Written evidence from the Department of
Health (COM 01)
EXECUTIVE SUMMARY
On 30 March 2010, the House of Commons Health
Select Committee published the Fourth Report of Session 2009-10
entitled Commissioning, following their inquiry into this
area. The Committee commented on the previous Government's reforms
since 2000 and made it clear that, under those reforms, progress
in improving commissioning was not sufficiently fast or comprehensive.
This Government agrees with the Committee's assessment.
The Coalition: our programme for government[1]
document indicated this Government's intention to strengthen the
power of GP practices as patients' expert guides through the health
system by enabling them to commission care on patients' behalf.
It also pledged to break down barriers between health and social
care funding to incentivise preventative action.
Commissioning is a key component of any healthcare
system. It is about deciding how healthcare resources are used
to secure the best care for patients and the best health outcomes.
To be effective, commissioning decisions should be taken at a
level as close to patients as possible—it is vital that
clinical responsibility should not be divorced from commissioning
responsibilities. The weaknesses in commissioning, previously
identified by the Committee, are symptomatic of a system that
did not emphasise the importance of clinical involvement in decisions
about how the precious resources of the NHS should be spent.
The proposals set out in the White Paper Equity
and Excellence: Liberating the NHS,[2]
published on 12 July, set out a clear sense of direction, with
consistency of strategy and the commitment to put commissioning
decisions in the hands of those who are closest to patients themselves—GP
practices. Under these proposals, GP practices will work with,
and draw upon, expertise from those working in health and social
care to ensure that they have appropriate specialist input into
their commissioning decisions. Liberating the NHS outlined the
Government's long-term vision for the future of the NHS, building
on the core values and principles of the NHS—a comprehensive
service, available to all, free at the point of use, based on
need, not ability to pay.
Liberating the NHS set out how we propose
to:
— put patients at the heart of everything
the NHS does;
— focus on continuously improving those
things that really matter to patients—the outcome of their
healthcare; and
— empower and liberate clinicians to innovate,
improve healthcare services and be accountable for results.
We propose shifting decision-making as close
as possible to individual patients, by devolving power and responsibility
for commissioning services to local consortia of GP practices.
This change will build on the pivotal and trusted role that primary
care professionals already play in co-ordinating patient care,
through the system of registered patient lists and brings together
responsibility for management of care with the management of resources.
This is an essential component of a more effective commissioning
structure.
We propose to establish an NHS Commissioning
Board whose role will include supporting and developing an effective
and comprehensive system of consortia and holding consortia to
account for delivering outcomes and financial performance. The
Board would also provide leadership for quality improvement through
commissioning, promote and extend public and patient involvement
and choice, commission certain services (such as primary care
services and specialised services) and allocate and account for
NHS resources.
Our plans to introduce a new commissioning system
led by groups of GP practices at local level and overseen nationally
by an independent NHS Commissioning Board, are intended to transform
the quality of care and health outcomes for patients. Giving Commissioning
consortia more responsibility and control over commissioning budgets
will align clinical decisions with their financial consequences
and support more effective use of NHS resources.
To ensure that local services work together
effectively, the Government proposes to establish new statutory
arrangements to strengthen the role of local authorities. Local
authorities would have greater responsibility in four areas:
— leading joint strategic needs assessments
to ensure coherent and co-ordinated commissioning strategies;
— supporting local voice, and the exercise
of patient choice;
— supporting joined up commissioning of
local NHS services, social care and health improvement; and
— leading on local health improvement and
prevention activity.
Under the proposals set out in Local democratic
legitimacy in health,[3]
local government would have an enhanced responsibility and a statutory
duty for promoting partnership working and integrated delivery
of public health services across the NHS, social care, public
health and other services.
Liberating the NHS was the start of an
extensive engagement process on how best to implement these changes.
A number of supporting documents have now been published. In particular,
Liberating the NHS: Commissioning for Patients[4]
and Increasing Democratic Legitimacy in Health invite views
on questions in a number of areas of the commissioning agenda.
This exercise closes on 11 October.
Within this evidence we have set out the proposed
direction of travel for commissioning in a number of areas. This
should be seen within the context of the wider engagement exercise
that is currently underway. The overall design of the proposals
set out in Liberating the NHS will be subject to the outcomes
of this consultation and engagement exercise and to Parliamentary
approval of the necessary primary legislation.
CLINICAL ENGAGEMENT
IN COMMISSIONING
How will commissioners access the information
and clinical expertise required to make high quality decisions
about the shape of clinical services?
The provision of quality and timely information
is essential to ensure informed decision-making. Currently, active
clinical commissioners use information provided by their Primary
Care Trust (PCT) on budgets, expenditure, referrals, prescribing,
activity and where possible, clinical performance to review local
need and current service provision. They can use this information
to release and reinvest resources by using their skills and knowledge
to challenge ineffective and inappropriate clinical interventions
and clinical practice.
Devolving power and responsibility for commissioning
of services, along with real budgets, to local consortia of GP
practices would mean the quality of management data and financial
information will become of increasing importance.
Under the proposals set out in the document
Local democratic legitimacy in health,[5]
local government would have an enhanced role in public health,
with direct responsibility and funding (allocated to local Directors
of Public Health) for improving the health of local communities.
