The Commissioning Framework for Health and Well-being

Aims 1.A shift towards services that are personal, sensitive to the needs of the individual and focused on maintaining independence. 2.A reorientation towards promoting health and well- being, and proactive prevention of ill health. 3.A stronger focus on commissioning for outcomes, across health and local government, working together to reduce health inequalities & promote equality

Where we are now Health reform and investment has changed the NHS Clinical outcomes have improved Increasing effectiveness of joint working across health & social care More choice among services, which are delivered closer to home BUT Commissioning for volume and price not quality and outcomes Too much care in institutional settings Health inequalities remain Focus on treating illness not preventing it Limited diversity of providers Individual choices still limited, local voices sometimes unheard

They told us: Health links to the community are less systematic than LA links Joint strategic needs assessment is happening – but in few places The sharing of information to support commissioning is often patchy Commissioners often find that providers are unwilling or unable to provide the new and innovative services they want to secure When people need a package of care delivered by more than one provider, it often requires front-line practitioners to pull this together Being in work matters to the health and well-being of individuals and communities Incentives within commissioning systems do not yet fully support the delivery of better health and well-being The accountability for partnership working can be weak, leading to misunderstandings and the breakdown of relationships Capability to commission well is under-developed We asked a cross section of health and local authority commissioners what the obstacles were

Our Vision Applies to everyone and includes social care, work, housing - to build a sustainable community BY providing personalised services proactively preventing ill health and promoting well-being supporting independence and working in partnership to promote equality by focusing on outcomes

Does it work? We know commissioning in this way works for people 3 people share their story Additional local case studies available

Ali’s story My daughter, Ali, is sixteen years old and has complex needs. Eighteen months ago, we were anticipating a crisis; Ali’s foster mother was planning to retire, the respite services offered by the local authority were unsuitable and the local Social Services Children’s Department were struggling to find any alternatives. The final solution involved us taking control by designing our own wrap-around staff team for Ali. This has meant that we can hand-pick Personal Assistants to ensure we get the right people for the job, people we can trust and feel comfortable around. Ali enjoys having these new friends in her life to help her become more independent. Her social life has taken on a new dimension. More information is available at control.org.ukwww.in- control.org.uk

Eric’s story I am 65, and waiting for a hip replacement. My Health Visitor referred me to Pedal Back the Years. I now go on cycle rides in beautiful scenery regularly, and have made some good friends. I have found the exercise and companionship offered by PBTY to be invaluable. It has not only given me a reason to take regular exercise, but has provided support with up-to-date advice. It is also an added boost to my cardio vascular exercise routine, which I have been on since having a heart attack some years ago. Some younger people I have met on the scheme have been able to go back to work, because they are fitter, and have so much more confidence. More information about Pedal Back the Years is available at

Freda’s story I am 82 years old and I live in Poole. I am registered partially sighted and sometimes have trouble remembering things. A few months ago, I fell and hurt my leg, which needed regular dressing by the nurse. I didn’t always remember to go to the surgery, or that the nurse was supposed to be coming to visit, so the nurse referred me to the Partnerships for Older People Project (POPP). They arranged for George, a Help and Care Volunteer Driver, to come and pick me up and take me to the surgery, which meant I was able to get to my appointments. My leg has now healed. More information about the POPP is available from the Department of Health website:

Eight steps to more effective commissioning 1.Putting people at the centre of commissioning 2.Understanding the needs of populations and individuals 3.Sharing and using information more effectively 4.Assuring high quality providers for all services 5.Recognising the interdependence of work, health and well-being 6.Developing incentives for commissioning for health and well-being 7.Making it happen: local accountability 8.Making it happen: capability and leadership

Putting people at the centre of commissioning Solutions: Greater choice over services and treatments (including self-care) Access to good information and advice about local services and health Using PBC to design care packages that suit individual needs and supporting users to design their own Individual budgets Developing mechanisms for the public to get involved in shaping services, with advocacy for groups who find it hard to express views Working with Overview and Scrutiny Committees (OSCs) to ensure that commissioning decisions reflect the needs of the whole community Obstacle:Health links to the community tend to be less systematic than LA links

Understanding the needs of populations and individuals Obstacle:Joint strategic needs assessment is happening – but in few places Solutions: At individual level… Using recognised assessment and care planning processes Understanding and mitigating risks to the health and well-being of individuals At population level… Carrying out a joint strategic needs assessment (backed up by a new duty), pooling knowledge between local commissioners Using appropriate analytical techniques

Joint Strategic Needs Assessment Who:  Local commissioners (with local communities, providers, GPs) What:  description of future health, care and well-being needs of local populations  strategic direction of service delivery to meet those needs Outcomes:  Services that have been shaped by local communities (‘voice’)  Inequalities are reduced  Social inclusion increases  These outcomes are maximised at minimum cost (VfM)

Sharing and using information more effectively Obstacle:the sharing of information to support commissioning is often patchy Solutions: At individual level… Clarifying what information, and under what circumstances, can be shared Supporting local action to join up IT systems of front-line practitioners At population level… Consolidating informatics, analytical skills and capability across public sector partners Consulting on a shared minimum dataset for Joint Strategic Needs Assessment (see Annex A) Clarifying the legal requirements

