chairs and chief executives network...2016/06/09 · reality – what’s changed • worse than...
TRANSCRIPT
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CHAIRS AND CHIEF EXECUTIVES NETWORK
9 June 2016
Chris Hopson Chief Executive
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Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 NHS PROVIDERS UPDATE
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Things that have changed since we last met
2015/16 closes with a £2.45bn / £3.3bn deficit and 65% of
providers in deficit; 2016/17 control
total exercise round two; £22bn plan
“unveiled”
Second cut of place-based STPs being
developed & a new strategic framework
for specialised services
Government and junior doctors
committee reach initial agreement on
contract with growing questions
over implementation
impact
New care models sees large funding cuts for vanguards
and new programmes for maternity, U&EC, cancer and MH,
diabetes
New CQC strategy unveiled and NHSI
oversight framework to
shortly be unveiled
A lot going on across a range of different fronts
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Struggle through 16/17… but 2017-21 U-Bend is coming
It looks like we will just struggle through 2016/17, the
supposed year of plenty…
…but current profile of additional NHS funding, increasing activity and new policy
commitments leads to crunch period in 2017/18 – 2020/21
3.7
1.3
0.3 0.7
1.3
0
1
2
3
4
2016/17 2017/18 2018/19 2019/20 2020/21
% in
crea
se in
NH
S Bu
dget
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Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 NHS PROVIDERS UPDATE
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System under sustained operational pressure 98% 92% 91% 88% 86% 83% 82% 80% 77% 75% 73% 67%
97% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%
96% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%
95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%
95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%
94% 92% 90% 87% 84% 83% 81% 79% 77% 75% 72% 63%
94% 91% 89% 87% 84% 82% 81% 79% 77% 74% 72%
94% 91% 89% 87% 84% 82% 81% 78% 77% 74% 71%
94% 91% 89% 87% 84% 82% 81% 78% 76% 74% 70%
92% 91% 89% 86% 84% 82% 80% 78% 76% 74% 69%
92% 91% 88% 86% 84% 82% 80% 77% 76% 74% 68%
92% 91% 88% 86% 84% 82% 80% 77% 76% 73% 67%
% seen in 4
hours
Type 1 A&Es
Q4 2015/
16
Source: NHS England
Worst A&E performance figures since the standard was introduced – 4Q 87%
Ambulance services under sustained demand and performance pressure
Elective operations cancelled
District nursing and health visiting
caseloads increasing just as contracts come up for tender
Mental health referrals increasing
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System under sustained operational pressure
Seven year growth figures @ Norfolk and Norwich UHFT. Demand doubling over 15-20 years
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And traditional levers no longer available
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2016/17 NHS strategic financial framework Initial plan • Use 3.7% frontloaded settlement to eliminate provider
deficits and start 5YFV transformation • £1.8bn 15/16 provider deficit; £2.1bn sustainability /
transformation funds; £3.5bn CCG uplift; sensible tariff
Reality – what’s changed • Worse than planned 15/16 year end provider deficit:
£2.45bn / £3.3bn • Commissioning finances under pressure: loss of NHSE
surplus and HMT control over CCG 1% non recurrent • Contracting round therefore far tougher than expected • Providers hit by combination of 16/17 starting point;
ongoing pressures; tough contracting round; impact of cuts to wider DH budget etc (e.g. CQC fees; JDC costs)
• DH refuses to carry on being banker of last resort • Therefore, major current arm wrestle over 2016/17
provider / commissioning financial balance • STF: £1.8bn sustainability, £0.3bn transformation:
supporting provider deficits not transformation
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwisq6Sqr5DNAhUjBMAKHQe1DfUQjRwIBw&url=https://www.yumpu.com/en/document/view/54913523/delivering-the-forward-view-nhs-planning-guidance-2016-17-2020-21/7&bvm=bv.123664746,d.ZGg&psig=AFQjCNFYjhRYPSd1qfFcOcN2mzHJO-5vxg&ust=1465198341492117
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Conflicting system level views on how to manage 2016/17 “Nail down providers” view “Support providers and be realistic” view
Individual providers responsible for provider deficit