This enhanced role for local government would provide a framework
through which Commissioning consortia alongside other partners,
contribute to a joint assessment of the health and care needs
of local people and neighbourhoods and draw on the advice and
support of the local authority or the proposed health and wellbeing
board in relation to population health.
We will work with the profession and the wider
NHS to identify how best to support consortia in the significant
challenge of accessing accurate, real-time data that can be translated
into information to support efficient and effective care along
the patient pathway and to understand the relationship between
patient needs, service provision, health outcomes and financial
expenditure. The NHS Commissioning Board would be responsible
for helping to identify the information needs of commissioning
consortia. Local authorities or the proposed health and wellbeing
boards, in partnership with their relevant consortium/consortia
and others, would have wider responsibilities to undertake joint
assessments of needs, identify strategic priorities and promote
innovation in services to meet local needs. This work will provide
an agreed local strategic context in which commissioning takes
place, strengthening local accountability.
GP practices co-ordinate patient care and are
well placed to lead on the commissioning of care for patients.
However, we would expect consortia to involve relevant health
and social care professionals from all sectors in helping design
care pathways or care packages that achieve more integrated delivery
of care, higher quality, better patient experience and more efficient
use of NHS resources. This would mean consortia ensuring that
they have access to and draw upon the necessary expertise of those
working in health and social care to ensure that they have the
most appropriate specialist input into their commissioning decisions.
How will commissioners address issues of clinical
practice variation?
The NHS Commissioning Board would provide a
framework to support Commissioning consortia in commissioning
services, including setting commissioning guidelines on the basis
of clinically approved Quality Standards which would be developed
with advice from NICE, in a way that promotes joint working across
health, public health and social care. NICE Quality Standards
will provide a single evidence-based framework for commissioning
and delivery of good quality care that can be shared by both clinicians
and commissioners. NICE Quality Standards will be based on outcomes
for people across health and care, and will address prevention
and support as well as clinical treatment.
The performance of consortia as commissioners
will be closely bound up with the quality of services provided
by their constituent practices. The effective identification and
management of long-term conditions, the accessibility and responsiveness
of GP services, and decisions on referrals and prescribing all
have a major impact both on the overall quality of patient care
and on the efficient use of NHS resources. We propose, therefore,
that consortia should play a role in working with individual GP
practices in their consortium to drive up the quality of primary
medical care and improve overall utilisation of NHS resources.
We propose that the NHS Commissioning Board
should have the power, where it judges it appropriate, to ask
consortia to carry out on its behalf some aspects of the work
involved in managing primary medical services contracts, for instance
by promoting quality improvement or reviewing and benchmarking
practice performance. This potential role for Commissioning consortia
will help to ensure that action to ensure good financial management
sits alongside and complements GPs clinical responsibilities to
patients and their role in supporting patient choice. Consortia
would have some responsibility to challenge any behaviours that
are inappropriate both for good clinical care and for efficient
use of NHS resources. Peer review would play an important part
of the process.
We propose that the NHS Commissioning Board,
supported by NICE, will develop a commissioning outcomes framework
that measures the health outcomes and quality of care (including
patient-reported outcome measures and patient experience) achieved
by consortia, with an appropriate adjustment for patient mix.
This would, for instance, assess the health outcomes achieved
for people with long term conditions, the quality of urgent care
and acute hospital care, and health outcomes for people with long-term
mental health conditions or a learning disability. It would include
measures to reflect the consortium's duties to promote equality
and to assess progress in reducing health inequalities.
We want the NHS to focus on securing improved
health outcomes for patients rather than on top-down process targets
that do not lead to improvements in patient health. We propose
to reform the Quality and Outcomes Framework so that it better
promotes improvement in healthcare outcomes achieved by GP practices
as individual providers of primary care. We will discuss this
with the profession over the coming months.
How will GPs engage with their colleagues within
a consortium and how will consortia engage with the wider clinical
community?
It is our intention that GP commissioning is
put on a statutory basis, with powers and responsibilities set
out through primary and secondary legislation. However, we do
not propose to be prescriptive about the exact organisational
and governance arrangements that Commissioning consortia would
need to follow, aside from certain essential requirements (such
as financial accounting).
Commissioning consortia would need to develop
arrangements for both working with their constituent practices
and for holding their constituent practices to account.
Commissioning consortia might also want to develop
their own arrangements for engaging with other consortia, for
example through networks of commissioners. The need for such arrangements
might vary depending on geography, the disease area for which
services are being commissioned, and the wishes of Commissioning
consortia themselves.
Commissioning consortia would be able to involve
specialist expertise in the commissioning of services as they
see fit. Effective GP commissioning will require the full range
of clinical and professional input alongside that of local people.
Hospital doctors, nurses, pharmacists, Allied Health Professionals
and others all have a vital role to play and a real opportunity
to develop services and improve the health outcomes of their local
populations. Consortia will need to ensure that they have access
to and draw upon the necessary expertise of those working in health
and social care to ensure that they have the most appropriate
specialist input into their commissioning decisions.
