The first of April 2013 sees a new approach to NHS commissioning and with it a new set of priorities and outcomes for commissioners to achieve. To guide the nascent Clinical Commissioning Groups (CCGs) through their commissioning responsibilities the NHS Commissioning Board (NHSCB) has published a planning framework, Everyone Counts: Planning for Patients 2013/14, together with supporting information. Thoreya Swage looks at it in detail.
The NHSCB has identified three key objectives for the new NHS commissioning structure to achieve. They are:
balancing the need for change with that of continuity
ensuring “assumed liberty” for CCGs
ensuring a balance between short-term (annual) priorities with those of the longer-term future.
The planning document sets out the actions and support NHSCB will provide to CCGs, as well as the mechanisms whereby these can be implemented.
The NHSCB mandate
The Government published its mandate to the NHSCB in November 2012 providing a steer on the strategic framework within which the Board will operate. This includes making measurable progress in achieving better outcomes in each of the five domains of the NHS Outcomes Framework, plus supporting the requirement to permit autonomy for the local NHS to develop innovative solutions to the delivery of healthcare and greater involvement of the NHS in research.
Underlying all this is the requirement to ensure robust financial management and value for money, including limiting the expenditure on administration.
The NHSCB cannot achieve this alone and requires the involvement of CCGs to ensure that the mandate is implemented. The planning framework, “everyone counts”, is the means by which this joint working can be ensured.
From April 2013 the NHSCB is responsible for overseeing the expenditure of a £95.6 billion NHS budget, of which £63.4 billion is allocated to CCGs to commission acute, community, mental health and ambulance services for their local populations. The remaining £25.4 billion will be held by the NHSCB to commission specialised healthcare and primary care.
CCGs are expected to set an annual budget to support their commissioning plans and to set aside at least 0.5% of this budget to cover areas of financial risk and an additional 2% to cover non-recurrent spending.
Assumed liberty for CCGs
This will be the first year of clinically-led commissioning of services through the local leadership of CCGs. The Government is keen to encourage locally determined decisions for healthcare and therefore has stated that “liberty is assumed rather than granted”. In other words, the priorities for healthcare will be for the local commissioners to decide, in conjunction with other partners including social care and patients and the public and based on local needs.
The NHSCB has published the NHS Outcomes Framework, which reflects the Government’s priorities, and this framework provides the overall guidance with regard to improvement in outcomes that CCGs and partners are required to achieve. Not only is there a need to improve outcomes, there is also a need to reduce the variation in outcomes that currently exist across the country. The difference in this planning framework compared to the previous (operational) frameworks is how the improvement in these outcomes is achieved; this will be determined locally.
CCGs are also required to be mindful of the pledges within the NHS Constitution when undertaking their responsibilities. The NHSCB has made five “offers” to support CCGs in delivering better health outcomes.
1. Ensuring that routine healthcare is available seven days a week
The NHSCB national medical director will be setting up a forum comprising commissioners, providers and regulators to identify how access to services could be improved to cover the full seven days of the week. It is anticipated that a full report will be published in the autumn of 2013.
This work will first address how diagnostic services can be improved as well as access to emergency care. The main emphasis will be the fact that emergency care should not be the first port of call, particularly if care is available in other settings.
In addition to the commissioning role of the CCGs, the review will address how primary care can provide effective out-of-hours care through the direct commissioning of the NHSCB.
2. Greater choice and transparency
In order to understand the quality of services delivered by healthcare providers, the NHSCB Medical Director, together with the Healthcare Quality Improvement Partnership and NHS Choices, will develop clinical quality measures and survival rates for every consultant (from national clinical audits) for a number of specialties. These include cardiovascular, gastrointestinal, orthopaedic, urological and head and neck specialties. This data will be published in the summer of 2013.
3. Involving patients and ensuring their participation
A new mechanism called real-time feedback will be in place to capture comments when patients have directly experienced healthcare. This will include a “Friends and Family Test” to cover all acute inpatient care and A&E from April 2013, maternity services by October 2013, and eventually other services by 2014/15.
In addition, there is a commitment to guarantee patients access to their own online GP records by the spring of 2015, a greater emphasis on the take-up of telehealth and telecare and a move to paperless referrals enabling patients to book their appointments at the GP surgery and hospital outpatients by March 2015.
4. Better data informing outcomes
There is a renewed drive to improve and integrate information systems through the development of care data, including health and social care across care pathways, which requires the universal use of the NHS number by all providers during 2013/14. There will also be a core set of clinical data collected from GP practices to enable CCGs together with partner agencies to commission integrated care.
In addition there is renewed emphasis on enforcing sanctions on the Secondary Users Service, which processes data from providers in the case of publishing poor-quality data.
