Memorandum by Cambridgeshire Primary Care
Trust (COM 117)
COMMISSIONING
EXECUTIVE SUMMARY
Cambridgeshire Primary Care Trust is pleased
to have the opportunity to contribute to the Health Select Committee's
inquiry into commissioning.
Cambridgeshire Primary Care Trust is responsible
for improving the health of the population of Cambridgeshire by
assessing health needs and by commissioning services from providers
in response to those needs. The population of Cambridgeshire is
changing and is expected to grow significantly in size and in
age over the next ten years. Despite having areas of relative
affluence, there are significant pockets and areas of deprivation
in the County which need to be addressed.
Looking ahead, it is clear that the impact of
the economic downturn will have a significant impact on future
public sector funding. Having undertaken a strategic assessment
together with key stakeholders, our view is that this is an opportune
time to think more radically and innovatively about how commissioning
could be conducted, whilst benefitting from the practical experience
of Practice based Commissioning Consortia.
Cambridgeshire has a good history of support
for NHS Reform and this is evident from the work of our service
providers and our commissioning teams, past and present. The Purchaser/Provider
split has proved to be a useful means of defining clearly our
respective roles and responsibilities and has led to a steady
path of evolution both separately in our respective roles and
together by working in partnership.
Key elements of this are the introduction of
a new commissioning model in 2010-11, supporting the aspiration
of the PCTs provider arm to become a NHS Trust and taking forward
the quality and safety agendas.
1. INTRODUCTION
AND CONTEXT
1.1 Cambridgeshire Primary Care Trust (CPCT)
was established on 1 October 2006 and is responsible for
improving the health of the population of Cambridgeshire by assessing
health needs and by commissioning services from providers in response
to those needs.
1.2 Just over 600,000 patients are
registered with GPs within the CPCT boundary. By 2021, it is estimated
that there will be a further 90,000 people living in Cambridgeshire,
mainly in South Cambridgeshire and Cambridge City, where a number
of significant new housing developments are planned, including
the new town of Northstowe.
1.3 The number of people aged over 65 is
anticipated to increase by 60% between 2006 and 2021 in
Cambridgeshire with the greatest proportional increase expected
in South Cambridgeshire.
1.4 Life expectancy in Cambridgeshire has
been increasing across all groups identified and has been consistently
higher than the East of England average level from 2001 to
2007. However, life expectancy of the most deprived fifth has
always been below the East of England average over this period
and there is a 4 per cent relative difference between the
most and the least deprived areas in Cambridgeshire.
1.5 Across all districts, Cambridgeshire
has a lower deprivation score than the England average. The most
deprived areas in Cambridgeshire are concentrated in the north
east of the County. Deprivation varies greatly across the county,
with Fenland, north-east Cambridge and parts of North Huntingdon
having the highest levels of relative deprivation. The same pattern
exists for children living in poverty.
1.6 Income deprivation for older people
is more widely dispersed. Mapping of adverse lifestyle behaviours
and health outcomes across Cambridgeshire follows the pattern
of deprivation.
1.7 The annual budget is over £800 million.
Nearly 90% of this is used to commission services from acute hospital
and out of hospital care providers. The remainder is spent on
mental health services (8%) and PCT support services (3%).
1.8 There are several Practice Based Commissioning
(PBC) Consortia within Cambridgeshire with whom CPCT works closely
covering Cambridge and South Cambridgeshire, Huntingdonshire and
East Cambridgeshire and Fenland. Currently PBC budgets are indicative.
1.9 CPCT is lead commissioner for the following:
(a) Cambridge University Hospitals NHS Foundation
Trust.
(b) Hinchingbrooke Health Care NHS Trust.
(c) Cambridgeshire and Peterborough NHS Foundation
Trust (mental health services).
1.10 Community services are provided by
Cambridgeshire Community Services, the PCTs provider arm which
works on an arms length basis but has aspirations to become a
Foundation Trust in its own right.
2. WORLD CLASS
COMMISSIONING
2.1 CPCT welcomes the introduction of World
Class Commissioning (WCC). The WCC programme is only in its second
year of development but we believe that it has several advantages:
(a) It sets out a staged development path to
assist commissioning organisations to achieve world class commissioning
status;
(b) it places emphasis on the importance of robust
strategic planning supported by a range of under-pinning plans;
(c) the range of competencies requires commissioning
organisations to consider carefully their approach to balancing
and managing external relationships as well as the developmental
changes to their organisations; and
(d) it aims to ensure consistency of standards
across all commissioning organisations whilst enabling PCTs to
develop at their own pace.
2.2 However, we believe that WCC is at too
early a stage of development for it to provide a clear and reliable
indication of the effectiveness of a PCT's commissioning approach.
The WCC assurance process itself is changing and evolving. During
this year, we have seen greater specificity of assessment criteria
this year but appreciate that these, too, will continue to evolve
as experience nationally and locally improves.