In addition, we envisage that local authorities
would have a pivotal role in promoting integration between NHS,
social care and public health services. Consortia would be required
to work closely with other public services in the local area brought
together by local authorities or by the proposed health and wellbeing
boards. In the Programme for Government[6]
we were clear that the NHS would work in strong partnerships with
patients, carers, families, local services, councils and the police.
Effective commissioning would address the needs of the population
and the specific needs of people who are vulnerable and require
safeguarding.
HOW OPEN
WILL THE
SYSTEM BE
TO NEW
ENTRANTS?
Will potential new entrants be free to offer alternative
commissioning models?
Any GP practice awarded a primary medical services
contract and having a registered list of patients would be obliged
to join a consortium. We envisage a reserve power for the NHS
Commissioning Board to assign practices to consortia, if necessary.
GP practices would have the flexibility within
the proposed legislative framework, to form consortia in ways
that they think will secure the best healthcare and health outcomes
for their patients and locality. This would be subject of course,
to the NHS Commissioning Board being satisfied that a consortium
is able to fulfil its statutory duties and that there is a comprehensive
system of consortia across England.
Within the scope of NHS services as defined
by the Secretary of State, Commissioning consortia, in consultation
with their respective local authorities, would be broadly free
to decide commissioning priorities to reflect local needs, supported
by the national framework of NICE Quality Standards, tariffs and
national contracts established by the NHS Commissioning Board.
They would be able to adapt model contracts to include the quality
dimensions that they judge will produce the best outcomes. Consortia
would be expected to participate in assessing local needs. Local
government would set and agree local strategies for health improvement
and delivering public health priorities, to ensure that commissioning
activities meet the needs of the local population.
Each consortium would be free to develop its
own arrangements for commissioning services. This could include
working with those currently in PCTs with whom they have a close
relationship with, working with local authorities, and working
with external partners. Each approach would offer an alternative
commissioning model, which consortia would be free to change and/or
build upon over time.
Will care providers be free to offer new solutions
which offer higher clinical quality, better patient experience
or better value?
Care providers would be free to offer new solutions
offering higher clinical quality, better patient experience and
better value. Under our twin policies of Any Willing Provider
and patient choice, those that do so are likely to attract greater
patient numbers and corresponding increases in income to enable
them to meet the costs of expanding the services that they provide.
Under GP-led commissioning, these incentives
may be further strengthened. In aligning clinical decision-making
with the financial resources used to support those decisions,
consortia would be free to work with healthcare providers to help
design and redesign care pathways and care packages. In addition,
collaborative and joint commissioning arrangements with local
authorities would present opportunities for greater integration
between health and social care services and for developing innovative
care solutions that achieve better value, better quality services
and better outcomes for people.
Consortia will be commissioning bodies and would
not be able to provide services in their own right. However, consortia
would be able to commission services from individual practices
or groups of practices, subject to appropriate safeguards, where
this would provide best value in terms of quality and cost.
Will commissioners be free to access new commissioning
expertise?
We have set out very clear expectations that
Commissioning consortia would work closely with other health and
social professionals under the new system of commissioning and
this would help to ensure a wealth of expertise and knowledge
is harnessed during the commissioning process.
It is envisaged that commissioning budgets would
include a maximum management allowance for Commissioning consortia,
to reflect the necessary management and running costs associated
with commissioning. Consortia would be free to determine how this
management allowance is used to meet the costs associated with
commissioning.
It is important to remember that commissioning
is a set of many actions. Consortia would be likely to carry out
a number of commissioning activities themselves, especially those
where clinical input is involved. For the more technical aspects
of commissioning (eg data analysis or contract management), it
might be that they would not have these skills in-house. In some
cases, consortia might choose to act collectively, with a lead
commissioner negotiating and monitoring contracts with large hospital
trusts or urgent care providers. They might also choose to buy
in expertise and support from external organisations, including
local authorities and private and voluntary sector bodies, to
assist in the exercise of their functions. This might, for instance,
include analytical activity to profile and stratify healthcare
needs, support for procurement of services and contract monitoring.
What arrangements will be made to encourage the
Third Sector both as commissioners and providers?
Charities and voluntary organisations have a
vital contribution to health and care, not only as the providers
of services but also as advocates, partners in the co-design of
services and involvers and engagers of local communities.
They often have valuable expertise, insight
and experience that can improve local public services, often for
the most excluded people in our communities. The voluntary sector
could, for instance, be well placed to support commissioners in
developing needs assessments and commissioning guidelines. Current
examples of voluntary sector involvement include Mumsnet who have
been particularly valuable in helping to shape maternity services
and Turning Point on the Connected Care Audit.
There are a range of options we need to explore
over the coming period to help maximise the potential contribution
of this sector. We need to ensure that commissioners and providers
across healthcare, public health and social care are able to harness
the potential role of voluntary sector organisations in communities—helping
to build strong and resilient communities as part of the Big Society.
Commissioning consortia would be able to decide
which commissioning activities they undertake for themselves and
for which activities they choose to buy in expertise and support
from external organisations, including from voluntary sector bodies.
Charities and voluntary organisations could potentially strengthen
the process of public and patient engagement and needs assessment
through their knowledge and understanding of local people's needs.
