A new Commissioning and a new Opportunity to improve

the Public’s Health

Professor David Colin-Thomé

Staffordshire Case Study

Whose NHS is it?

• The NHS is good for social justice but its poor clinical outcomes disproportionately most affect the ‘poor’

• Do public services tend to make providers of care treat their service users as grateful supplicants?

• Can we make the concept of a meeting of two experts a reality?

• And why do we not make all performance data of providers publically available

A New NHS Commissioning

• Being the ‘people’s organisation’ • New relationships with the wider health eco system• The healthcare system leader ensuring quality-

safety, effectiveness and patient experience and equally to promote and deliver on innovation, prevention and productivity delivered by providers

• So a key fourth domain is a new and essentially a completely new relationship with providers of care

Public’s Health

• Centrality of local government• Population responsibility of commissioners and general

practice providers• Role of third sector• Public health component of individual consultation• Locus of control-e.g. social enterprise, self care,

individual budgets, Sure Start, Family Nurse Partnership

Public Health OutcomesA consultation

• 5 Domains• Protect the population’s health from major

emergencies and remain resilient to harm• Tackling the wider determinants of health• Health improvement• Prevention of ill health• Healthy life expectancy and preventable

mortality

Health and Wellbeing BoardsGovernment response to the NHS Future

Forum report 2011• ‘We proposed to create statutory health and wellbeing boards in every upper tier local

authority to improve health and care services, and the health and wellbeing of local people. Health and wellbeing boards will bring together locally elected councillors with the key commissioners in an area, including representatives of clinical commissioning groups, directors of public health, children’s services and adult social services, and a representative of local HealthWatch. Health and wellbeing boards will assess local needs (through the joint strategic needs assessment) and develop a shared strategy (in the form of a new joint health and wellbeing strategy) to address them, providing a strategic framework for commissioners’ plans.’

 • The Future Forum’s report supports the idea of health and wellbeing boards, but

recommends that we strengthen them, so they are truly the “focal point for decision-making about local health and wellbeing”, enabling local authorities to work in partnership with clinical commissioning groups and other community partners to deliver meaningful joint health and wellbeing strategies and maximise opportunities for integrating health and social care. In response to the Forum’s recommendations, we will make a number of changes designed to strengthen the role of health and wellbeing boards and increase public and patient involvement.

Health and Wellbeing Boards Government response to the

NHS Future Forum report 2011

• The boards will provide the vehicle for local government to work in partnership with commissioning groups to develop robust joint health and wellbeing strategies, which will in turn set the local framework for commissioning of health care, social care and public health. The creation of health and wellbeing boards will maximise opportunities for integrating health and social care, and for the NHS and local government to drive improvements in the health and wellbeing of their local population.

• Health and wellbeing boards are not just about assessments and strategies. Health and wellbeing boards will have a stronger role in promoting joint commissioning and integrated provision between health, public health and social care.’

Health and Wellbeing boards

• The H& WB boards to deliver on such an ambitious approach will need to be leader, commissioner, facilitator and where necessary follower

• They will and in particular for the NHS need a co-operative but clear performance improvement approach for the providers of care

• The Board however is not a statutory commissioner so will need to ensure its formal leaders have indeed leadership qualities to engender engagement and partnerships for progress and change - not least with the statutory commissioners of the NHS and local government..

Health and Wellbeing Boards

• The overarching priority for health and well being is for sustainable development.