2.3 The process of preparing for WCC assurance
has been helpful in several respects. Firstly, the discipline
of following through from strategic vision to explicit clinical
outcomes has encouraged greater clarity of thinking and a need
for a logical and structured approach to strategic formulation.
2.4 Secondly, by incorporating the requirement
to demonstrate good clinical and partner organisational engagement,
partnership working has been enhanced. For example, in June last
year, we held a stakeholder conference entitled "the Storm
Scenario" comprising 80 leaders from a wide range of
organisations to explore the likely impacts of the economic downturn.
The results of this conference and the ensuing summit meeting
were used to determine at least one of our major strategic change
programmes set out in the five year plan. One of the by-products
of this work is greater mutual recognition of our respective strategic
challenges and a willingness to explore more and innovative ways
of working together in future.
2.5 Finally, the need to closely align service
and financial planning and to demonstrate this explicitly during
the WCC assurance process has yielded several important benefits
which, in time, will manifest as clear indications of the effectiveness
of commissioning. These include:
(a) better clarity of commissioning intention,
supported by relevant performance metrics;
(b) close working between directorates to ensure
that commissioning intentions are sufficiently thought through
and aligned with the strategic priorities set by the Board; and
(c) assessment of the market development opportunities
and the appropriate use of the procurement pipeline for service
procurements.
3. PURCHASER/PROVIDER
SPLIT
3.1 The Purchaser/Provider split has been
in place for many years. It was introduced initially during the
Internal Market in the 1990's and has continued since then. The
distinction between the roles and responsibilities of those who
purchase (commission) services and those who provide them has
been an essential part of the development path for system reform.
3.2 We believe that the initial separation
of purchaser and provider roles resulted over time in an approach
which was dominated by transactional management. In its early
stage of development, there was a lot of focus on devising and
developing the transactional mechanisms for such a split to work.
For example, this included the development of a range of contract
types, development of information systems to sustain invoicing
for services delivered and the initial development of the strategic
and operational planning infrastructure required to support the
development of a health care market.
3.3 Since then, the approach has become
more sophisticated for several reasons:
(a) the establishment and development of Foundation
Trusts which has led to the creation of sophisticated provider
operational management and service performance management systems;
(b) the emergence of Intelligent Commissioning
and the Intelligent Board concepts resulting in a better understanding
of the role of purchasers (commissioners) and a push to translate
more overtly the health needs of the population into coherent
and achievable strategies for investment and/or service transformation;
(c) recognition and better understanding of the
opportunities which can be afforded by developing the health and
social care market;
(d) continuing development by the Department
of Health of model contracts which ensure that respective roles
and responsibilities of purchasers and providers are clearly set
out within a legally binding setting; and
(e) the introduction of World Class Commissioning
and the continuation of Foundation Trust development programmes
foster such a separation and provide a pathway for future development.
3.4 The continuation of the purchaser/provider
split is needed if we are to avoid confusion of roles and if we
are to maximise the opportunities for developing the health and
social care market with the aim of achieving the best value for
public money.
4. COMMISSIONING
AND SYSTEM
REFORM
4.1 Cambridgeshire has been and remains
committed to taking forward System Reform. Examples of this include:
(a) the early piloting and rapid development
of Payment by Results at Cambridge University Hospitals NHS Foundation
Trust;
(b) the development of a more rational and intelligent
commissioning approach shortly after inception of the PCT;
(c) exploring with the Department of Health Commercial
Team the feasibility of introducing the Framework for procuring
External Support for Commissioners (FESC) in Cambridgeshire; and
(d) in the diabetes integrated care pathway (which
represents £19 million annual spend in acute with 38%
related to diabetes direct admissions) a pilot in East Cambs and
Fenland has been successful. Early indications show that there
is potential to roll out across the county and reduce diabetes
related admissions and out patient referrals.
4.2 CPCT has also wished to support actively
the development of Practice based Commissioning (PBC) and we now
have several thriving PBC Consortia in place.
4.3 In the light of the economic downturn
and its estimated impact on future public sector funding, we believe
that there are opportunities to be more radical and innovative
in approach, particularly with respect to PBC. During formulation
of our latest strategy, it became clear that the current commissioning
model would be insufficiently robust to ensure that health and
social care commissioning in Cambridgeshire could be confidently
developed.
4.4 Our approach to commissioning in the
past has been based on a centralised model with PBC Consortia
providing complementary commissioning input within their localities
using indicative budgets. Whilst this was an essential part of
the development path to achieve more localised commissioning of
services (and therefore more pertinent to the needs of patients),
our view is that this centralised approach has not been as successful
as it could have been.
4.5 Our Practice Basing Commissioning journey
has taken some time, but we now have significant and improving
clinical engagement. We have a great deal of interest in GPs forming
into "clusters" to manage their own budgets. We believe
this model will be more responsive to patient needs and less bureaucratic.
