Stabilisation of the NHS
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Transcript of Stabilisation of the NHS
StabilisationProposed approach to continuing reform in
NHS without major legislation
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Agenda for ReformNicholson Challenge (QIPPR)
Patients at the centre (no decision about me .…)Greater patient and public involvement Clinicians in charge Reduce bureaucracy and management
Improving outcomes
5 Year plan?
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Key Reform ThemesClinically led commissioningAcute – primary shift – prevention
But investment required and potential strains on social care
Specialisation (tier one/two/three) as for trauma, stroke etc
Reducing unacceptable variation (costs and outcomes)Reducing inequality of outcomesSocial – health care integration and integration around
patient needs
Elephant – Social Care collapsing - Dilnott04/02/2012 SHA D R A F T 5
The AlternativeWithout Primary Legislation
Using Existing Powers
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Key PrinciplesNo major primary legislation
Use existing SoS powers or Bill without Part 3. Integrated local commissioning – clinically
ledEarned autonomyConvergence with local authoritiesCompetition within managed frameworkSystem planning approach to reconfiguration
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Stabilisation PlanConcentrate on Nicholson Challenge/QualityConsult, then develop and publish proper 5 year planPlanning and system management with genuine involvementKeep CSHAs and CPCTs as proper statutory bodiesIntroduce NCB (operational not policy)Tell SoS and NCB not to micro manage
Actually culture change not organisational change required.Complete provider transitionFacilitate reconfiguration across systems (acquisitions &
mergers?)Build on commissioning strengthsProvide flexibility in commissioning support
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Stabilisation PlanIncrease clinical involvement – devolve through
earned autonomyAllocate commissioning functions to right level
Local wherever possibleBegin serious engagement with local authorities
Provide incentives use existing flexibilitiesContinue developing incrementally tariff, outcomes
framework, PRCC.Park further changes until after NC is achievedConsult on longer term plans.
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Secretary of State RolePromotes the comprehensive NHS - secures
provisionLegally and politically accountableDelegates powers and dutiesIntervenes when necessary in best interests of
NHSBUT not compelled to interfereDefines the foundationsDirects the system (Op. Framework or Mandate)Sponsors key bodies
Nice, CQC, SpHAs04/02/2012 SHA D R A F T 5
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FoundationsNHS ConstitutionPrinciples and Rules for Cooperation and
CompetitionNHS Tariff (could be set by independent
body)Standard contract termsOutcomes FrameworkCommissioning Outcomes FrameworkNational Service FrameworksTerms and Conditions – GPs contractsMandate (Operating Framework)
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CompetitionValuable as one tool – within managed frameworkRetain existing Principles and Rules for
Cooperation and Competition (PRCC) Retain Cooperation and Competition Panel to
advise on disputesSet boundaries for services open to competition
through Mandate (choice mandate as from Future Forum)
Flexibility to extend AQP already usedClarification of EU position
Protection for commissioners acting in good faithNo externally applied imposition of competition
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Provider DevelopmentAccept role for some NHS Trusts (safe haven)Complete TCS transitionEmpower PDA to manage pipeline to FT status
Continue with supervision through TPAsReview pipeline and challenged FTs on whole system basis
(Monitor looking at this)Revise reconfiguration process – mandate use
Needs planning and leadership – much faster route than market/failure
Allow de authorisation by choice to enable reconfigurationRather than under pressure from commissioners or regulator
Licensing can wait – reconsider 201604/02/2012 SHA D R A F T 5
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MonitorMaintains current roleRegulator of providers of service to NHSContinues to authorise FTsContinues to oversee FTs (including PP Cap)
Change to PPI Cap requires legislationCompromise possible if cap set by local
governance
Can advise SoS on prices, contract conditions and competition rules
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Failure RegimeFocus on prevention of failure – whole system
approach Continue deauthorisation of FTsIntroduce pre–failure regimeStrengthen but streamline reconfiguration
processImplement Special Administration powers
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Wellbeing BoardsUse existing local authority “wellbeing” powersContinue to promote pro-active community involvementUse access to funding incentives to join up provision of
careWide membership base including public and patient
representativesInclusion of elected members (Councillors)Support and drive integration across all public servicesJoins up public health, social care and health care Involve and engage with Tier Two authorities if present
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Wellbeing BoardsProduce strategic needs analysis (as now)*Produce wellbeing strategy (generally as now)*Produce integrated commissioning plan*
*Working with CPCTs and CCGs as appropriateSign off commissioning plans from CPCTs and CCGsOversee implementation of plans
and can refer to SoS if any dispute or disagreement
Could be integrated with CPCTs to become Commissioning Authorities - as recommended by Health Committee
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Commissioning ArchitectureSimplifying Structures
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Under HSC BillNational Commissioning Board Part A
Commissioning of servicesNational Commissioning Board Part B
Oversight of commissioningRegional Outposts (4)Local Outposts (50)Clinical Commissioning Groups (250)Commissioning Support Organisations (40)Health and Wellbeing Boards (160)Clinical Senates (30?)