• To reduce carbon emissions is hugely important but the guiding principles of sustainable development are much broader;

• Living within environmental limits; Ensuring a strong, healthy and just society; Achieving a sustainable economy; Promoting good governance; Using sound science responsibly. Presidency conclusions of the European Council on Guiding Principles for Sustainable Development (16.-17.06.2005)

NHS role

• There are many facets of improving the public’s heath that the NHS will lead for instance-vaccination and immunisation, cervical screening and improving the health of those who have a long term condition. Services in which population list based general medical practice providers have already achieved much

• The responsibility for a population is essential to having an important role in improving the public’s health whilst recognising that a population is made up of individuals and their needs. Population responsibility is often interpreted in an utilitarian collectivist manner rather than a way of enabling individuals within that population to fulfil their health potential

• Where population and individual care clearly conflate and as a priority is in better support and care for those with long term conditions. Conditions that have a major impact on health inequalities

Long Term conditions

• Prevention• Early diagnosis• Self care• Bioclinical interventions in primary and

secondary care• Meeting of two experts-care planning and a

‘Year of Care’• Social Care

NHS OUTCOMES FRAMEWORKDomain 1

Preventing people from

dying prematurely

Domain 2Enhancing the quality of life for

people with LTCs

Domain 3Recovery

from episodes of ill health /

injury

Domain 4Ensuring a

positive patient

experience

Domain 5Safe

environment free from avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning Outcomes Framework

Commissioning Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Du

ty of q

ua

lityDu

ty o

f qu

alit

y

tariffstandard contract

CQUIN QOF

5

6

Duty of quality

NHS OUTCOMES FRAMEWORKDomain 1

Preventing people from

dying prematurely

Domain 2Enhancing the quality of life for

people with LTCs

Domain 3Recovery

from episodes of ill health /

injury

Domain 4Ensuring a

positive patient

experience

Domain 5Safe

environment free from avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning Outcomes Framework

Commissioning Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Du

ty of q

ua

lityDu

ty o

f qu

alit

y

tariffstandard contract

CQUIN QOF

5

6

Duty of quality

Pregnancy and baby

Winter deaths: housing/ warmth

Infectious diseases

Mental health

Diabetes

Infant Mortality: smoking, obesity,

Cancers, circulatory and respiratory diseases

Dementia

Musculoskeletal

Accidents: home safety, road safety

Preschool School Young People Adults Older people

Public Health Challenge / Significant burden on health BothDamage done / opportunity for prevention

Bone health: diet & exercise

Smoking, obesity, diet and alcohol

Trips and falls prevention: exercise,

vitamin D, safe homes / pavements

Quality of care / parenting

Healthy aging / maintaining

independence

STDs: safe sexual

behaviour

Childhood diseases:

vaccination

MH prevention / early recognition: resilience and emotional

intelligence?

TB

Cancer screening

Broader Public Health Issues

• Resources• Education services• Gender• Criminal justice• Race• Faith

The Potential of a New Commissioning

• Commissioning has historically been a widely used but ill-defined concept in the NHS

• Is the process of planning, securing and monitoring the health services and health improvement services for a defined geographical area and population

• Commissioning takes place at various levels and by different bodies, including the very large-scale (for specialist services) but also at a much more local level, where detailed knowledge of smaller areas is needed

Attributes of list based general practice

• ‘soul of a proper, community orientated, health-preserving care system’. Berwick DM. A transatlantic review of the NHS at 60. BMJ 2008;337:a838

• “The well known but underappreciated secret of the value of primary care is its person and population, rather than disease, focus” (Starfield, 2009,).

• “There is lots of evidence that a good relationship with a freely chosen primary-care doctor, preferably over several years, is associated with better care, more appropriate care, better health, and much lower health costs.” Starfield

• The ability to “organise the chaos of the first presentation’. Paul Freeling late emeritus Professor of General Practice

Commissioning for Health Care

It’s all about provision

The Primary Care Home

• All providers need to also define a population responsibility if they are to be a more influential and proactive organisation. This is of particular import to improve the care of people who have a long term condition.

• Future care will inevitably be more integrated and overtly accountable, much more based in community settings and optimally delivered if chiefly responsible for a defined population.

• Hence the concept of the Primary Care Home, a community based, integrated, accountable home for population care where the needs of the individual and of the community can be met. Served by an holistic budget that enables a ‘make or buy’ approach to care delivery and commissioned by the statutory commissioner(s)