Written evidence from the Department of
Health (CFI 01)
EXECUTIVE SUMMARY
1. On 25 January 2011 the House of Commons
Health Committee announced a follow-up inquiry into commissioning,
taking as its terms of reference 10 points from its Third Report
of Session 2010-11, Commissioning.
2. On 31 January the Department published
a Command Paper response to the Committee's Third Report commenting
in detail on each of the Committee's recommendations, including
those which form the terms of reference for the follow-up inquiry.
3. This evidence provides further information
on the Committee's topics. It should be read in conjunction with
the Department's response to the Committee's Third Report, as
it builds on our earlier response to these points.
4. As the Health and Social Care Bill was
introduced after the Committee published its Third Session Report,
this submission of evidence provides a suitable opportunity for
the Department to demonstrate how the Bill provides a coherent
framework across the NHS and social care for a new approach to
commissioning that will focus on empowering patients, carers and
the public; on achieving better outcomes; and on promoting greater
freedom for clinicians to work collaboratively to shape services.
INTRODUCTION
5. The House of Commons Health Committee's
Third Report of Session 2010-11, Commissioning, summarised
their inquiry as "How do we make commissioning effective?"
In articulating our proposals, we have always identified effective
commissioning as one of the cornerstones for improving the quality
of patient care and the outcomes achieved by the NHS. We have
also been clear that commissioning needs to be clinically led,
that it needs to be more directly connected to patients' and clinicians'
day-to-day experiences of the NHS, and that responsibility for
commissioning needs to be aligned with existing responsibilities
for coordinating patient care and making patient referrals. It
is these principles that are at the heart of our proposals for
GP-led commissioning.
6. We would draw the Committee's attention
to the consistency with which this message has been given in the
successive statements of policy since the election, and how the
proposals have been developed by an ordered process of consultation,
engagement and discussion.
7. The Coalition: our programme for government
(May 2010)[1]
said that GPs should be commissioners of care. Equity and Excellence:
Liberating the NHS (July 2010)[2]
reaffirmed the Coalition Government's commitment to devolve responsibility
for commissioning most NHS services to groups of GP practices.
As our response to the Committee's Third Report emphasised, rather
than representing a "significant policy shift" or "change
of approach", the White Paper proposals were foreshadowed
in principle by both the Conservative and Liberal Democrat health
manifestos, and represented a sensible development of the Coalition
programme.[3]
8. The consultation documents accompanying
the White Paper invited views from professionals, from the public
and from other organisations to help shape policy development.
Liberating the NHS: commissioning for patients (July 2010)[4]
sought views on the proposed framework for GP consortia and the
NHS Commissioning Board. Transparency in outcomes: a framework
for the NHS (July 2010)[5]
proposed a robust framework of transparency and accountability
for the NHS, including an NHS Outcomes Framework to allow the
NHS Commissioning Board to be held to account for improvements
in the quality of NHS care and healthcare outcomes. Liberating
the NHS: local democratic legitimacy in health (July 2010)[6]
sought views on proposals for patients and local communities to
get a powerful voice through local HealthWatch and local Health
and Well-being boards. Local authorities will have a major new
role in promoting joined-up commissioning of NHS, public health
and social care and they will also regain responsibility for local
health improvement.
9. We have maintained the consistency of
purpose articulated in the White Paper. Our proposals constitute
a credible programme of modernisation, developed through extensive
engagement with the public and with stakeholders across health
and social care. The Government's response to the consultations
- Liberating the NHS: legislative framework and next steps
- set out how we were adapting some aspects of these proposals
to reflect the views raised during the consultation and engagement
process, including the announcement of the GP consortia pathfinder
programme to allow early testing of the principles of GP-led commissioning.[7]
10. This process of planning and public engagement
culminated in the introduction to Parliament on 19 January of
the Health and Social Care Bill 2011,[8]
which sets out the proposed legislative framework for the White
Paper reforms including the establishment of commissioning consortia
and the NHS Commissioning Board. On 31 January, the Commons agreed
that the Bill should proceed to Second Reading, and it is currently
under the scrutiny of the Health and Social Care Public Bill Committee.
11. While the Bill is subject to Parliamentary
scrutiny, the process of engagement and testing continues, in
particular through the GP consortia pathfinder programme which
now encompasses 141 pathfinders covering over half the population.
The first cohort of pathfinders came together at a national event
on 26 January to help shape the pathfinder programme and discuss
how best to use the programme to support effective consortia development.
12. The Department launched a pathfinder learning
network at the 26 January event. This is an online resource that
will complement the support given to pathfinders by primary care
trusts (PCTs) and strategic health authorities (SHAs). It will
help spread pathfinder learning through the wider GP community
and accelerate the development of GP commissioning by facilitating
engagement and organisational development. It will also help design
and test the approaches that the NHS Commissioning Board will
use to authorise consortia and hold them to account for outcomes.
This network will be supported by national primary care stakeholders
to help spread learning across the wider GP community, facilitate
connections between pathfinders working on similar areas, and
support the development of clinical leaders. The network is supporting
a systematic approach to maximise and share learning, with—for
instance—specific pathfinders working on areas such as cancer
services, long term conditions, mental health and involving patients
and the public.
13. In order to support a managed transition
to the new commissioning arrangements, the Department is establishing
clusters of PCTs for the transitional period 2011-12 and 2012-13.
Clusters will sustain PCT capacity and accountability during this
transitional period, ensure continued pace in the delivery of
quality and productivity improvements under the QIPP programme,
support the development of GP consortia and ensure that consortia
have access to high-quality and cost-efficient forms of commissioning
support.
14. On 31 January, Sir David Nicholson wrote
to the NHS with guidance on establishing PCT clusters by June
2011 and on their functions during 2011-12 and 2012-13.[9]
Each SHA has been asked to ensure that by the beginning of June
2011 sensible clusters of PCTs exist, each with a single Chief
Executive, with responsibility for the development of the commissioning
functions across the whole cluster, supported by a single executive
team.
15. The cluster model will support pathfinders
in taking on increasing commissioning responsibilities on behalf
of PCTs during the transitional period, with a number of staff
from the clusters assigned to consortia to work on their behalf.
This will support emerging consortia in developing to the point
where they are ready to be established as statutory organisations
and to commission services in their own right. It will also ensure
that emerging consortia play a central role in shaping local responses
to the QIPP challenge and in ensuring that these plans reflect
the needs of local patients and communities.
COMMISSIONING
16. Each point raised by the Committee is given
below in italics, numbered 1-10; the reference in brackets is
to the relevant paragraph in the Third Report of Session 2010-11,
Volume I: Report, together with formal minutes.
1. We intend to examine further the assurance
regime which it is proposed to establish around commissioning
consortia in order to satisfy ourselves that the NHS Commissioning
Board has sufficient authority to deliver its objectives defined
in its Commissioning Outcomes Framework. (Paragraph 89)
17. The Health and Social Care Bill 2011 creates
a clear framework that will enable the Board to deliver its objectives
(as reflected in its Mandate and the NHS Outcomes Framework) through
the initial process of authorising consortia, through the subsequent
framework for annual assessment of consortia (including the Commissioning
Outcomes Framework) and through a range of powers to intervene
to support consortia in defined circumstances.