System responsible for provider deficit
Must use 2016/17 year of plenty to eliminate deficit & recover performance
Be realistic about 2016/17 finances and performance given pressures
Individual control totals and performance trajectories must, in aggregate, eliminate deficit & recover performance
Individual control totals and performance trajectories must be achievable to create a credible framework
Every Board must have control total and performance trajectory, at required level to deliver aggregate, mandated if needed
Control totals and performance trajectories only work if deliverable and provider boards own them
Provider Boards must be held to hard account, up to and including removal, if they miss a quarterly milestone
Providers need support and accountability that recognises factors beyond their control, 16/17 starting point & overall environment
Strong, recent, last six weeks, direction of travel
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16/17 finances: best guess on what happens next
Control totals • 139 signed up in February; a further 80-ish signed up in May following slight
sweetening exercise, particularly aimed at community and mental health • Pressure on remaining to follow suit, individual follow up • Those with high year on year pay bill increases will be asked to cut these back
Performance trajectories • Strong emphasis on back loading trajectories to Q4 to minimise Q1-3 trajectory misses • Indemnity if trajectory missed due to circumstances clearly beyond control • Scope to get back on track in later quarters if you miss a quarter
Accountability • Difficult to predict how hard accountability will be: • NHSI leadership determined to be reasonable and supportive; • Centre of Government desperate to regain control; • NHSE seriously worried about ability to balance off any provider deficit and want to
invest in transformation, not provider deficits.
Provider / commissioner /overall financial balance • NHSI currently targeting provider sector -£500m in 2016/17. We think end 16/17 looks
like -£500m to -£1 billion • Brexit prevents more aggressive timely 16/17 plans so recoup -£500m in 17/18 • Commissioners need to generate at least £500m surplus to cover provider deficit • CCG 1% non recurrent (£800m) used as contingency
http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiyqcmPspDNAhXsA8AKHdSDCrcQjRwIBw&url=http://www.scientificpsychic.com/tarot/crystal-ball.html&bvm=bv.123664746,d.ZGg&psig=AFQjCNGBFIoD3jX3CaGI3wOhysvsHD2K4w&ust=1465199091560056
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The coming U bend – DH spend by head of population
Source: The Health Foundation, Nuffield Trust and Kings Fund ‘The spending review: what does it mean for health and social care?’ December 2015
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Lack of focus / in denial • Been busy with difficult 2016/17 and traditional focus on year ahead • “It’s the run up to the election they’ll have to put more money in” The Reality • Impossible to get through U Bend on current trajectory, given:
Financial starting point Rising demand and cost No flexibility on current service offering Extra policy commitments £22 billion savings plan will clearly not deliver
What we’re asking for • Decide right now whether you mean the U bend or not • If you do, fully accept consequences and start properly planning now:
Break normal NHS financial marching pace Finalise 2017/18 to 2019/20 framework by end summer 2016 Add “how will you get through 2017-20” to STP process
• You can only get through the U bend with honesty and realism; an appropriate lead time; doing something very different at pace
• A way of bringing much needed reality to the system
NHS currently in denial on consequences of U bend
http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi-1YmHwpDNAhVDC8AKHYm6Do0QjRwIBw&url=http://www.ebay.co.uk/itm/1-1-2-Inch-Kitchen-Sink-Waste-P-Trap-U-Bend-/111510278635&bvm=bv.123664746,d.ZGg&psig=AFQjCNH8jOghx5Shwq2PovVAV0YS06FABA&ust=1465203356572402
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The £22 billion savings plan – how credible?
Source: Comprehensive Spending Review 2015, FYFV savings technical note May 2016
• 1% public sector pay cap to 2019/20
• Renegotiating the community pharmacy contract
• Income generation • Reducing central admin costs
• RightCare • Self care • QIPP and demand
management • New Care models
• Lord Carter • Classics CIPs
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But…..