Assuring high quality providers for all services Obstacle:providers are sometimes unwilling or unable to provide new and innovative services Solutions: Commissioning focused on outcomes Wider range of providers – from all sectors Develop effective, strong partnerships with providers Transparent and fair procurement National contract templates More innovative provision, tailored to the needs of individuals (engage providers in needs assessments) Intelligent decommissioning And the review of the regulatory system (The future of regulation of health and adult social care in England, consultation closed 28 Feb 2007)

Recognising the interdependence of work, health and well-being Being in work matters to the health and well-being of individuals and communities Commissioners could help individuals retain or gain employment, and promote workers health and well-being by: Re-modelling health service delivery for working age population Facilitating collaborative approaches with businesses to improve advice and support for individuals Encouraging providers to recruit locally and provide work opportunities for individuals with long-term illness or disability Incentivising providers of NHS and social care to support and promote health and well-being of their employees Including actions to enable individuals to return to and stay in good health in the commissioning of acute and urgent care services Encouraging all local employers to use workplaces as settings for health improvement

Developing incentives for commissioning for health and well-being Obstacle:Incentives within commissioning systems do not yet fully support the delivery of better health and well-being. Solutions: Using LAAs to bring together local partners Use existing investment vehicles to deliver the vision, eg pooled budgets Using contracts and a contractual regime that encourage providers to deliver health, well-being and independence Enabling people to join up their own care e.g. through individual budget pilots, direct payments, Year of Care approach PBC spending on non-health interventions Ensuring fit between Children’s Trusts and PBC

Practice Based Commissioners Practice based commissioners should be more flexible in using NHS funds (including spending on non-health interventions), where they can:  provide a more appropriate alternative to hospital admission  avoid more expensive interventions which may also reduce independence  examples might include the purchase of respite care and supporting healthy lifestyles PBCs are well placed to make referrals for interventions that support self care and continued independence As part of a local joint strategy, PBCs can play a key role in shaping services to better address the unmet needs of population groups that have been significantly under-served in the past

Practice Based Commissioners Purchase of respite care – This allows carers to take a break, particularly families of children with a disability, or when patients with a terminal illness need more intensive nursing for a fixed period of time. This significantly reduces unnecessary hospice and acute hospital admissions. Supporting carers of terminally ill patients so that people with a terminal illness can choose to stay and die at home. Supporting greater independence for people with long-term conditions – This could include provision of self-monitoring equipment (e.g. to measure blood pressure) and self-care educational programmes. Purchase of anger management support for children and young people – This helps prevent situations arising of self-harm or harm to others which would otherwise require medical treatment and so reduces calls on practice-based or acute health services.

Commissioning for health and well-being relies on a partnership between: Department of Health Other Govt Departments Communities & Local Govt SHAs Government Offices PCT Local Authorities GP PracticesNeighbourhoods Regional Directors of Public Health Local Strategic Partnership

Making it happen – local accountability Obstacle:Accountability for partnership working can be weak, leading to misunderstandings and the breakdown of relationships Solutions: DH and CLG will develop a single health and social care outcomes framework, with an aligned set of outcomes metrics Joint, published local strategies for improving health and well-being PCT Prospectuses Local Area Agreements OSCs, Petitions and LINks Learn from commissioning of children’s services

Making it happen: capability and leadership Obstacle:Capability to commission well is under- developed Solutions: For PCTs and social care commissioners: Building on the Fitness for Purpose programme (FfP) and State of Social Care 2005/06 report Developing appropriate development plans and a National Improvement Programme of education, training and support For Practice Based Commissioners: Reviewing their development needs and working out how best to meet these, drawing on the range of nationally available programmes led by the Improvement Foundation

Next Steps The consultation opened on March 6 th and will run until May 29 th 2007 Please do take the opportunity to comment at We will analyse the responses received and report back in the summer The framework will apply from 2008/09 onwards – although we will expect commissioners to use it to inform their preparations during 2007/08. It is important to ensure that discussions are taking place now with frontline staff about how to put the framework into practice.

Choice beyond elective care remains minimal Local voice is limited Too few providers for some types of care Rarely possible to choose various providers as part of a single, seamless care package Too much long term care is still provided in institutional settings Health inequalities still exist and could be exacerbated unless choice is implemented carefully Currently choice of 4 or more providers for elective care From July 2007 free choice of providers for orthopaedic procedures From April 2008 free choice of providers for all elective care The Choice Framework BUT

Making choice happen We will consult on the best way to make sure people are offered real choices. One possible approach is: National Guarantee –Everyone, no matter where they live, is guaranteed this choice. It will be performance managed from the centre. Local Guarantee –To be determined by commissioners in consultation with their local population, and published in prospectuses. Or a mixture of the two

Next Steps Ongoing engagement with stakeholders Drafting of choice framework Publication of framework for consultation Consultation period (3 months) Frame- work finalised, based on consult- ation