Comprehensive clinical data for secondary care will be developed during 2013/14, starting with the dataset for improving cancer outcomes. Outcomes for patients will be monitored through secure record keeping adopted by secondary care providers by 2014/15.
5. Improved standards of care
In the light of Transforming Care: A National Response to Winterbourne View Hospital and the Francis Report into the inquiry into care in Mid-Staffordshire NHS Foundation Trust, commissioners and providers will be required to implement the recommendations from both reports. In particular, there is an expectation that there will be a large reduction in hospital placements for people with learning disabilities or autism who have challenging behaviour or a mental health condition.
In parallel with these recommendations there is a need to improve the culture of all clinical and non-clinical staff such that the values of care, compassion, competence, communication, courage and commitment (the six Cs) are promoted; this should be underpinned by medical revalidation and better professionalism amongst healthcare managers.
A revised NHS Standard Contract
The first NHS Standard Contract was introduced by the Department of Health in 2008 for use by Primary Care Trusts to place the commissioning of services on a more robust footing. Since then NHS Standard Contracts have been developed for other services including community, mental health and ambulance care.
The NHSCB has revised these contracts for CCGs to use from April 2013. These changes include a proposed e-contract; simplification into three sections, “the Particulars, the Conditions and the General Conditions”; and an update to take account of the new NHS landscape.
The Service Specification Template has been altered to reflect that the NHS is now contracting for outcomes and not processes. In addition, the quality requirements now consist of three sections: “Operational Standards” (based on the NHS Constitution rights and pledges), “National Quality Requirements” (identified in the planning framework) and “Local Quality Requirements”.
Health and Wellbeing Boards, due to be formally established in April 2013, will play a major role in commissioning joint health and social care for their local populations, including ensuring the best use of joint resources and supporting the reconfiguration of services to ensure safe and sustainable care. An example of this will be the development of services across health and social care and education for children with special educational needs or disabilities, using the model of a single assessment for those sectors of care and personal budgets. The local commissioning priorities will be determined by the Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy.
Outcomes from joint commissioning will be measured by a Clinical Commissioning Group Outcomes Indicator Set, which is based on the NHS Outcomes Framework, as well as other indicators developed by NICE and the Social Care Information Centre.
The NHSCB will be supporting joint commissioning and ensuring that disadvantaged groups have a say in the development of services locally, including those for people with long-term conditions. CCGs have statutory duties that they must meet such as reducing inequalities, obtaining professional advice and ensuring public involvement, as well as meeting their financial requirements and taking account of the Joint Health and Wellbeing Strategy.
The NHSCB will be assessing CCGs in these key areas on an annual basis.
Responsibilities of the NHSCB
The NHSCB has its own commissioning responsibilities, including the direct commissioning of the four primary care contractor services, specialised services, some public health screening and immunisation services, and services for prisons and the armed forces. The NHSCB will devolve the responsibility for the operational management of GP IT services to CCGs.
The commissioning landscape in 2013/14 is different from that of previous years in that improvements in care will be measured through outcomes rather than processes. The measures of the improvements are based on the five domains of the NHS Outcomes Framework.
In addition, all providers of NHS services have a legal requirement to have regard to the NHS Constitution, a key feature of which is ensuring that patients do not wait longer than 18 weeks for non-urgent consultant-led treatment. This is reinforced by the NHS Standard Contract, which requires outpatient appointment letters to include information on the right to treatment within the 18-week timeframe, and advice to patients on what to do if this is not achieved. Choose and Book will be another way in which patients can be advised of their right to timely treatment.
Other areas in which outcomes are expected to improve include time limits on waiting for emergency care such as minimum response times for A&E or ambulances, 15-minute handovers between ambulance and A&E staff, and shorter trolley waits (a maximum of 12 hours). Patients who have had their operations cancelled should be offered another date within 28 days or offered another hospital of the patient’s choosing, and there should be universal coverage of the access to psychological therapies programme by 2014/15.
Quality, Innovation, Productivity and Prevention (QIPP) continues to be a theme driving the commissioning decisions of CCGs, who are expected to use the QIPP how-to guides published by the National Quality Board to help them meet these challenges.
The Commissioning for Quality and Innovation (CQUIN) requirement in the NHS Standard Contract is a key mechanism to secure improvements in quality. For 2013/14 providers will be paid 2.5% of the value of their contract if they deliver improvements against the national CQUIN goals including the “Friends and Family Test”, “NHS Safety Thermometer”, dementia care and prevention of venous thromboembolism as well as locally negotiated improvements.
Similarly, CCGs will be rewarded with a Quality Premium if they achieve improvements in reducing “potential years of life lost” from causes that can be treated by healthcare, avoidable emergency admissions, “Friends and Family Test” and healthcare-associated infections, as well as locally agreed measures.
Last reviewed 11 February 2013