AUTHORISATION
18. The Board must, before granting an application
for establishment as a consortium, satisfy itself as to a number
of key tests, including the ability of the proposed consortium
to discharge its statutory functions. This will mean satisfying
itself that the consortium has appropriate arrangements in place
to commission healthcare for those patients for whom it is responsible,
including appropriate arrangements for managing financial resources,
promoting quality improvement, involving patients and the public,
working in partnership with local government, and securing expert
advice from other health professionals.
19. The Board will also need to satisfy itself
that the area specified in the constitution of the consortium
is appropriate (eg for the purposes of commissioning emergency
care and commissioning healthcare for patients not registered
with any GP practice); that its constitution complies with the
requirements of the legislation and is otherwise appropriate;
that it has the right membership (eg each of its members will
be providers of primary medical services on the date of establishment);
and that it would be appropriate for the Board to appoint as the
accountable officer the person nominated for this role by the
consortium.
ONGOING ACCOUNTABILITY
20. During 2011-12, the shadow NHS Commissioning
Board, supported by NICE, will start to develop a Commissioning
Outcomes Framework. This will enable the Board to hold consortia
to account for the quality of the services that they commission,
the clinical and patient experience outcomes achieved from those
services, and their contribution to reducing health inequalities.
The Framework will ensure that there is clear, publicly available
information on the quality of healthcare services commissioned
by consortia and will support Health and Well-being Boards in
understanding local healthcare needs and shaping strategic priorities
for improvements in health and well-being. The Department will
publish a discussion document shortly, seeking more detailed views
on possible features of the Framework.
21. The Commissioning Outcomes Framework will
form part of a wider accountability framework that will also enable
the Board to hold consortia to account for how effectively they
perform their other statutory duties of consortia, including their
duties relating to management of financial resources, involvement
of patients and the public in commissioning, promoting patient
and carer involvement in their own healthcare, partnership with
local authorities and securing expert advice from other health
professionals. There is likely to be an important role for local
authorities, Health and Well-being Boards, local HealthWatch and
other health and care professionals in feeding into this annual
assessment.
22. A significant element of the Board's oversight
of consortia performance will be to ensure their financial stability.
Consortia will be required to maintain annually audited accounts,
and to provide financial and other data to the Board as required,
to allow in-year monitoring against budgetary controls. The Board
will have the power to support consortia in developing appropriate
risk-sharing arrangements, for instance pooling resources with
other consortia or local authorities or with the Board itself.
23. Each consortium will have to produce an annual
commissioning plan, which sets out how it intends to fulfil its
responsibilities to its patients, particularly in regard to improving
quality and outcomes and discharging its financial duties. The
plan must take account of the relevant local joint health and
well-being strategy (or strategies). Each consortium will also
produce an annual report, which will further support accountability.
24. The Bill gives the Board the power to make
an additional payment to a consortium if it considers the consortium
has performed well in the previous year. This "quality premium"
will enable the Board to provide appropriate incentives and rewards
for consortia that achieve high-quality outcomes for patients
within the resources available to them. During 2011-12, the shadow
NHS Commissioning Board will start to work with pathfinders and
with patient and professional groups to design these arrangements.
INTERVENTION AND
SUPPORT
25. The Bill gives the Board the powers to intervene
to support consortia where there is evidence that a consortium
is failing to fulfil its statutory duties or there is a significant
risk that it will fail to do so. The Bill will enable the Board
to apply a range of proportionate measures to intervene and support
consortia, depending on the nature of the problem or risk. Depending
on the circumstances, this could include directing a consortium
to fulfil its functions in a different way, arranging for another
consortium or the Board itself to undertake some functions for
a time-limited period, or appointing a new Accountable Officer.
Where necessary, the Board will also be able to vary the constitution
of a consortium, or—after consultation with those concerned
and with relevant local authorities—to dissolve a consortium
and make other arrangements for the GP practices in that consortium.
26. The pathfinder programme will enable the
Board to test these arrangements with emerging consortia and with
other stakeholders to ensure that they provide an effective framework
to anticipate and put right potential problems at a sufficiently
early stage, whilst providing the freedom for well-performing
consortia to decide for themselves how best to commission services
to improve outcomes for patients.
2. We intend to review the arrangements proposed
in the Bill for defining the lines of accountability between the
NHS Commissioning Board, the Department of Health and the Secretary
of State to prevent potential future conflicts arising. (Paragraph
91)
27. The Secretary of State will retain the duty
to promote a comprehensive health service; and will be responsible
for setting the strategic direction and legislative framework
for the NHS. The Secretary of State will consult upon and set
the Mandate for the NHS Commissioning Board (issued on a three-year
basis with an annual update) and will hold the Board to account
against it. The Mandate will include the objectives and requirements
for the Board during that period. Each year the Government will
report publicly on the performance of the health service. This
will give the public and Parliament a clear basis for holding
the Government to account. In addition, Parliament will continue
to be able to scrutinise decisions and actions in the normal way.
28. The Bill maintains the overarching duty of
the Secretary of State, which dates from the original NHS Act
of 1946, to promote, "a comprehensive health service designed
to secure improvement in the physical and mental health of the
people of England, and in the prevention, diagnosis and treatment
of illness". It distinguishes for the first time between
healthcare and public health, laying the way for the new public
health system. It also sets clear constraints on the Secretary
of State's ability to intervene in the NHS.
29. Alongside the Mandate, the Bill proposes
a power for the Secretary of State to make "standing rules"
through regulations, setting legal requirements for commissioners.
These would, for example, provide the basis for the continuation
of certain rights in the NHS Constitution that currently depend
on directions to PCTs and would also give Ministers power to ensure
compliance with European Union (EU) obligations.
30. The Bill proposes a limited list of areas
where standing rules can be made. Balancing the need for future
flexibility with proper Parliamentary scrutiny, the Secretary
of State would be able to make new standing rules in additional
areas only through regulations made by the affirmative resolution
procedure. Furthermore, the expectation is that the Secretary
of State would make changes to the standing rules only at the
same time as the Mandate is set; where that is not the case, the
Secretary of State would be obliged to lay a report in Parliament
explaining why.
31. The overall framework proposed in the Bill
is designed to give the NHS greater freedoms, improve transparency
and help prevent political micro-management. The powers of the
Secretary of State would be constrained and made more transparent.
At the same time, political accountability to Parliament would
be strengthened. This is illustrated by the use of the affirmative
resolution procedure to scrutinise the Secretary of State's powers
in a number of areas, including the power to confer additional
functions on the Board and to extend the existence of new Special
Health Authorities beyond three years.
