When the Coalition Government published its strategy for the NHS (Equity and Excellence: Liberating the NHS) in July 2010, it provoked much discussion over a number of areas resulting in a period of listening and consultation about the proposed reforms. An independent group, the NHS Future Forum, was set up to undertake this exercise. The group published its report in June 2011, making a number of recommendations, one of which was to strengthen the input of clinical professionals in how healthcare is provided. In addition to the Clinical Commissioning Groups (CCGs), two other sets of groupings would help to achieve this: the clinical networks and the new clinical senates, both to be hosted by the NHS Commissioning Board (NHSCB). Thoreya Swage looks at them in detail.
What are clinical networks?
Clinical networks are groups of clinical experts that provide advice on the development and redesign of specific service areas or disease or professional group. Many such networks currently exist, eg for the management of stroke or pathology services, and are either formal or informal groupings and vary in their function and funding structures. Some of the clinical networks are hosted by Primary Care Trusts.
The NHSCB is keen to ensure that clinical networks continue to exist and to grow and develop in areas that have not had the benefit of this expertise. As a new commissioning landscape will be established on 1 April 2013, there is a need to ensure the continuation of these formal clinical networks, including their funding support.
From April 2013, the NHSCB will be building on the work that has been done before by establishing strategic clinical networks. These will be focused on areas where an integrated whole system approach is required to achieve demonstrable changes in quality and outcomes of care. The aim will be to reduce unnecessary variation in the delivery of services and promote innovative practice.
A single change model will be used as a framework to ensure a consistent approach to the improvement activities of the networks. This will include frameworks to support the development of the network, evaluation of the effectiveness of the network as well as accountability and governance arrangements.
A key aspect of the way the networks are to function is that they are required to have the input of both commissioners and providers acting as prime movers for changes and improvements in care.
Both the NHSCB and CCGs will be using clinical networks to provide a steer on the commissioning of the relevant services they cover.
What type of clinical networks will there be?
The NHSCB will be encouraging the development of a wide range of clinical networks that will perform other functions, including networks:
that concentrate on co-ordinating pathways of care between providers to ensure access to specialist services, eg burns units or critical care beds
of professionals at the local NHSCB level to advise on the commissioning of dental, pharmacy and optometry services
determined and funded by CCGs to drive the achievement of local priority areas and change the ways of working
of groups of providers that are established and maintained by them to facilitate the joint delivery of a service.
Strategic clinical networks
In addition to the above, there will be a small number of strategic clinical networks whose role will be to advise commissioners, drive change and promote outcomes, supported by the NHSCB. These will be established in order to help facilitate improvements in key identified areas, especially when:
large-scale changes are needed across complex patient pathways which involve many organisations and professional groups
a combined and co-ordinated approach is needed to address healthcare challenges that have not responded to previous attempts at improvement.
The NHSCB has developed a set of criteria to identify the need for the establishment and/or continuation of the strategic clinical networks and the key health issues they are required to address including that:
there is a clear case for the potential to improve the quality of care when compared to international comparators or where there are great variations across England
there is the potential to achieve great benefits for patients, professionals and partner agencies
there is already wide-ranging involvement of professionals and bodies in the delivery of care
due to the scale and volume of the condition, a network approach is the best method to plan and deliver a specific care pathway
there are clear links to NICE guidance
quality improvement cannot be achieved through other means such as CCGs or via contracts or tariffs
quality improvement can be achieved using a network model
an approach across the whole of the country is the optimum way to improve services
there is a great risk or impact if no strategic clinical network existed.
The NHSCB has identified four conditions that strategic clinical networks are to address from 2013. They include:
cardiovascular disease (including stroke, cardiological and kidney conditions and diabetes)
children and maternity care
mental health, including dementia and neurological disease.
The NHSCB anticipates that the life of a strategic clinical network will be five years or less, depending on the type of service redesign that is required. It will also establish other strategic clinical networks as the need for such an approach is identified for specific conditions or patient groups.
Strategic clinical networks and the NHS Outcomes Framework
Strategic clinical networks, like other NHS bodies, are required to conform to the requirements of the NHS Outcomes Framework. The table below shows how their work meets these requirements.