Provider sector has to demonstrate we are doing all we possibly can to: • Recover finances • Recover performance • Sign up to “sweet spot as stretching as possible
but achievable” control totals and performance trajectories
• Reduce agency spend • Deliver more than £ for £ benefit on extra
£1.8bn STF funding
A battle for the dominant narrative between: • Providers not trying hard enough and not well
enough led • Providers meeting every reasonable
expectation, and a bit more, in a very difficult strategic environment
http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwilqILnyJDNAhWTOsAKHdpZBCEQjRwIBw&url=http://www.johnjudy.net/2011/10/fairfax-county-sample-ballot-for-november-8th-2011/&bvm=bv.123664746,d.ZGg&psig=AFQjCNGPMCxn_EquVZi2hg-qvcfVLMWYcw&ust=1465205161653065
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Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 NHS PROVIDERS UPDATE
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STPs right idea and system starting to learn as we go…
• All agree that moving to multi year, place based, strategic plans is right idea
• Central system leaders now recognise that different patches going at very different speeds based on appetite, relationships and resources
• Moving to three segments: well advanced, making progress, still developing
• Flexing “real” sign off deadlines and central support to reflect emerging segmentation
• Capacity & capability to complete to time/ quality • Dealing with multiple overlapping footprints:
STP footprints; Smaller “natural vertical integration” footprints; Traditional local authority footprints; LETB footprints; Academic Health Science Networks; MH provider / ambulance service footprints; Local digital roadmaps; Urgent and emergency care network footprints; Maternity and other network footprints
• Local authority and general public involvement • Comms handling around big change proposals
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjAkZiPy5DNAhWHBsAKHUnqDYkQjRwIBw&url=https://calderdaleandkirklees999callforthenhs.wordpress.com/tag/sustainability-and-transformation-plan/&bvm=bv.123664746,d.ZGg&psig=AFQjCNEnlNTAO7LC-oJfWrbhIi_7VIq8-g&ust=1465205782383676
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…Some big questions emerging…
• Is this about sustainability or transforming to new care
models: creating a viable acute hospital model or a viable new integrated out of hospital service…or both
• Is this more about a few really big wicked issues that we have been trying to sort out for some time…or setting out how will meet national planning requirements?
• How far is it really worth going on major service
reconfigurations that we know we will struggle to get away locally?
• What happens if we can’t get agreement…or have very
different future visions…or can’t even get the big hairy questions on the table
• What do we do if we can’t create a plan that closes the current structural financial gap because the gap is simply too big
http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjd8b-m0pDNAhWMLMAKHRYxDLkQjRwIBw&url=http://www.wmscnsenate.nhs.uk/home/our-work-current-projects/our-work-partner-organisations/sustainability-and-transformation-plans/&bvm=bv.123664746,d.ZGg&psig=AFQjCNEnlNTAO7LC-oJfWrbhIi_7VIq8-g&ust=1465205782383676http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwja9pKT1JDNAhXBCMAKHZFWDeAQjRwIBw&url=http://www.slideshare.net/KingstonVA/south-west-london-sustainability-and-transformation-plan&bvm=bv.123664746,d.ZGg&psig=AFQjCNEnlNTAO7LC-oJfWrbhIi_7VIq8-g&ust=1465205782383676
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…And significant governance issues remain
Source: HSJ
ISSUES TO CONSIDER
1. STPs have no statutory basis and very immature governance. How are disagreements resolved? Is top down answer from system leaders the right approach?
2. Some parts of system leadership showing clear appetite to quickly put a lot more business through STP footprints. But are they right footprints, on what legal basis and what about governance?
3. NHS still regulated as individual organisations , where director’s legal duty lies – significant governance and accountability issues feel parked and ignored not solved.
4. When everyone is responsible, who do you hold to account when things go wrong e.g. system control totals for finance and performance?