3. The Committee believes it is essential
for clinical engagement in commissioning to draw from as wide
a pool of practitioners as is possible in order to ensure that
it delivers maximum benefits to patients. GPs have an essential
role to play as the catalyst of this process, and under the terms
of the Government's changes they, through the commissioning consortia,
will have the statutory responsibility for commissioning. They
should, however, be seen as generalists who draw on specialist
knowledge when required, not as the ultimate arbiters of all commissioning
decisions. The Committee therefore intends to review the arrangements
proposed for integrating the full range of clinical expertise
into the commissioning process. (Paragraph 96)
32. We agree that effective commissioning will
rely critically upon engagement and collaboration with a wide
range of health and care professionals. Our proposals to root
most healthcare commissioning responsibilities in the system of
general practice are designed to build on the holistic overview
that GPs and other practice staff have of patients' needs and
on the existing role of general practice in coordination and continuity
of care, making referrals to more specialist services, and acting
as patients' advocates. Through these existing roles, GPs, nurses
and other practice staff already have a network of local relationships
with other health and care teams and professionals. We agree that
it will be essential for them to build on and strengthen these
networks so that commissioning draws on their collective clinical
expertise and experience and improves clinical collaboration.
This will mean commissioning that is not only clinically led,
but also informed by an expert, multi-professional view of local
health needs and solutions.
33. One of the key aims of the White Paper and
the Bill is to liberate clinicians from the burdens which previous
governments have imposed on how services are planned and provided.
The Bill places a statutory duty on consortia to obtain appropriate
advice from health experts, but does not seek to prescribe precisely
how they meet this duty. We consider that a more prescriptive
approach would risk tokenism and would not achieve the meaningful
engagement and collaboration that will underpin successful commissioning.
34. The arrangements for authorisation, accountability
and (where necessary) intervention described above will, however,
enable the NHS Commissioning Board to satisfy itself that consortia
have appropriate arrangements in place to involve other healthcare
professionals and, if necessary, to work with consortia to support
them in improving these arrangements if there were evidence that
insufficient or ineffective clinical engagement were preventing
a consortium for fulfilling its duties effectively.
35. We envisage, in particular, that the authorisation
process—and the wider developmental process for emerging
consortia of which it will be part—will help ensure that
consortia develop effective relationships with a range of health
and care professionals. We also envisage that the ongoing accountability
framework for consortia will allow health and care professionals
to provide their own views of how effectively consortia are developing
multi-professional engagement and for this to feed into the Board's
annual assessment of consortia.
4. Although the Committee understands the
value of the separation of the commissioner and provider functions
it believes it is important that this function separation is not
allowed to obstruct the development of high quality and cost effective
service solutions. We therefore intend to review the arrangements
proposed in the Bill for reconciling these conflicts. (Paragraph
102)
36. We regard it as a false dichotomy to suggest
that the separation of commissioner and provider functions is
in conflict with the development of high quality and cost-effective
service solutions. The purpose of commissioning is to understand
patients' healthcare needs, to ensure that patients have access
to services that meet those needs, and to monitor the quality
of those services. It has always been—and will remain—an
integral part of good commissioning to work collaboratively with
providers to review services and pathways of care and identify
how to improve quality and cost-efficiency.
37. The Government fully supports the development
of more integrated care, for example for cancer services, emergency
care, and rehabilitation and recovery. Clinically-led commissioning
will support this. Commissioners will be able to "bundle"
services together across a pathway where this makes most sense.
38. There have been a number of suggestions that
collaborating with providers or developing more integrated care
would be regarded as anti-competitive. This is simply not the
case. Collaboration with providers and greater integration of
care are, on the contrary, good commissioning practice.
39. Where services are commissioned through competitive
tender, commissioners will need, as now, to ensure that services
are specified in a way that does not give an unfair advantage
to established providers. But, as now, commissioners will be expected
to work with a range of providers and practitioners to develop
innovative service models that contribute towards improvements
in quality and productivity. This expectation is set out in existing
DH procurement guidance. We expect it to remain central to the
guidance developed in due course by the NHS Commissioning Board
to support consortia in procuring services fairly and transparently
and in ways that promote competition in the interests of patients.
5. The Committee agrees that local engagement
with the commissioning of primary care services is important and
therefore welcomes this development. The potential conflict of
interest between consortia and local primary care providers does
however remain. We therefore intend to review the arrangements
proposed in the bill for the commissioning of primary care services.
(Paragraph 104)
40. We welcome the Committee's support for greater
local engagement in the commissioning of primary care services.
We can reassure the Committee that GP consortia will not, however,
have delegated responsibility for basic commissioning decisions
such as deciding which providers should receive contracts for
primary care services or dealing with any breaches of contract.
These commissioning decisions will always be carried out by the
NHS Commissioning Board.
41. The role of consortia will be to assist and
support the Board in securing continuous improvement in the quality
of primary care services. This will allow the Board to draw on
the relationships between GP practices within a consortium and
for the members of consortia to take a collaborative approach
to raising standards in primary care. There is a considerable
appetite amongst consortia pathfinders to explore how this relationship
will work, building on existing good practice in peer-driven quality
improvement.
42. The NHS Commissioning Board could also arrange
for consortia to commission some enhanced primary care services
on its behalf, subject to appropriate safeguards to ensure transparency
and fairness.
43. Whilst the NHS Commissioning Board will commission
primary medical care services (under the GP contract), there are
a range of other community-based services that consortia could
in principle commission from GP practices. We agree that it will
be important to ensure that consortia have good systems to prevent
conflicts of interest when practices are bidding to provide services,
or where they wish to provide services that are subject to an
"any willing provider" model (i.e. where patients choose
from which provider they wish to receive a referral service).
These arrangements can build on existing good practice.
44. Consortia will be required to set out their
arrangements for dealing with conflicts of interest in their constitution.
GPs are in addition bound by GMC guidelines on conflicts of interest
and by the requirements of Good Medical Practice.
45. The Bill provides that the Secretary of State
may make regulations that impose requirements on the NHS Commissioning
Board and consortia to ensure that they adhere to good procurement
practice, protect and promote patient choice and promote competition.
The regulations could include a power for Monitor to investigate
complaints that consortia have not met the requirements of these
regulations, although we would expect that the Board would aim
to resolve complaints in the first instance. GP consortia and
the NHS Commissioning Board will be required to act transparently
and non-discriminatorily in their commissioning activities.
46. The NHS Commissioning Board will develop
guidance to help consortia ensure that they have good governance
arrangements, including transparency of decision-making and clear
procedures for declaring interests.
47. Through a series of engagement events and
working groups with pathfinders and other stakeholders, we are
developing scenarios and testing safeguards to inform the approach
of the shadow NHS Commissioning Board and Monitor.
6. The commissioning of services that either
work across [health and social care] boundaries, or are intimately
linked is therefore an issue to which the Committee attaches great
importance, and we intend to review the effectiveness of the structures
proposed in the Bill which are designed to safeguard co-operative
arrangements which already exist and promote the development of
new ones. (Paragraph 107)
48. The Health and Social Care Bill provides
for a Health and Well-being Board to be established for every
upper tier local authority. We propose that these will be established
by April 2013, although we have invited all local authorities
to become part of an early implementer programme to explore the
potential of Health and Well-being Boards. The Boards will increase
the influence of local people in shaping services through democratically
elected councillors and local HealthWatch. They will bring together
commissioners from the NHS, public health and social care to agree
priorities and commissioning strategies and provide the opportunity
to achieve greater integration of services and joint working.