Examples of where we have made progress include:
(a) in the south of the County, working with
the complexity of secondary and specialist services provided by
Cambridge University Hospitals NHS Trust;
(b) in Huntingdonshire, ensuring that there is
a sustainable health system in place for the future; and
(c) in East Cambrigeshire and Fenland, improving
community hospital service provision and accessibility to services
in what is largely a rural part of the County.
4.6 Having held wide-ranging discussions
with primary leaders and opinion shapers, we have concluded that
our current commissioning model is too removed from clinicians
on the ground, in particular GPs, who make decisions every day
about the treatment individuals receive. The result is a separation
of clinical and financial responsibility. The people who probably
know most about their patients' needs are unable to be intimately
involved in designing and commissioning the disposition of services
to meet those needs.
4.7 If we are to achieve a commissioning
model whereby local clinicians are able to respond directly and
intelligently to health needs of people within a locality whilst
maintaining a county-wide oversight at PCT level, the current
commissioning model for Cambridgeshire will require a more innovative
approach.
4.8 Therefore, we intend to introduce a
new commissioning model which has at its heart Clusters of GP
practices who accept responsibility for commissioning health services
for their patients. They would be rewarded in proportion to the
success they achieve against the agreed performance framework
and would accept a share of the risk of failure.Cluster size could
vary but a population of between 50,000 to 100,000 appears
to be a reasonable proposition. Although the detailed prospectus
is still being prepared, we are clear that we would need to agree
real commissioning budgets with each Cluster and devolve as much
authority to them as possible. Clusters would operate within a
governance framework agreed with the Primary Care Trust, clearly
setting out the roles and reponsibilities of each party. Our aspiration
is that the first wave of Clusters will be operational during
the financial year 2010-11. Subject to satisfactory formal evaluation,
we will invite future waves to participate. Participation in this
system is voluntary. Any new system that allows and encourages
GPs to commission in a more innovative way, on a larger scale,
must also ensure rigour in governance and outcomes monitoring.
They will also need support and the infrastructure to be able
to hold their providers to account and to performance manage contracts
they hold.
4.9 Whilst the introduction of a more radical
commissioning model is an important part of our strategy to take
forward NHS Reforms, we also have a responsibility to ensure that
the health care "market" in Cambridgeshire has a viable
and thriving community services provider. This is an important
element in our strategy to ensure that there is a secure foundation
of community service provision to support the safe shift of clinically
appropriate care from an acute hospital setting to a clinical
setting based at or near the patient's home.
4.10 Cambridgeshire Community Services (CCS)
operates as an "arms length" trading organisation but
is legally part of the PCT. CCS provides a range of community
based services including district nursing, therapies and a wide
range of services for older people through managing the pooled
budget for social care.
4.11 CCS has sought approval from the Secretary
of State for Health to become an NHS Trust from 1 April 2010.
The PCT Board welcomes this and sees it as a natural outcome of
CCS' current organisational development path.
5. SPECIALIST
COMMISSIONING
5.1 Specialised services tend to be high
cost and low volume services and are either very expensive to
provide or they comprise services for rare conditions, for example,
rare cancers, renal dialysis, complex surgical care and specialised
care for children. These services are not provided by every hospital
but require the expertise of highly trained and experienced clinicians,
often using complex medical technology. Such services tend to
be provided in specialist centres supported by satellite hospital
units.
5.2 In the East of England, specialised
commissioning is undertaken by the East of England Specialised
Commissioning Group (EoESCG) which was established in April 2007 through
an amalgamation of several smaller groups. The PCT is a full member
of the EoESCG Board and make an active contribution to its constituent
working groups.
5.3 While CPCT believes that this is a useful
model for commissioning these sorts of services, it does not believe
that it works as well as it could do at the moment. There needs
to be better engagement with PCTs in this process, and closer
monitoring at a local level of the impact of the services and
the outcomes for patients. We also need a systematic approach
for PCTs to hold the Specialised Commissioning Group to account
when things don't work well.
6. COMMISSIONING
FOR QUALITY
AND SAFETY
OF SERVICES
6.1 The quality and safety of the services
we commission is of paramount importance and, for that reason,
the PCT Board re-structured the board meetings agenda to ensure
that quality and governance issues are the first to be discussed
at every meeting.
6.2 CPCT welcomes the introduction nationally
of Quality Accounts and the Commissioning for Quality and Innovation
(CQUIN) payment framework arising from High Quality Care for
All, led by Lord Darzi. During the past year, the PCT has
drawn up a CQUIN schedule for inclusion in our acute provider
contracts and, although the content of the CQUIN schedule is continually
evolving, our view is that provides a helpful focus during the
contract negotiation stage and at subsequent performance management
meetings.
6.3 In addition, we have organised a regular
provider performance review day with each of our main providers
and use this time to focus on key clinical quality, safety and
contract performance issues.
6.4 The work of developing CQUIN frameworks
will, in time, be complemented more overtly by the publication
of Quality Accounts by Trusts and we believe that this will further
enhance the value of the commissioner/provider discussion to the
benefit of our patients.
January 2010
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