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Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 NHS PROVIDERS UPDATE
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Clear Jim Mackey narrative emerging We're here to help and support … but there has to be accountability
• The much needed honest and realistic
provider voice at national system level
• Genuinely trying to support and build headroom for leaders…but under huge, unrealistic, system level, pressure to deliver
• Multiple helpful interventions: contracting round, CQUINs, CCG tendering, 16/17 provider / commissioner financial balance etc.
• Need to show can handle performance and finance to get other players off the pitch.
• Being robust about getting a reasonable ask, being on top of the detail and then delivering… at both a national and local level
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A new NHSI oversight framework coming shortly
QUALITY CQC rating
MONEY Old metrics
Use of resources Carter
OPERATIONAL PERFORMANCE
Small set of constitutional
standards
LEADERSHIP Well led framework Systems leadership
STRATEGIC CHANGE
In progress, likely to include NCM
Earned autonomy
More autonomy
Limited autonomy
Essentially special
measures
• Local decision making free of constraints
• Fewer data and monitoring requirements
• Simpler processes for transactions
• Recognition and opportunity to spread success
A new single oversight framework for FTs and Trusts, which establishes a single definition of success and a new relationship between the regulator and the regulated
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Ten initial thoughts on new NHSI oversight framework
Danger of two competing CQC /
NHSI ratings
Individual institutional vs
system accountability
Relative or absolute standards
in current environment?
Developing leadership and
strategic change domains
What, when, how and why moving
through segments
How practical will benefits of full
earned autonomy be?
FT pipeline and FT status
Clarity on voluntary support
& intervention incl. mandation
Legal base
Overall narrative and relationship to
current strategic context
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CQC new strategy to 2020
• More flexible registration e.g. NCMs • Assessing use of resources • Views of quality across populations and
local areas
• Development of CQC Insight • Targeted and risk-based inspection where
comprehensive inspection is exception to the norm
• Alignment with NHSI oversight framework
• Focus on CQC VfM and changes to fees
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Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 NHS PROVIDERS UPDATE
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Junior doctor contract
• Provisional agreement on new contract but needs to be ratified by referendum
• Additional costs to providers including additional employer pension contributions – needs close tracking
• Significant additional duties for monitoring safe working hours and breaks and rotas
• Need to track impact on wobbly existing rotas
• Bad blood lingering on both sides
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Lack of a national workforce strategy recognised
Given the size of the NHS, workforce planning
will never be an exact science, but we think it clearly could be better
than it is.
The current shortage of nurses is largely of the
health, care and independent sectors’
own making
Workforce is a relatively neglected area of policy which is often pursued
as an afterthought
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Some other workforce developments
Agency/locum caps - some expected zero-
sum behaviours & some unexpected
consequences e.g. therapists
Consultation on “nursing associate” role & reform of healthcare
education funding
New safer staffing work ongoing with Care Hours
Per Person focus
Consultant contract bubbling in the
background
HEE establishing Local Workforce Action Board
to cover STPs
“We are however supportive of view that appropriate oversupply
is a desirable goal within the context of appropriate value for
money” (HEE)
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Contents
01 FINANCES & PERFORMANCE
02 PLANNING
03 REGULATION
04 WORKFORCE
05 NEW CARE MODELS
06 NHS PROVIDERS UPDATE
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5YFV New Care Models growing
Two further new care models proposed
Reinvention of the acute medical model in small district general hospitals
Differs from Acute Care Collaboration (ACC) vanguards by specific focus on small district general hospitals, and
interest in care pathways and clinical workforce, rather than organisational
forms and operating models
Tertiary mental health services
Secondary MH providers taking on tertiary MH services such as secure MH and forensic services, perinatal mental health, Tier 4 CAMHS, CAMHS eating disorders, Tier 4 personality disorder
services
x14
x9
x6
x8
x13
Reduction in funding in 2016/17
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It’s easy to be cynical but 5YFV KPIs matter
1 Brave CCGs where the council will become the strategic commissioner, the operational commissioning will move to the provider, and the CCG remains as a shell for statutory purposes
2
Fundamental changes to how we do things. PACs that may not have outpatients in the future. Move from a position where high DNA rate in geriatric outpatients (booked 6 weeks out) due to confusion or admitted already, to an open access outpatient slot tomorrow, telehealth and primary care access
3 Emergency department consultants after telehealth support to care homes launched: fewer patients come to our department to die. They die where they chose to.