49. The proposed legislation governing Health
and Well-being Boards will provide a consistent, yet flexible
framework. We expect this to strengthen relationships between
the different organisations represented as people can come together
to discuss issues in an open manner, breaking down organisational
barriers, misconceptions and historical rivalries. They can consider
the total resources available and come to a joint understanding
as to how resources can best be deployed to secure better health
and well-being outcomes for local communities, better quality
of care and better value for taxpayers.
50. Building on this platform, local authorities
and GP consortia will have a duty to undertake and publish joint
strategic needs assessments (JSNAs). This duty will have to be
discharged through the Health and Well-being Boards. PCTs and
local authorities have been under a statutory duty to undertake
a JSNA since 2008. Liberating the NHS—Legislative Framework
and Next Steps; Healthy Lives, Healthy People and A
vision for adult social care: Capable Communities and Active
Citizens[10]
set out the Government's ambition for an enhanced role for JSNAs
that will sit at the heart of local action to improve the outcomes
from NHS, social care and public health services. The Bill further
strengthens this duty by requiring JSNAs to consider future, as
well as current, needs.
51. Having identified local needs through the
JSNA, local authorities and GP consortia will be required to develop
a joint health and well-being strategy for addressing these needs.
This will span the NHS, social care and public health, and could
potentially consider commissioning of services that cover wider
determinants of health such as housing or education.
52. Local authorities, GP consortia and the NHS
Commissioning Board will each have to have regard to this strategy
when developing their commissioning plans. Consortia will have
to seek the views of the relevant Health and Well-being Board(s)
when preparing their commissioning plan as to whether the plan
takes proper account of the most recent JSNA and joint health
and well-being strategy, and the Board's view must be included
in the plan. Health and Well-being Boards may also write to the
NHS Commissioning Board or the local authority if they feel that
commissioning plans do not adequately have regard to the JSNA
or the joint health and well-being strategy.
53. Both Health and Well-being Boards and the
NHS Commissioning Board will be under a duty to encourage integrated
working. In developing the joint health and well-being strategy
and in broader conversations, the Health and Well-being Board
must encourage commissioners to work in an integrated manner,
and in particular encourage commissioners to make use of the flexibilities
in the NHS Act 2006 where these are likely to lead to improvements.
For example, section 75 of the Act supports a range of partnership
arrangements, such as pooled budgets or lead commissioner arrangements.
54. To ensure existing arrangements are sustained
during transition, we are using the NHS Operating Framework to
ask all PCTs to work with their Local Authority partners to ensure
that a succession plan is in place for existing pooled budgets
and joint commissioning arrangements.
55. In order to support local government in taking
on its new roles, we will create a network of "early implementers"
of Health and Well-being Boards to share learning and feed this
into policy development. The emphasis of the work will be on working
across local government and partners to accelerate sharing of
learning and supporting the development of effective Health and
Well-being Boards that can bring together partners in local areas
to better serve their communities.
56. Many of the responses to the consultation
on Liberating the NHS underlined the importance of developing
Health and Well-being Boards—and local authority capacity
more generally—alongside the development of GP consortia.
The Department is working with local authorities and with SHAs
and PCT clusters to align the implementation approaches for Health
and Well-being Board early implementers and GP consortia pathfinders.
57. Our initial focus is on aligning communications
through shared websites, bulletins and learning materials for
GP consortia pathfinders and Health and Well-being Board early
implementers, as well as ensuring early implementers and consortia
are able to come together as part of regional transition events.
We are also working to develop a "shared offer" on learning
and support for pathfinders and early implementers. A number of
pathfinders are already actively engaging with shadow Health and
Well-being Boards, building on joint commissioning.
58. The government is extending the remit
of NICE to social care to support the creation of effective quality
standards for all those using health and social care services.
This will enable NICE to approach issues covering the whole pathway
between health and social care, focusing on the holistic needs
of individuals. One such NHS quality standard, published in June
2010, looks at quality in relation to services for dementia—an
important cross-sector issue which has resonance for both social
care and healthcare services.
7. We intend to review the arrangements proposed
in the Bill to enable commissioning consortia to address these
issues [cross-area collaboration by consortia in reconfiguring
services] effectively; this will include a review of the ability
of the new system to encourage commissioning consortia to cooperate
in achieving the benefits to patients which may be available from
major service reconfiguration. (Paragraph 110)
59. Our response to the Committee's Third Report
of Session 2010-11 explained how GP commissioners would have unprecedented
influence over how healthcare services are delivered locally,
and that this brings the opportunity to lead service redesign.[11]
Leading any major service change is about building effective partnerships,
including with other consortia where changes may benefit a wider
population. We emphasised also how patients and the public will
be able to influence service redesign through requirements on
consortia to involve the public.
60. The scrutiny functions of local authorities
will also be extended to cover any substantial changes to designated
services, regardless of provider. This will bring a wide range
of NHS services provided by independent providers within the scope
of local authority scrutiny for the first time. We also intend
to strengthen the democratic legitimacy of referrals from local
authorities to the Secretary of State for Health, as we intend
for these decisions to be subject to a vote of the full council,
allowing every councillor to contribute to the discussion.
61. The new arrangements for commissioning will
provide a strong framework for local co-operation between providers,
local authorities, GP consortia and local HealthWatch. This will
help make commissioning decisions more responsive to local health
needs and patient views. Health and Well-being Boards will support
a culture of local collaboration, centred on the joint health
and well-being strategy. This will facilitate the development
of more joined-up services that make better sense for patients
and the public and improve quality and efficiency.
62. The Health and Social Care Bill provides
wide-ranging powers to support collaborative working between consortia
and with local authorities. Consortia may delegate commissioning
functions to a lead consortium or local authority, commission
jointly between consortia and commission jointly with local authorities,
pooling funds and expertise as necessary. This will allow consortia
to build on the success of existing regional commissioning networks
and joint commissioning arrangements.
63. The pathfinder programme will help the NHS
and local authorities to explore how these collaborative arrangements
can best evolve and identify any support that may be necessary.
During transition, both PCT clusters and the NHS Commissioning
Board will have a role in supporting the development of cross-consortia
working arrangements. However, we will not be prescriptive in
the approach consortia should adopt, as we want to encourage successful
arrangements to emerge locally through the work of pathfinders.
8. The Committee intends to review the arrangements
proposed in the Bill for enabling consortia to reconcile this
potential conflict [between patient choice and commissioning]
by enhancing patient choice at the same time as delivering the
consortium's clinical and financial priorities. (Paragraph 115)
64. Giving patients choice and control over the
care they receive should not be a luxury, but a routine element
of the service which the NHS provides to patients. There is evidence
that giving patients choice and control can improve both quality
and efficiency of care—and should not, therefore, be seen
as being at odds with clinical and financial priorities.
65. It may be helpful to address here some common
misunderstandings about how choice of provider will work under
the "Any Willing Provider" model, which are inhibiting
an honest assessment of its value to patients and commissioners.