We propose that consortia should have the power, where they consider
it appropriate, to award grant funding as a way of supporting
the sector to be able to contribute.
To help build the Big Society, Commissioning
consortia and local government could consider the role of grant
funding to charities and voluntary organisations to stimulate
community involvement and social action in improving health and
care. An example of this would be stimulating volunteering activity
supporting people with long term conditions.
As part of the reforms, we aim to free up provision
of healthcare, so that in most sectors of care, any willing provider
can provide services that meet NHS standards within NHS prices,
giving patients greater choice and ensuring effective competition
stimulates innovation, improves quality and increases productivity.
We will look across government and public procurement to make
sure that charities, voluntary organisations and social enterprises
have maximum opportunities to offer health and care services.
We are committed to promoting continuous improvement
in the quality of services for patients and greater opportunities
for involvement of independent and voluntary providers in offering
more responsive and personalised services.
ACCOUNTABILITY FOR
COMMISSIONING DECISIONS
How will patients make their voice heard or their
choice effective?
Patients, and in particular people with long
term conditions, want to make a difference to the way that services
are designed and delivered so that they meet their needs. Evidence
shows that good engagement unlocks investment as it enables the
public to understand the need for and benefits of changes to the
service and to contribute to service development to ensure proposals
best meet the needs of patients.
One of the principal aims of our proposals for
GP commissioning is to make decisions more sensitive and responsive
to the needs and wishes of patients and the public. GP practices
are ideally placed to do this. With 300 million consultations
a year in general practice, GPs and other primary care clinicians
are best placed to understand the needs of their patients. Under
our proposals, both Commissioning consortia and the NHS Commissioning
Board would need to develop effective ways of harnessing the public
voice so that commissioning decisions are increasingly shaped
by people's expressed needs and wants.
The NHS Commissioning Board would champion effective
patient and public involvement and engagement in commissioning
decisions, and greater involvement of patients and carers in decision-making
and managing their own care. It will also develop the guarantees
for patients about the choices they make and promote and extend
information to support meaningful choice of what care and treatment
patients receive, where it is provided and who provides it. The
Board will also commission information requirements for choice
and for accountability, including patient-reported experience
and outcome measures.
We will strengthen the collective voice of patients,
bringing forward provisions in the forthcoming Health Bill to
create HealthWatch England, a new independent consumer champion
within the Care Quality Commission. Local Involvement Networks
(LINks) would become the local HeatlhWatch, creating a strong
local infrastructure, and we will enhance the role of local authorities
in promoting choice and complaints advocacy, through the HealthWatch
arrangements they commission.
The wider public voice will be heard through
our proposals to achieve greater local legitimacy in the health
service. Local authorities would lead on developing joint strategic
needs assessments with relevant commissioners including consortia
and on health improvement. The intention is that this provides
a strong framework through which local people can shape the priorities
and commissioning activity in their neighbourhoods. In addition,
local authorities would be able to escalate proposals for substantial
service developments or changes to the NHS Commissioning Board
and to the Secretary of State, where the local authority believes
that such changes run contrary to the interests of local people.
A representative of Local HealthWatch would
have a seat on the health and wellbeing boards proposed in the
Local Democratic Legitimacy consultation, which would give
it—and by extension patients—a powerful voice to scrutinise
and influence strategic decisions across the local health and
care system.
Professionals understand patients' health needs
but only local people understand their local community and their
everyday needs. Both sets of knowledge are essential for planning
and delivering outcomes that matter to patients.
What will be the role of the NHS Commissioning
Board?
The NHS Commissioning Board as an independent
statutory body will provide overall leadership on commissioning.
It would be accountable to the Secretary of State for managing
the overall commissioning revenue limit and for delivering improvements
against a number of health outcomes. We propose five broad functions
of the NHS Commissioning Board, which are:
— providing national leadership on commissioning
for quality improvement;
— promoting and extending public and patient
involvement and choice;
— ensuring the development and authorisation
of consortia and holding them to account;
— commissioning certain services that are
not commissioned by consortia, such as primary care services;
and
— allocating and accounting for NHS resources.
The role of the new NHS Commissioning Board
would provide strengthened leadership and oversight of commissioning.
What legal framework will be required to underpin
commissioning consortia?
Commissioning consortia would be statutory bodies
with powers and responsibilities set out through primary and secondary
legislation.
This legislation would include a consortium's
duties in relationship to financial management, including ensuring
that expenditure does not exceed its allocated resources and requirements
in relation to reporting, audit and accounts.
How will commissioning interface with the Public
Health Service?
The programme for public health will be set
out in a White Paper later this year. However, subject to Parliamentary
approval, the forthcoming Health Bill will enable the creation
of a new Public Health Service (PHS), to integrate and streamline
existing health improvement and protection bodies and functions,
including an increased emphasis on research, analysis and evaluation.
We envisage that where the PHS needs to commission public health
interventions from healthcare providers, including General Practice,
it would be able to do so either by commissioning services itself
or by asking the NHS Commissioning Board to do so on its behalf.