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Under Stabilisation PlanBoard – no need for separation of fucntions
Regional directorates (4) CPCTs – sub regional – coterminus with LAs
(50)CCGs (250 reducing over time)Wellbeing Boards – to be merged into CPCTs
over time
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Clustered PCTs Public bodies – NOLAN compliantHave publicly appointed non executives
Must include health professionalsSupport development of strategic needs assessmentsAgree commissioning plans - within local wellbeing
commissioning strategy and integrated planCoterminous with Tier One Local Authorities (one or more) Integration of commissioning to drive integration of provision
Commission specialist services Commission and manage PMS contracts
Conduct periodic service reviews to demonstrate VfMDelegate hard budgets to CCGs – monitor deliveryAccountable (through CSHAs) to NCB to SoS
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CCGsPublic governance and accountability – but as sub committees of
CPCT (as now)Formal constitutions and Boards (local within a national template)
Must include lay representatives as well as professionalsLocal commissioning (but not PMS or specialist)Delegated Hard BudgetsEarned autonomy
Use authorisation framework already developed nationally – apply locally
Same relationship of CCG – PCT as already developed for CCG – NCB
No bonuses!04/02/2012 SHA D R A F T 5
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Functions from CPCTs to CCGs?CGGs can draw on support as required – not as mandated
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Functions from CPCTs to CCGs?
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Do not create market ready CSOsKeep functionality within CSHA/CPCT/CCG as
appropriateWill vary across localities
Very large CCGs could have (mostly) own capacityExpertise kept within NHS (reduces redundancies)Supplement where required (?data analysis) from
external sourcesSome services may be national (economies of
scale)Some services might be shared with local authority
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National Commissioning BoardNHS Management Board? DH?Management of Commissioners and NHS TrustsHost for specialist commissioningEnsures continuity of CommissioningRegional outposts with locally appointed Boards/NEDs
Split Operational/Policy
Policy development - mandateTariffNational Service FrameworksOutcomes etc frameworksNational programmesResource allocations – capital programme
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Other Issuesto be resolved without primary legislationHealthwatch (replacing Links)H&SC Information CentreNICEALBsWorkforce Regulation
TrainingResearch
Widespread support for changes can be built upon and existing powers used where necessary.
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Solution HeadlinesNCB as SpHA – system performance management
Commissioning development and oversight Reconfiguration Hosts national specialist commissioning Hosting networks, senates, national services
Keep SHA and PCT Clusters CPCTs and CSHAs have strong governance structures
in placeAppoint clinicians to Boards – keep proper NEDsSenate for each CPCT (not PECs - more multi
professional)where CCG not appropriate or not competent04/02/2012 SHA D R A F T 5
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Solution HeadlinesMerge the CSOs into CPCTs – support to CCGs
(no market)Migrate capacity into CCGs as appropriate Will vary depending on size and capacity of CCGs
Converge CPCTS and HWBBs over timeColocation, shared posts, pooled budgets, shared
systems and informationContinue CCG authorisation process as CPCT
sub committees – but genuine delegationCPCTs have role in commissioning04/02/2012 SHA D R A F T 5