66. The "Any Willing Provider" model
is not new: patients have been able to access a free choice of
any qualified provider for routine elective care since April 2008.
The proposal is to extend this to most NHS services by 2013-14.
This will mean that, when a patient requires a referral, they
will be able to choose from a range of providers who are qualified
to provide safe, high-quality care and treatment and select the
one that best meets their needs.
67. Giving patients this choice will not conflict
with a consortium's clinical priorities, as it will still very
much be for commissioners to decide on the services to which they
want to be able to refer their patients to have access and to
establish quality criteria for these services. Only providers
that meet the commissioner's quality criteria will be eligible
to provide these services. Nor does it conflict with financial
priorities, as consortia will set a fixed price that will then
apply to all providers (so the patient's choice of provider does
not affect the price paid) and the model does not alter the decisions
that GPs and other clinicians reach with patients about whether
a referral is needed. Allowing patients this choice of provider
should help support effective commissioning, as commissioners
will know that a range of safe, good quality and affordable providers
are available. It will also avoid the cost, time and effort involved
in competitive tendering.
68. Obviously not all services will be suitable
for the "Any Willing Provider" model. Tendering will
be appropriate in some cases, including where a free choice of
provider would clearly not be appropriate (eg for a range of emergency
care services), or to provide complex, integrated packages of
care (eg for frail older people with multiple complex conditions),
or where commissioners need to provide income or activity guarantees
in order to ensure a guaranteed service. Consortia will be responsible
for determining which is the most appropriate approach.
69. The Department is aiming to issue guidance
in March about how the initial implementation of the "Any
Willing Provider" model for community services will work,
including how to select providers. The aim is to promote national
consistency in terms of quality and safety and ensure, where possible,
that a provider who is registered in one locality does not have
to go through a full application process again for that service
in another locality. This should maintain standards, whilst reducing
duplication and bureaucracy. We will be working with commissioners
and providers to decide how best to do this. We want to build
in sufficient flexibility for the "Any Willing Provider"
to work in the best interests of patients and fit local needs.
70. Our consultation on information and choice,
Liberating the NHS: greater choice and control, closed
on 14 January 2011 and we expect to report back shortly on the
results of that consultation, drawing on the public's responses
to inform further proposals for enhancing patient choice and control.
9. The Committee does not find the current
stance on patient and public engagement in commissioning persuasive.
The National Health Service uses taxpayers' resources to deliver
a service in which a high proportion of citizens take a close
interest both as taxpayers and actual or potential patients. While
the Department may be right to point out that there is no special
virtue in uniformity of structure, the Committee regards the principle
that there should be greater accountability by commissioners for
their commissioning decisions as important. We therefore intend
to review the arrangements for local accountability proposed in
the Bill. (Paragraph 118)
71. In our response to the Committee's Third
Report we considered the range of ways in which the public could
influence local commissioning. Without repeating our earlier comments,
we would like to emphasise the clear lines of accountability which
will support patient involvement and ensure commissioners are
answerable for the outcomes they achieve.
72. The NHS Commissioning Board will be responsible
for holding GP consortia to account annually for the outcomes
they achieve, their stewardship of public resources and their
fulfilment of other statutory duties. Paragraphs 18-26 above set
out the proposed arrangements for authorisation and ongoing accountability
and for intervention to support consortia where they are not carrying
out their functions effectively.
73. Under the Bill, consortia will have a clear
legal duty to ensure patients and the public are involved in the
planning of commissioning arrangements, in developing and considering
proposals that will significantly affect how services are delivered
or the range of services available, and in making decisions that
will have a similar impact. The NHS Commissioning Board will need
to satisfy itself both at the point of authorisation and on an
ongoing basis that consortia have effective arrangements in place
to meet this duty. We envisage that the Board will wish to draw
on the views of local HealthWatch, local authorities and other
community groups to enable it to assess how effectively consortia
are involving patients and the public.
74. Arrangements for public accountability will
be further enhanced through the introduction of a Commissioning
Outcomes Framework that enables local communities to understand
and compare the outcomes that consortia are achieving for patients
and the progress they are making in improving quality and reducing
inequalities.
75. Health and Well-being Boards will further
enhance accountability arrangements by enabling local authorities
and local HealthWatch to work alongside consortia in reviewing
local healthcare needs and in deciding strategic priorities for
improvements in Health and Well-being. Boards will be required
to include in its membership elected representatives, commissioners
of NHS, public health, social care, and children's services, and
representation from Local HealthWatch. They will also, if they
wish, be able to involve others such as providers and voluntary
sector organisations.
76. The January event for pathfinders highlighted
the enthusiasm amongst emerging consortia to build on what works
well locally to engage with patients and the public, including
Patient Participation Groups, local authority citizens panels
and PCT membership schemes. One pathfinder had a representative
from the patient participation group of every GP practice sitting
on a locality group with representatives from the local authority,
voluntary organisations and local special interest groups, to
constitute a stakeholder forum which the consortium could use
to gauge patient and public views.
77. We want to see all consortia develop robust
arrangements that are tailored to local circumstances and driven
by local initiative, rather than prescribe a single central approach.
The pathfinder learning network will provide a platform for consortia
to share best practice on this. Ultimately, however, it will still
be for the NHS Commissioning Board to satisfy itself that a consortium
has effective arrangements to meet its statutory duty of public
and patient involvement.
78. The Department's Voluntary Sector Strategic
Partners have been in early discussions to inform and develop
the arrangements for GP commissioning consortia and the NHS Commissioning
Board. Dame Barbara Hakin, the Managing Director of Commissioning
Development recently met with ten leading patient organisations,
including the Chair of National Voices and representatives from
Age UK. This group will provide a link back into the broader voluntary
and community sector.
10. The Government must support consortia
and existing commissioning organisations to form clear and credible
plans for debt eradication and for tackling structural deficits
within their local health economy. The Committee intends to further
review this issue in its further work. (Paragraph 123)
79. The 2011-12 NHS Operating Framework establishes
that GP consortia will not be responsible for resolving PCT legacy
debt that arose prior to 2011-12. We expect pathfinders and emerging
consortia to work closely with PCT clusters during the transitional
financial years 2011-12 and 2012-13 to ensure that no new deficits
are created and that appropriate control and balance are maintained,
so that from 2013-14 consortia will commence full responsibility
for commissioning on a robust financial basis. GP consortia will
otherwise be responsible (from 2013-14 onwards) for any unresolved
debt that arises during these two years.
80. Where consortia carry out commissioning functions
during 2011-12 and 2012-13, they will do so on a delegated basis.
In other words, the relevant PCT(s) will remain statutorily accountable
for expenditure and service outcomes, but will delegate responsibilities
to consortia (either as sub-committees of the PCT or, once consortia
are statutorily established, as bodies in their own right). The
Department is working with pathfinders to develop best practice
guidance on the arrangements for delegating commissioning responsibilities
and associated budget provision. These arrangements will support
emerging consortia in taking an increasingly active role in shaping
QIPP plans and ensuring that improvements in quality and productivity
are based on a good understanding of patient needs.
