could have better, safer care and millions of pounds could be saved for reinvestment in effective treatments and services for COPD.

Grainne d’Ancona, principal pharmacist at Guy’s and St Thomas’ NHS Foundation trust, speaking on behalf of the King’s Health Partners Integrated Respiratory Team, explains: “Drawing on the expertise of respiratory specialists, we were able to change the focus of COPD care in a number of cases.

“Where appropriate, the gradual withdrawal of inhaled corticosteroid treatment (ICS) was recommended; allowing patients to move away from high dose ICS, to effective interventions like smoking cessation and pulmonary rehabilitation.

“As a result of this collaboration, Lambeth CCG reduced its high dose ICS prescribing from above the London average to well below it in a matter of months. These findings show that integrated working through respiratory virtual clinics offers huge scope to improve care for the population and maximise value within limited NHS budgets.”

Another survey presented at the meeting reveals that nearly 8 in 10 (77%) said that integrated care improved health outcomes for patients with a long term health condition, with 87% highlighting continuity of care for patients as a key benefit.

Professor Martyn Partridge, Professor of Respiratory Medicine at the National Heart and Lung Institute, Imperial College London, said: “Respiratory medicine covers a huge range of conditions from tuberculosis, COPD and lung cancer to asthma and sleep apnoea.

“This diverse and demanding area calls on health care professionals to diagnose, manage and treat a huge range of diseases everyday. So the more we can work across both primary and secondary care, getting the specialist nearer to the patient, the better. Virtual COPD clinics are a prime example of the positive work happening right now with specialists sharing their knowledge and expertise with GPs - benefiting both patients and the NHS.”

Better Care Fund will require continued support

By Johnny Marshall, director of policy, NHS Confederation - 11th November 2014 12:00 pm

We recognise the hard work put in by all those involved in developing and agreeing Better Care Fund plans locally, including NHS providers and commissioners, working with local authority partners, but we also echo many of the valid observations and concerns expressed by the NAO regarding the quality of the planning and preparations behind this ‘ambitious’ policy.

We are pleased that the NAO report recognises the areas of concern we have highlighted on behalf of our members regarding the BCF planning, notably the tight timescales set  for submitting local BCF plans; the conflicting directives around the objectives behind the policy, the burdensome ‘tick-box exercise’ nature surrounding the planning process; and the frustration of local areas having to re-submit plans after the original April planning deadline.

We also reiterate our concerns about the ability of some local areas to achieve the reductions in levels of emergency activity and financial savings that the BCF requires.

We agree the BCF’s success rests on “assumptions” which “may still  be over-optimistic” regarding the ability of integrating services to reduce costs. It is our view that whilst there is much evidence that greater integration and personalisation improves outcomes, the evidence that it delivers financial savings is still in its early stages.

It will take time for the new models of care to allow us safely to disinvest in existing services. This is why we will need financial flexibility and extra resources to allow double running of some services while we move to the new models of integrated care. This will require us to consider health and social care spending together.

As the NAO report notes, ‘the Funds effectiveness will depend on local implementation’. This requires the continued development of strong working relationships between the different parts of the health and care system locally around shared outcomes. It is therefore essential that providers are properly involved in the BCF planning process in order to build in local expertise and manage risks to patient safety.

In particular we want to see better alignment with the regular planning cycle for providers and commissioners, allowing for practical timescales to allow time for open discussions to take place between all those involved across health and social care.