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Contents
01 FINANCES 02 PLANNING 03 REGULATION 04 WORKFORCE 05 NEW CARE MODELS 06 NHS PROVIDERS UPDATE
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Representing your views
Mental health taskforce – Lords’ debate Baroness Brinton I ask the Minister to update your Lordships’ House on the progress of the five-year forward view task force implementation plan. Time and funds are running out and I know that many providers are keen to hear the Government’s view. The Government’s commitment to an extra £1 billion to meet the report’s recommendations after the launch is welcome but this will not be enough to deliver the report’s recommendations. Even more worrying, it seems that the funding may come from the additional £8 billion the Government have already pledged to deliver the general five-year plan, meaning that mental health will not receive any more than it would have got on the basis of its historical and deeply inadequate share of resources—about 13% of the total NHS budget, despite accounting for around a quarter of the national burden of disease. A figure of 13% is neither parity of esteem nor parity of resource. Worse, the report Funding Mental Health at Local Level: Unpicking the Variation, published by NHS Providers a week ago, raised serious concerns that the necessary investment is not reaching many local areas and services. This is despite recent funding commitments such as the £1.25 billion five-year CAMHS investment announced by the coalition Government in the March 2015 Budget.
Luciana Berger MP House of Commons Oral Question Research published yesterday by NHS Providers and HFMA showed half of MH trusts had not had an increase in budget in 2015/16, and just quarter of providers were confident that they will this year. Will the sec of state finally admit that the supposed increased investment in MH has not materialised for MH and what will he do about it?
https://hansard.parliament.uk/search/MemberContributions?house=Lords&memberId=4241http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj36fXe6obNAhVbF8AKHTPpDjkQjRwIBw&url=http://www.telegraph.co.uk/news/politics/9019327/Parliament-logo-should-be-axed-according-to-adviser.html&bvm=bv.123325700,d.ZGg&psig=AFQjCNHwZYSVdXxnHIAely_fs4OcrymACw&ust=1464870696034724
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Representing your views
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Representing your views
Aspiring chief executive
programme
https://twitter.com/BBCr4today
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Governance Conference
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Annual conference & exhibition 2016
Event bookings open for our annual event at Birmingham ICC on 29-30 November Delegates can take advantage of group discounts of up to 25% Please see our website for further details Confirmed speakers include the Secretary of State for Health and chief executives of CQC, NHS England and NHS Improvement 89% of delegates rated 2015 event as ‘good’ or ‘excellent’
https://nhsproviders.org/courses-events/annual-events/annual-conference-and-exhibition/early-bird-rates-for-2016
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THANK YOU Q&A
Images from Googleimages & HSJ
Slide Number 1ContentsThings that have changed since we last metStruggle through 16/17… but 2017-21 U-Bend is comingContentsSystem under sustained operational pressureSystem under sustained operational pressureAnd traditional levers no longer available2016/17 NHS strategic financial frameworkConflicting system level views on how to manage 2016/1716/17 finances: best guess on what happens nextThe coming U bend – DH spend by head of populationNHS currently in denial on consequences of U bendThe £22 billion savings plan – how credible?But…..ContentsSTPs right idea and system starting to learn as we go……Some big questions emerging……And significant governance issues remainContentsClear Jim Mackey narrative emergingA new NHSI oversight framework coming shortlyTen initial thoughts on new NHSI oversight frameworkCQC new strategy to 2020ContentsJunior doctor contractLack of a national workforce strategy recognisedSome other workforce developmentsContents5YFV New Care Models growingIt’s easy to be cynical but 5YFV KPIs matterContentsRepresenting your viewsRepresenting your viewsRepresenting your viewsGovernance ConferenceAnnual conference & exhibition 2016THANK YOU