81. To support the transition, the NHS Operating
Framework 2011-12 sets out our intention increasingly to deliver
business through PCT clusters. They will in essence work as transition
vehicles for overseeing and accounting for delivery of financial
and service priorities, supporting the development of the new
commissioning system, ensuring that emerging consortia have access
to good commissioning support, and directly commissioning those
services (such as primary care and specialised services) that
will in future be commissioned by the NHS Commissioning Board.
82. Some regions of the NHS have already developed
clusters of PCTs. In order to secure the capacity and flexibility
needed for the transition period, we shall undertake a managed
consolidation of PCT capacity to create clusters across all regions
of the NHS. As part of this transitional process, PCT staff will
be increasingly assigned to emerging GP consortia to support their
development and support them in taking on delegated commissioning
responsibilities.
83. In creating clusters, our aim is to maintain
the strength of the commissioning system in light of the significant
financial challenges ahead and to provide maximum opportunities
and support for emerging consortia to grow their capacity and
capability. Clusters of PCTs will have greater resilience to manage
the demands of the service during transition, whilst supporting
the development of emerging consortia.
84. SHAs will oversee the development of PCT
clusters and ensure local coherence across the local development
of the new architecture, such as relationships between GP consortia
pathfinders and local Health and Well-being Board early implementers.
IMPROVING HEALTH
OUTCOMES
85. Equity and excellence: Liberating the
NHS expressed the intention that in giving the NHS a stable,
enduring framework for quality and service improvement, the focus
of debates on health should move to priorities and progress in
health improvement. With the new arrangements for commissioning
still in development, we have not reached that stage yet. But
as those new arrangements for commissioning and accountability
take greater shape, we hope to reinforce the fact that these changes
are not an end in themselves, but are designed to allow a renewed
focus on improving health outcomes and reducing health inequalities.
86. The Government has made it clear that tackling
health inequalities is a priority, with a determined focus on
equity and fairness. Everyone should have the same opportunities
to lead a healthy life, no matter where they live or who they
are. As well as helping people live longer, healthier and more
fulfilling lives, we aim to improve the health of the poorest
fastest.
87. Tackling health inequalities and unacceptable
variations in service outcomes is an important aspect of our drive
to improve service quality and health outcomes of services across
the board. People in many disadvantaged groups and areas live
shorter lives and experience poorer health throughout their lives.
The more devolved health system we are developing will support
a sharper focus on the pockets of disadvantage that exist across
the country.
88. Reducing health inequalities will be embedded
into the reformed systems of accountability for both the NHS and
public health. Subject to Parliamentary approval, the Secretary
of State for Health, the NHS Commissioning Board and GP consortia
will each have specific duties as regards reducing inequalities.
GP consortia and Health and Well-being Boards will need to look
strategically at the needs of local populations when developing
JSNAs and identify strategic priorities for reducing health inequalities.
89. The Department has developed an NHS Outcomes
Framework to provide national accountability for the outcomes
that the NHS delivers. The framework will not only be a mechanism
to hold the NHS to account, but will act as a catalyst to drive
quality improvement and delivery of better outcomes across the
system.
90. One of the underpinning principles in developing
the NHS Outcomes Framework has been the need to promote equalities
and reduce inequalities in health outcomes. To encourage this,
the outcome indicators, as far as possible, will be chosen according
to whether data can be disaggregated by equalities characteristics
and by geography so that outcomes for disadvantaged groups can
be measured.
PUBLIC HEALTH
91. Action to tackle health inequalities is also
at the centre of our approach to public health. The Public Health
White Paper, Healthy Lives, Healthy People: our strategy
for public health in England (November 2010),[12]
sets a radical new vision for improving the health of the nation.
The public health budget will be ring-fenced and allocated to
reflect relative population health needs, with a new "health
premium" to promote action to reduce health inequalities.
Public Health England will lead national action to protect and
improve health, with local authorities given new responsibilities
and ring-fenced funding for health improvement in local communities.
92. The Department is consulting on the funding
and commissioning routes for public health. We are also consulting
on a public health outcomes framework, which will contain indicators
designed to allow progress to be measured towards a number of
public health outcomes and provide incentives for local health
improvement and reductions in inequalities. A key criterion in
choosing which indicators to include in the final outcomes framework
will be whether or not they can be measured at the local authority
level.
93. Public Health England will publish progress
against the outcome indicators for each local authority. This
will enable the population locally to hold their council to account
for local performance, and for Directors of Public Health and
colleagues to assess their performance against comparator authorities.
94. The Public Health White Paper responds to
the report of the independent review, chaired by Professor Sir
Michael Marmot, to explore the impact of the wider social determinants
of health and advise on future action to reduce health inequalities
in England. The White Paper adopts the review's life course framework
to provide a focus for tackling the wider social determinants
of health.
NICE
95. Under the proposals in the Health and Social
Care Bill, NICE will be re-established on a statutory footing
and its remit will be extended into social care. NICE is at the
heart of the Government's plans for promoting quality in the NHS,
and the extension of its role into social care will help to create
a seamless and integrated approach to health and social care.
Our plans for NICE build on its strong track record, and NICE
as re-established will continue to support the delivery of high
quality health and social care through the production of robust,
evidence-based advice and guidance.
96. The Bill also sets out the key role of NICE
quality standards in supporting the overarching duty of quality
and improving outcomes. NICE quality standards describe the core
elements of a high quality service or care pathway and, under
our plans, the NHS Commissioning Board and the Secretary of State
will be required to have regard to them in carrying out their
functions. We envisage, for example, that the NHS Commissioning
Board will draw on quality standards in developing indicators
for the Commissioning Outcomes Framework and in developing appropriate
incentives for healthcare providers through model contracts for
secondary care providers and through the Quality and Outcomes
Framework for GP practices.
97. The Government wants to give NHS patients
better access to effective and innovative medicines and we are
currently consulting on plans to introduce value-based pricing
for medicines. Our intention is to introduce the new arrangements
from 2014, on expiry of the current Pharmaceutical Price Regulation
Scheme. Through value-based pricing, our aim is to ensure that
a drug's price appropriately reflects the value it offers, so
that clinicians and commissioners can have greater confidence
that medicines are cost effective as well as clinically effective.
NICE's role will evolve under value-based pricing, but, as an
international leader in the evaluation of drugs and health technologies,
it will continue to have a crucial part to play through the provision
of authoritative and expert advice to support clinical decision-making.
CANCER
98. On 12 January we published Improving Outcomes:
A Strategy for Cancer.[13]
It sets out how the Coalition Government's reforms of health and
care services will drive improvements in cancer outcomes and put
patients and the public at the heart of cancer services.
99. Commissioning for cancer is complex and needs
to be coordinated across the care pathway involving teams in general
practice, community services, social care, acute general hospitals
and specialist centres.
100. The NHS, public health and social care outcomes
framework will set the direction and provide clear accountability.
The Secretary of State for Health will hold the NHS Commissioning
Board to account for delivering national outcome goals.