The Secretary of State, through the Public Health
Service, would set local authorities national objectives for improving
population health outcomes. It would be for local authorities
to determine how best to secure those objectives, including by
commissioning services from providers of NHS care. They would
have a ring-fenced health improvement budget, allocated by the
PHS, and they would be able to deploy these resources to deliver
national and local priorities. There would be direct accountability
to the local authority and (through the PHS) to the Secretary
of State.
In order to manage public health emergencies,
the Public Health Service would have powers in relation to the
NHS matched by corresponding duties for NHS resilience. The NHS
Commissioning Board would have a role in supporting the Secretary
of State and the Public Health Service to ensure that the NHS
in England is resilient and able to be mobilised during any emergency
it faces, or as part of a national response to threats external
to the NHS. The NHS Commissioning Board would promote involvement
in research and the use of research evidence.
How will commissioning interface with HealthWatch?
We will strengthen the collective voice of patients
and the public through arrangements led by local authorities,
and at national level, through a powerful new consumer champion,
HealthWatch England, located in the Care Quality Commission.
The NHS Commissioning Board would take the lead
in extending public and patient involvement and choice in the
NHS by championing effective patient and public involvement and
engagement in commissioning decisions, and greater involvement
of patients and carers in decision-making and managing their own
care, working with consortia, local authorities, patient groups
and HealthWatch.
Subject to the consultation, local HealthWatch
would be represented on the proposed health and wellbeing boards,
which would help ensure that the views and feedback from patients
and carers inform local commissioning across health and social
care.
Where will the "buck stop" when commissioners
face hard choices?
Determining the comprehensive service which
the NHS provides will remain the responsibility of the Secretary
of State. In addition, the Secretary of State would hold the NHS
Commissioning Board to account for delivering improvements in
outcomes, strengthening patient choice and patient involvement,
and maintaining financial control.
The NHS Commissioning Board would be responsible
for holding consortia to account for their stewardship of NHS
resources and for the outcomes they achieve as commissioners.
Where commissioners fail to fulfil their statutory functions,
the NHS Commissioning Board would have powers to intervene and,
if necessary, to take over a consortium's commissioning responsibilities.
Local authorities and Commissioning consortia
would work together to take decisions in the best interests of
local people, and support joint commissioning arrangements where
they have the potential to deliver improvements in patient care.
Where disputes over commissioning priorities arise, the test of
the new arrangements would be the ability of the local authority
or the proposed Health and Wellbeing Board to resolve them locally.
We have specifically asked for views through the current consultation
on what support commissioners and local authorities might need
to empower them to do this. In a small minority of exceptional
cases, where a consortium proposes a major service development
or major service change in a local authority area and a dispute
cannot be resolved locally, we propose that local authorities
would have the right to refer to the NHS Commissioning Board to
seek resolution. If local authorities continue to have concerns
after all other resolution routes have been exhausted, we are
considering whether they would have the option to refer cases
to the Secretary of State (who may ask the Independent Reconfiguration
Panel for advice if a substantial service change is proposed).
Ultimately, the consortia would be accountable
to their patients for the decisions they take as commissioners.
Our plans to allow patients to choose a GP practice will give
the public the freedom to change their commissioner.
INTEGRATION OF
HEALTH AND
SOCIAL CARE
How will any new structures promote the integration
of health and social care?
There are a number of routes through which the
integration of health and social care would be promoted:
First, local authorities would have a crucial
oversight role in relation to health services. Local authorities
would be able to exercise influence over NHS commissioning decisions
through promoting joint commissioning. This would enable them
to seek to ensure that such decisions are aligned with social
care commissioning decisions. Local authorities would lead the
statutory joint strategic needs assessment, which will inform
the commissioning of health and care services and promote integration
and partnership across areas, including through joined up commissioning
plans across the NHS, social care and public health. They would
support joint commissioning and pooled budget arrangements and
will undertake a scrutiny role in relation to major service redesign.
One option for doing this is through the creation of statutory
health and wellbeing boards within local authorities, which would
bring together elected representatives, NHS commissioners (including
Commissioning consortia), social care and public health to assess
the health and well-being needs of local people and ensure that
they are being met.
Second, we propose to ring-fence public health
monies and allocate them to local authorities. This will help
deliver truly integrated preventative health and social care services—for
example, in relation to falls, early years' services and safeguarding
of children and vulnerable adults.
Third, we are driving forward with our proposals
to create personal budgets by combining both health and social
care revenue streams—giving individuals themselves the opportunity
to drive integration of services according to their needs.
In addition to commissioning arrangements, we
are also examining financial incentives to deliver better integration.
As a first step, we are making the NHS pay for the first 30 days
of care after a patient is discharged from 2011-12—at a
point when a patient is often in need of integrated health and
social care services.
What arrangements are proposed for shared health
and social care budgets?
The enhanced role for local government would
provide a framework through which Commissioning consortia alongside
other partners contribute to a joint assessment of the health
and care needs of local people and neighbourhoods and ensure that
their commissioning plans, and relevant joint commissioning plans,
reflect the health needs identified in these assessments. It would
also help identify ways of achieving more integrated delivery
of health and adult social care, for instance through pooled budgets
or lead commissioning arrangements (eg a local authority becoming
the lead commissioner for some older people's services).