Strategic clinical network
1. Preventing premature deaths
Cancer; cardiovascular disease
2. Enhancing the quality of life for people with long-term conditions
Mental health, including dementia and neurological disease
3. Aiding the recovery of people who have had episodes of illness or injury
Children and maternity care
Domain 4 (ensuring a positive experience of healthcare) underpins all healthcare and therefore will be incorporated as part of the work of the strategic clinical networks.
What are clinical senates?
The Future Forum Report also highlighted a need for clinical senates: multi-speciality groups to provide strategic advice to commissioners.
The role of the clinical senates is to provide advice, based on evidence, to help commissioners consider the needs of patients, rather than those of institutions or professions, and to provide an overview of services which cross organisational boundaries. In this role, clinical senates will be important in providing a strategic perspective on major changes in services. This role will be developed further in a separate document to be published in the future.
The NHSCB has divided up the country into 12 geographical areas based around major tertiary or specialist centres into which the major patient flows occur. Each area contains geographically related groupings of CCGs and local authorities whose boundaries are coterminous with the larger area.
In addition, each area will contain other bodies including strategic clinical networks, clinical senates and academic health science networks.
Academic health science networks consist of groups of universities, providers of NHS services and healthcare-related industries that have committed themselves to ensuring collaboration between education, training, research, delivery of healthcare and informatics in their locality in order to encourage innovative practice and secure the enhancement of patient and population outcomes.
All these bodies will work together to promote and support local improvements in health services. There will be one clinical senate for each geographical area and they will work closely with the strategic clinical networks.
The 12 geographical areas are:
East of England
Cheshire and the Mersey
Greater Manchester, Lancashire and South Cumbria
Yorkshire and the Humber
North East, North Cumbria and North Yorkshire (Hambledon and Richmondshire).
The clinical senate and clinical network areas coincide mostly with the local 27 outposts of the NHSCB, apart from three. The latter differ because this is necessary to take account of the pattern of patient flows to specific specialist centres in those localities.
Accountability and support for the clinical senates and clinical networks
Each of the 12 areas will have a team, based in the local office of the NHSCB and funded by the board, to support the work of the clinical networks and clinical senates.
The support teams will build and ensure a coherent network set up in their locality including:
developing a yearly programme of quality improvement initiatives based on locally and nationally identified priorities
providing project and programme management input
encouraging the promotion of innovation and adoption of best practice
helping the network to carry out quality assurance processes, eg clinical audits and the assessment of the activities the networks undertake
ensuring access by the network to services that provide information (including public health information) and analysis, audit, funding and expertise in economic appraisals.
The actual support team will be led by a network director and a part-time clinical director whose roles include determining the type and level of clinical input necessary for the network. This input will be mostly on a part-time or sessional basis and will come from local healthcare institutions. The types of healthcare professionals required for the network include doctors, nurses, allied health professionals and scientists.
In terms of their legal position, strategic clinical networks are not statutory bodies in their own right and are not responsible for commissioning healthcare; only CCGS and the NHSCB have this responsibility. However, the networks will be required to have clear terms of reference and an accountability agreement which is renewed on an annual basis with the NHSCB. This process will ensure that the quality programmes the networks are required to carry out are formally assessed and monitored. A governance and accountability framework will be developed for each network by the network and clinical directors in conjunction with their support team.
The network and clinical directors will be accountable to the local NHSCB director and on to the regional NHSCB office director.
At a national-level strategic clinical networks will have support in the areas of sharing and disseminating good practice, building knowledge and problem solving, training, development and coaching and communication. This service will be provided by a new improvement body which will probably include the functions of the National Cancer Action Team, NHS Diabetes and Kidney Care and NHS Improvement.
The work of the strategic clinical networks will be subject to a formal evaluation process including demonstration of evidence of their effectiveness and publication of the quality initiatives and annual reports.
Timetable for implementation
The NHSCB has set out a timetable for the development and establishment of clinical networks. Although little detail has been provided for the establishment of clinical senates, both bodies will be up and running by 1 April 2013.
By September 2012
By December 2012
By March 2013
The Way Forward: Strategic Clinical Networks (PDF), NHS Commissioning Board
Clinical Networks: Frequently Asked Questions (PDF), NHS Commissioning Board
For more information on clinical networks and clinical senates see www.commissioningboard.nhs.uk/resources/networks-senates