101. The NHS and Public Health England (PHE)
will need to work together closely, offering integrated advice
and care to the public and patients with many shared areas of
accountability for cancer services. While the NHS Outcomes Framework
has cancer survival as an improvement area, Healthy Lives,
Healthy People: Transparency in Outcomes proposes that cancer
mortality should be an improvement area for PHE as this covers
improvements in prevention as well as in diagnosis and treatment.
Key indicators spanning a number of domains will drive prevention
and earlier diagnosis of cancer as well as improvements in NHS
outcomes.
102. The Coalition Government's proposed Health
and Well-being Boards will provide a forum for the development
of cross-cutting commissioning approaches to improve cancer services,
providing more effective engagement between NHS, public health
and social care commissioners.
103. GP consortia are well placed to commission
the majority of cancer services. Those cancer services best commissioned
for larger populations may require consortia to group together
to commission services and some services will continue to be commissioned
at a national level, including specialised surgical services and
services for some rarer cancers (eg children's cancers).
104. The Strategy sets out how choice for patients
in their cancer care will be extended and identifies the gaps
in information on health outcomes which are crucial to ensuring
patients are empowered.
105. Although we have made considerable progress
on cancer over the past 10 to 15 years, we know from available
data that our survival rates lag behind those in comparable countries.
The main reason for this is late diagnosis of many patients. The
Strategy therefore has a significant focus on earlier diagnosis,
which we will achieve through raising the public's awareness of
the signs and symptoms of cancer and providing better access to
diagnostic tests. To support the NHS to achieve earlier diagnosis
of cancer alongside efficiency savings, the Strategy is backed
up with over £450 million investment over the Spending Review
period.
106. The Strategy sets out our aim to save an
additional 5,000 lives every year by 2014-15 and improve cancer
outcomes through:
- reducing the incidence of cancers which are preventable,
by lifestyle changes;
- improving uptake of screening and introduce new
screening programmes where there is evidence to justify them;
- achieving earlier diagnosis of cancer, to increase
the scope for successful treatment; and
- making sure that all patients have access to
the best possible treatment, care and support including improving
access to innovative treatments such as proton beam therapy.
107. Improving outcomes for people with cancer
is also about improving patients' experience of care and improving
the quality of life for cancer survivors. The Strategy therefore
also sets out a range of actions to deliver improvements in those
areas.
108. The Strategy highlights that information
will be central to the drive for better outcomes, underpinning
stronger commissioning and patient choice. Commissioners will
need better information to drive up the quality of services and
outcomes and to make efficient use of resources. We will ensure
that we have better activity information and full clarity about
costs for different services, and the right incentives to reward
quality and efficiency. In addition to taking forward the tariffs
for chemotherapy and radiotherapy, during 2011-12 we will investigate
the potential development of a range of tariffs to incentivise
high quality, cost-effective services.
109. It is intended that the Commissioning Outcomes
Framework will incentivise high quality commissioning and will
be closely aligned with NICE Quality standards. The library of
Quality Standards being developed by NICE will be an important
resource for commissioners in identifying issues to prioritise
and will enable scrutiny of the extent to which they are commissioning
high quality care.
110. The Department of Health and the National
Cancer Action Team have provided guidance and support to commissioners
through the Cancer Commissioning Toolkit and the Cancer Commissioning
Guidance. We will now work with GP consortia to identify their
specific needs for commissioning support. The Cancer Networks
will support pathfinder consortia through transition.
MENTAL HEALTH
111. On 2 February the cross-Government strategy
for mental health, No Health Without Mental Health,[14]
was published. The strategy is based on outcomes, giving mental
health "parity of esteem" with physical health issues
as central to priorities across Government and in the mainstream
of health and social care services.
112. The strategy has the twin aims of promoting
and sustaining good mental health and well-being in the wider
population, and improving the quality of existing services for
people across the full range of mental health problems. It looks
at the prevalence of problems and effective approaches at different
stages across the whole life course and stresses the importance
of prevention and early intervention. The Strategy makes clear
that our approach is based on the principles that the Government
has laid down for its health reforms, such as focusing on measurable
outcomes and the NICE Quality Standards that deliver them rather
than top-down process targets.
113. In support of the strategy, on 2 February
the Department published Talking Therapies: a four year plan
of action.[15]
The plan sets out how the NHS will complete the nationwide roll-out
of the Improving Access to Psychological Therapies programme,
ensuring older people get good access to talking therapies and:
- initiating a stand alone programme with the ambition
of making the same step forward for children and young people
as has already been made for adults;
- achieving other NHS savings by offering talking
therapies to people with long-term physical conditions or medically
unexplained symptoms; and
- developing ways to expand access to talking therapies
to people with serious mental illness.
KIDNEY DISEASE
114. A greater focus on the outcomes that matter
most to patients, and in particular more attention given to patients'
experience, has the potential to yield great benefits for people
with kidney disease. For example, GP consortia will be well placed
to maximise opportunities for the efficient integration of primary
and secondary care for people with chronic kidney disease, meaning
that people are seen at the right place and time without the frustration
of unnecessary referrals and duplication. A Quality Standard on
chronic kidney disease is in the final stages of preparation by
NICE and will help to guide commissioners and providers of services
in this area.
115. Similarly the explicit emphasis on effectiveness
and patient safety set out in the first Outcomes Framework, together
with clinical leadership, lend themselves to a more systematic
approach to the prevention, detection and management of acute
kidney injury, which research suggests may affect up to 20% of
emergency admissions—resulting in significant morbidity
and mortality. This is primarily a matter of consistently providing
good quality basic and generic care for the acutely unwell, which
will benefit from a clear and unfettered drive by commissioners
to yield improvements in all the domains of quality.
116. Preparation for and delivery of renal replacement
therapies—dialysis and transplantation—will be commissioned
by the NHS Commissioning Board with due regard for patients' needs
to maintain their day to day lives. Patient choice and control—"no
decision about me without me"—will be the watchwords
of quality services after the transition, with informed choice
of treatment modalities including care at home; conservative care
in the community and, at an appropriate time, good end of life
care. For example, an increase in the availability of dialysis
at home—which is known to be more clinically and cost effective
than in-centre treatment—will mean that patients will be
able to plan their treatment around their lives rather than vice
versa. For dialysis patients of working age, this treatment modality
will help them to continue in employment with benefits to themselves
and the wider community.
DIABETES
117. Diabetes is a life-long complex condition
that affects every part of the body and throughout the course
of their lifetime people with diabetes will need to engage with
a range of healthcare professionals. There is no one single care
pathway for people with diabetes and it is essential that they
receive the relevant care and attention as and when they need
it. The NHS reforms present the opportunity for stronger, closer
partnership working between GP consortia and secondary care specialists,
ensuring that evidence-based multi-disciplinary care is commissioned
and is focused on the needs of the individual patient sitting
in the GP practice.
118. Engaging patients in a better understanding
of their condition and educating them how to manage their own
condition results in better outcomes. These reforms offer the
potential to provide more tailored treatment for people with diabetes
so that they can access specialist care from the primary, community
and acute sectors.