There are a number of flexibilities in the NHS
Act 2006 that are designed to encourage integrated working. These
include for example Section 75 regulations which enable local
authorities and NHS Bodies to pool budgets and Section 77 which
enables specified NHS bodies to apply to become a Care Trust.
Subject to the views put forward in response to the White Paper
consultations including Local democratic legitimacy in health,
we believe that it is important to ensure that current legal flexibilities
that enable integrated working are applied in most localities
in ways that meet requirements and deliver health and care outcomes
effectively.
WHAT WILL
BE THE
ROLE OF
LOCAL AUTHORITIES
IN PUBLIC
HEALTH AND
COMMISSIONING DECISIONS?
The local authority will lead the process of
undertaking joint strategic needs assessments (JSNA) across health
and local government services and would support joint commissioning
between consortia and local authorities. Consortia and the NHS
Commissioning Board would be responsible for making healthcare
commissioning decisions, informed by the local commissioning strategies
that reflect JSNAs.
Health and wellbeing boards would have a key
new role in promoting joint working, with the aim of making commissioning
plans across the NHS, public health and social care coherent,
responsive and integrated. In future, local authorities would
have a stronger influence on the health outcomes of their local
area. When, under our proposals, PCTs cease to exist, we intend
to transfer responsibility and funding for local health improvement
activity to local authorities. Embedding leadership for local
health improvement activity within local authorities would build
upon the existing success of the many joint Director of Public
Health appointments between local authorities and PCTs. Directors
of Public Health might commission local health providers, including
GP practices, to provide local health improvement initiatives,
such as tailored advice and support services.
The Department will create a ring-fenced public
health budget and, within this, local Directors of Public Health
would be responsible for health improvement funds allocated according
to relative population health need. The detail of how these budgets
would operate and how they would be allocated are still in development
but the allocation formula would include a new "Health Premium"
designed to promote action to improve population-wide health and
reduce health inequalities.
HOW WILL
THE NEW
ARRANGEMENTS STRENGTHEN
COMMISSIONERS AGAINST
PROVIDER INTERESTS?
Implementation of the new commissioning proposals
set out within the White Paper would be driven bottom up, with
Commissioning consortia working with PCTs to ensure a smooth transition
(although PCTs would until their abolition remain legally responsible
for commissioning).
Consortia would be free within the new legislative
framework to develop collaborative or pan-consortia arrangements
which may help balance dominant providers in their negotiations.
In addition, anti-competitive behaviour by providers would be
subject to the Competition Act under which Monitor will be given
concurrent powers of enforcement.
Consortia would commission the great majority
of NHS services on behalf of patients, including elective hospital
care and rehabilitative care, urgent and emergency care, most
community health services, and mental health and learning disability
services.
The NHS would be focused on outcomes and the
NICE Quality Standards that define their delivery, with commissioners
using guidance drawn from the library. Commissioning consortia
and providers would agree local priorities for implementation
each year, taking account of the NHS Outcomes Framework. NICE
Quality Standards will be reflected in commissioning contracts
and financial incentives.
Together with essential regulatory standards,
these proposals will provide the national consistency that patients
expect from the NHS. Providers will be paid according to their
performance with payment reflecting outcomes, not just activity,
and providing an incentive for better quality. In addition, if
in future, providers deliver poor quality care, the commissioner
will also be able to impose a contractual penalty.
The absence of an effective payment system in
many parts of the NHS severely restricts the ability of commissioners
and providers to improve outcomes, increase efficiency and increase
patient choice. In future, the structure of payment systems would
be the responsibility of the NHS Commissioning Board, and the
economic regulator would be responsible for pricing. In the meantime
the Department will start designing and implementing a more comprehensive,
transparent and sustainable structure of payment for performance
so that money follows the patient and reflects quality.
We propose to accelerate the pace of development
of payment by results, starting in 2011-12 by mandating currencies
for use in contracting for adult and neonatal critical care and
introducing some new currencies for services such as smoking cessation
and cystic fibrosis. Good progress is being made towards mandating
currencies for adult mental health services in 2012-13, and in
developing currencies for child and adolescent services and payment
systems to support the commissioning of talking therapies. From
next year we will begin prioritising efforts to expand currencies
and tariffs into community services.
At the same time, we are making the current
payment system more effective at supporting high-quality, integrated
and efficient care. We will rapidly accelerate the development
of best practice tariffs, introducing an increasing number each
year, so that providers are paid according to the costs of excellent
care, rather than average price. In 2011-12 there will be best
practice tariffs for adult renal dialysis, some day case surgical
procedures, interventional radiology, mini-strokes and primary
hip and knee replacements. We are looking to develop currencies
and tariffs that support the entire patient pathway, beginning
in 2011-12 with a currency for cystic fibrosis based on a complexity-adjusted
year of care model, an approach that could be extended to other
areas such as multiple sclerosis. Maternity is a good example
of where we can make further progress. We are developing a small
number of simple and practical pathway tariffs for maternity care,
covering the whole period from the booking-in clinic through to
postnatal care, and we hope to implement these for payment from
2012-13.
From 2011-12, changes to the tariff will mean
that providers will have a greater incentive to discharge patients
at the right time, and with adequate support, so that numbers
of inappropriate readmissions—which have increased by over
50% in the last 10 years—are reduced. Other changes to the
tariff in 2011-12 will drive efficiency, including some benchmark
prices set below the average of reported costs, and better targeting
of payments for relatively long stays in hospital.
How will vulnerable groups of patients be provided
for under this system?
Under our proposals there are multiple arrangements
for protecting and improving quality of care for vulnerable patients:
— appropriate safeguarding responsibilities
will be conferred on commissioners;
— all providers of regulated health and
adult social care activities will have to be registered with the
Care Quality Commission and, under the new registration system
that CQC is introducing, meet the 16 essential requirements of
safety and quality;
— local authorities would take the lead
on promoting partnership working and integrated delivery of public
services across the NHS, social care, public health and other
services. It is intended that this enhanced role for local government
would provide a framework through which Commissioning consortia
alongside other partners, can play a systematic and effective
part in joint action to promote the health and wellbeing of local
communities, including combined action on safeguarding of children
and vulnerable adults;
— HealthWatch at both local and national
levels would have a role in ensuring services are not failing
vulnerable groups. At the national level, HealthWatch would have
a powerful new role to suggest areas for investigation by the
Care Quality Commission;
— the proposed NHS Outcomes Framework would
recognise the importance of reducing inequalities and promoting
equality. As far as possible, outcomes would also be chosen so
that they can be measured by different equalities characteristics.
This would be reflected in the Commissioning Outcomes Framework
which would include measures to reflect the consortium's duties
to promote equality and to assess progress in reducing health
inequalities;
— in order to ensure that consortia are
rewarded and incentivised for improving care for all population
groups, including those who are most vulnerable and for whom outcomes
may be more difficult to achieve, the commissioning outcomes framework
would include an appropriate adjustment for case-mix; and
— as NICE Quality Standards will underpin
the outcomes in the NHS Outcomes Framework we would also propose
that they should inform the development of the Commissioning Outcomes
Framework. This will promote greater sensitivity in commissioning
services for all patient groups.
HOW WILL
THE PROPOSED
SYSTEM FACILITATE
SERVICE RECONFIGURATION?
It is vital that the NHS continues to modernise
and improve, but this must go hand-in-hand with an NHS where improvements
are driven by local clinicians, patients and their representatives
from the ground up. The Government believes that the best decisions
are local decisions. We have been clear that service reconfigurations
that do not have the support of GP practices and other local clinicians
working with patients and communities should not happen.
With that aim in mind, the Secretary of State
has introduced four key criteria for service change, which are
designed to build confidence within the service, with patients
and communities. These criteria were set out in the Revisions
to the NHS Operating Framework for 2010-11 and require existing
and future reconfiguration proposals to demonstrate:
— support from GP commissioners;
— strengthened public and patient engagement;
- clarity on the clinical evidence base; and
— consistency with current and prospective
patient choice.
These criteria and the reforms proposed in Liberating
the NHS provide a significant opportunity for GPs and other clinicians,
local authorities and the public to have a greater role in how
services are shaped, and to ensure that any changes to services
lead to the best outcomes for patients. Future service change
will be rightly spearheaded by GP practices, through Commissioning
consortia and in consultation with local authorities, as it is
they who are closest to patients, know the healthcare that they
need, and know how patients can best access it. Under our proposals
to empower local clinicians to decide how best to achieve the
right outcomes for local people, and by enhancing the role of
local councils to shape health and care services, this Government
will ensure that patients and the public are provided with the
very best NHS services now and in the future.
The proposed health and wellbeing boards would
provide a powerful forum for planning service reconfiguration
to achieve greater integration between Social Care and Public
Health systems and the NHS.
TRANSITIONAL ARRANGEMENTS
Will the new arrangements safeguard current examples
of good practice?
Commissioning for patients provides further
information on the intended arrangements for GP commissioning
and the NHS Commissioning Board's role in supporting consortia
and holding them to account. It seeks views on a number of specific
consultation questions and includes an invitation to bring forward
examples of existing practice and evidence that support respondents'
views in order that we can learn from current examples of best
practice. Consortia would, in the future, be free to seek commissioning
expertise from a range of partners, whether they be independent
or voluntary sector organisations, local authorities, or from
those with whom GP practices already work closely in Primary Care
Trusts. Where there are current examples of good practice, consortia
would be free to continue these arrangements, and to build upon
them.
Who will drive innovation during the transitional
period?
The current position is that Strategic Health
Authorities have a legal duty to promote innovation. This will
continue to be the case during the transitional period and for
the duration of their formal constitution.
Our proposals for GP Commissioning build on
years of involvement of GPs in commissioning. The previous administration
introduced practice based commissioning (PBC) over five years
ago, and some PBC consortia are doing an excellent job. But many
PBC consortia have been frustrated by not having clear responsibility
and control and by the failure to transfer real freedom and responsibility
to PBC consortia. We are now learning from the past, and propose
to offer a clear way forward for GP practices and Commissioning
consortia.
Practice-based commissioners will have a significant
part to play in continuing to drive innovation, service change
and delivery of high quality services during the proposed transition
to GP commissioning.