119. We know that there is significant scope
for improvements in primary care in terms of managing people with
diabetes in the community. Because the performance of local health
services will increasingly be measured on whether or not patients
are in good health and able to live active, fulfilling lives,
it will become more apparent where people with diabetes are not
receiving good primary care and community services to help them
manage their condition, and there will be a greater onus on GP
consortia, health professionals and Health and Well-being Boards
to address this.
120. Strengthening the relationship between primary
and specialist care can only be a good thing for improving care
for people with diabetes. In anticipation of these changes, the
diabetes team in Portsmouth NHS Trust have already proposed a
solution that will drive specialist diabetes care into the community
cutting across the divide of primary and specialist care. This
not only provides more convenient services for people with diabetes,
but also ensures the integration of specialists into primary care.
HEART FAILURE
AND CARDIAC
REHABILITATION
121. The focus on patient experience, empowerment
and long-term conditions envisaged in the new arrangements should
give a welcome emphasis to the commissioning of services for heart
failure and cardiac rehabilitation. Moving commissioning decisions
closer to patients should ensure they are better able to influence
their care though direct discussion with their GP. This is of
particular importance to people with long-term conditions. GPs
should become more aware of the full menu of services available
and will be able to offer greater choice and control to their
patients to manage their own condition more effectively, with
specialist medical support only where necessary.
122. Facilitating the entry of new and different
local provider organisations will help people tailor their care
to meet their needs. For cardiac rehabilitation, this would mean
that patients not only have a choice of services from a variety
of providers in a range of settings, but also that they could
select only the components of the services that meet their individual
needs.
123. The NICE Quality Standard on Chronic Heart
Failure (due in summer 2011) will provide a robust evidence base
to enable GP consortia to understand the benefits and cost-effectiveness
of alternatives to hospital provision, through telemedicine and
community teams, in addition to the importance of self-care and
cardiac rehabilitation in preventing hospital admissions. It is
also likely to help the NHS Commissioning Board develop suitable
indicators as part of the Commissioning Outcomes Framework to
hold commissioners to account for delivering the outcomes that
people want.
COMMISSIONING FOR
STROKE CARE
124. The focus on improved stroke linkage between
primary and secondary care will offer opportunities to focus on
prevention through, for example, better management of patients
with atrial fibrillation and consequent reduction in the risk
of stroke. Patients with atrial fibrillation have worse strokes
with worse outcomes, so improving atrial fibrillation management
can improve overall outcomes.
125. As with cardiac services, the new arrangements
will support a strengthened focus on patient experience and patient
empowerment. GPs should become more aware of the benefits of continuing
rehabilitation, including understanding how best to deliver it
most effectively for most patients (eg via telemedicine facilities)
for as long as patients are able to benefit from it. By offering
greater choice and control to their patients to manage their own
condition more effectively, GP consortia should be able to commission
specialist medical support only where necessary.
126. The acute phase of stroke is a very small
part of the overall patient pathway. By providing improved focus
on post-acute and social care, patient experience and outcomes
will improve, enabling better integration into the community and
reduced social isolation, which will also benefit carers. Improved
understanding of the importance of high quality stroke care including
rehabilitation should reduce the numbers of people who are admitted
to residential care.
127. The NICE Quality Standard on Stroke provides
an evidence base to enable GP consortia to understand the benefits
and cost-effectiveness of high quality stroke care. It will also
help the NHS Commissioning Board develop suitable indicators as
part of the Commissioning Outcomes Framework to hold commissioners
to account for delivering the outcomes that people want.
NHS HEALTH CHECK
PROGRAMME
128. The NHS Health Check programme is a national
public health programme aimed at preventing heart disease, stroke,
diabetes and chronic kidney disease. The Government made clear
its commitment to the continuation of the programme in the Public
Health White Paper. The programme aims to prevent disease
and help people stay well for longer. As such, it is proposed
as an indicator in the Public Health Outcomes Framework.
129. The NHS Health Check programme is a clinically
and cost effective programme with a robust evidence base. It is
for everyone in England between the ages of 40 and 74 that does
not already have one of these diseases. Everyone having a NHS
Health Check will have an individual assessment to determine their
risk of having a heart attack or stroke, or of developing diabetes
or chronic kidney disease in the future. Each person will be offered
a tailored package of lifestyle advice and support to help them
reduce or manage that risk. For those at low risk, this might
be no more than general advice on how best to stay healthy. Others
may be assisted to join a weight management programme or a stop
smoking service. Those at the highest risk might also require
preventive medication with statins or blood pressure treatment.
130. Six Carers Strategy demonstrator sites,
focusing on health and well-being checks, are testing different
ways of reaching out to carers, including those in ethnic minority
communities. The findings from the independent evaluation of the
demonstrator sites, particularly around accessibility for carers
will be fed into the ongoing policy considerations for the NHS
Health Check Programme.
131. There is also a related annual health check
programme for people with learning disabilities that has been
running since 2008-09. The Government has confirmed it is keen
for this programme to continue in 2011-12, and is currently looking
at the most cost effective way of ensuring that. Evidence shows
people with learning disabilities value annual health checks.
Evidence also shows people with learning disabilities have greater
health needs than the general population, and that such checks
lead to earlier diagnosis and earlier treatment. Annual health
check data is analysed and published by the Public Health Observatory
in relation to people with learning disabilities.[16]
132. Vascular conditions (mainly coronary heart
disease, stroke, diabetes and chronic kidney disease) are the
largest contributors to the gaps in health between deprived and
better off, and between different ethnic groups. This programme,
if implemented sensitively, offers a real opportunity to make
significant inroads in tackling health inequalities and fits with
the wider agenda for improving public health.
March 2011
1 www.cabinetoffice.gov.uk/sites/default/files/resources/coalition_programme_for_government.pdf Back
2 www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf Back
3
Government Response to the House of Commons Health Select Committee
Third Report of Session 2010-11: Commissioning, Cm 8009,
p. 7, www.official-documents.gov.uk/document/cm80/8009/8009.pdf Back
4
www.dh.gov.uk/en/Consultations/Closedconsultations/DH_117587 Back
5
www.dh.gov.uk/en/Consultations/Closedconsultations/DH_117583 Back
6
www.dh.gov.uk/en/Consultations/Closedconsultations/DH_117586 Back
7
Liberating the NHS: legislative framework and next steps
(December 2010) www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122661 Back
8
www.publications.parliament.uk/pa/cm201011/cmbills/132/11132.i-v.html Back
9
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123933 Back
10
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_121508 Back
11
Government Response to the House of Commons Health Select Committee
Third Report of Session 2010-11: Commissioning, Cm 8009,
pp 22-23. Back
12
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_121941 Back
13
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123371 Back
14
No Health Without Mental Health: a cross-Government mental
health outcomes strategy for people of all ages (HM Government,
2011) www.parliament.uk/deposits/depositedpapers/2011/DEP2011-0193.pdf Back
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Talking Therapies: a four year plan of action (Department
of Health, February 2011) www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123759 Back
16
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