How will transitional costs (redundancy etc) be
minimized?
We are extremely conscious of the need to minimise
the costs of transition to the new system, and we are actively
looking at the ways to reduce these costs. As part of the transition
towards the new commissioning bodies, work will be carried out
to identify which PCT functions transfer where and which come
to an end. We will not be able to confirm the approach we are
taking until the consultation is completed and we know how the
new organisations will be designed.
However, we have already committed to reducing
management costs by over 45%. We will ensure that the changes
outlined in the White Paper—including abolishing PCTs and
SHAs—will enable us to achieve or exceed this objective.
We need to strike a balance between saving money
by reducing the costs of bureaucracy, and ensuring we retain essential
talent and capability through the transition to the new system
and make it work for patients.
RESOURCE ALLOCATION
How will resources be allocated between commissioners?
Currently, the Department of Health makes revenue
allocations directly to PCTs, targeted using a weighted capitation
formula. The weighted capitation formula is overseen by the independent
Advisory Committee on Resource Allocation. Pace of change policy—which
determines how quickly PCTs' actual funding moves towards the
target allocation derived from the weighted capitation formula—is
determined by Ministers. The revenue allocations to be announced
later this year will be made on this basis.
Our proposed changes to the current allocation
of resources are set out in Liberating the NHS. The majority of
the PCT commissioning function would be transferred to Commissioning
consortia; some would be undertaken by a new independent NHS Commissioning
Board, an organisation free from day-to-day political interference,
which would take over responsibility for commissioning guidelines
and the allocation of resources from the Department of Health;
and some would be undertaken by Directors of Public Health in
local authorities, working with a new ring-fenced local health
improvement budget.
It is proposed that shadow allocations for 2012-13
will be published for Commissioning consortia in late 2011, and
actual allocations for 2013-14 in late 2012. These would be made
on the basis of seeking to secure equivalent access to NHS services,
in all areas, relative to the prospective burden of disease and
disability. By 2013-14, Commissioning consortia would be responsible
for managing the combined commissioning budgets of their member
GP practices, and using these resources to commission the best
and most cost-efficient outcomes for patients.
Allocations to Directors of Public Health in
local authorities would be published on the same timescales as
for allocations to Commissioning consortia. The allocation formula
for these funds would include a new "health premium"
to target public health resources towards those areas with the
poorest health to reduce avoidable ill health and health inequality.
Local communities will be rewarded for success, to energise efforts
to improve public health and reduce health inequalities.
Commissioning primary care services (such as
GP services, dentistry, community pharmacy and primary ophthalmic
services) would be the responsibility of the NHS Commissioning
Board, as will national and regional specialised services and
maternity services.
During the transition, ACRA will continue to
provide independent advice to the Secretary of State on the funding
formula for the allocation of NHS resources. We will seek, in
making allocations in 2011-12, to reflect similar principles to
the future statutory basis.
Further details about the future allocations
process and the distribution of resources will be announced in
due course.
What arrangements are proposed for risk sharing
between commissioners?
Analysis is being undertaken to help develop
an understanding of the levels of risk that would be incurred
by commissioners. This will inform the arrangements that are put
in place to help Commissioning consortia ensure they have appropriate
levels of risk and suitable measures to deal with these risks.
What arrangements will be made to safeguard patient
care if a commissioner gets into difficulty?
The NHS Commissioning Board would be responsible
for ensuring consortia are accountable for the outcomes they achieve,
their stewardship of public resources, and their fulfilment of
the duties placed upon them. The NHS Commissioning Board would
have powers to intervene in the event, for example, that a consortium
is failing to fulfil its duties effectively or where there is
a significant risk of failure. For example, it is proposed that
the Board could require remedial action or in the last resort,
take over the consortium's commissioning responsibilities or assign
them to another consortium. The local authority would be able
to raise concerns on prescribed matters to the NHS Commissioning
Board
SPECIALISED SERVICES
What arrangements are proposed for commissioning
of specialised services?
The White Paper proposes that the NHS Commissioning
Board will commission certain services such as national specialised
services and regional specialised services as set out in the Specialised
Services National Definitions Set for a planning population of
over one million. Liberating the NHS: Commissioning for patients
specifically asks consultees to consider whether there are any
services currently commissioned as regional specialised services
that could potentially be commissioned in the future by Commissioning
consortia.
How will these arrangements interface with the
rest of the system?
We are consulting on specific questions raised
in Commissioning for Patients about the ways in which the
NHS Commissioning Board can effectively engage Commissioning consortia
in influencing the commissioning of national and regional specialised
services, how the Board and Commissioning consortia can best work
together to ensure effective commissioning of low volume services
and also what services that are currently commissioned as regional
specialised services could potentially be commissioned by Commissioning
consortia in the future. We will consider the comments received
as part of the working up of the detailed arrangements and the
interface with the rest of the system.
October 2010
1 http://www.cabinetoffice.gov.uk/media/409088/pfg_coalition.pdf Back
2
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353 Back
3
http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_117586 Back
4
http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_117587 Back
5
http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_117586 Back
6
http://programmeforgovernment.hmg.gov.uk/ Back
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