Implications of the Health and Social Care Act Cheryl Davenport Director of Business Development Leicestershire Partnership Trust

Equity and Excellence: Liberating the NHS

Overview of the Act - 1 The Health and Social Care Act received Royal Assent in March It contains a series of powers and structural changes to modernise and improve the health and care system. The Act is based on Equity and Excellence: Liberating the NHS, (published July 2010) and the Government’s Response to the NHS Future Forum (published June 2011). –Current local commissioning organisations (primary care trusts) will be abolished in April 2013 along with strategic health authorities. –The majority of local health sector commissioning will be led by clinical commissioning groups (CCGs) and local authorities who take over local public health responsibilities –The NHS Commissioning Board (national body) will be established in October 2012 and will commission some services on behalf of CCGs. It will have 4 main hubs, supported by a number of Local Area Offices. –Local democratic accountability is being improved through the creation of Health and Wellbeing Boards (in shadow form by April 2012, formally established by April 2013), and the establishment of Local Healthwatch organisations to be in place by April 2013) – work being led by local authorities (Information on this slide is supported by the “Fact Sheet” handout)

Overview of the Act - 2 –A number of other national bodies are being established including: Healthwatch England (October 2012) Public Health England (April 2013, incorporating current Health Protection Agency functions) Health Education England (June 2012) NHS Property Services Ltd (April 2013) –Monitor - an existing organisation regulating existing NHS Foundation Trusts has revised regulatory duties including licensing all healthcare provider organisations, - balancing choice, competition and integration to improve care –The NHS Trusts Development Agency (to be established June 2012) will be responsible for preparing all remaining NHS Trusts for Foundation Status –CCGs will go through a process of authorisation in four waves between June and December –A small number of Commissioning Support Services organisations (CSS) are being created and evaluated during 2012/13 to provide specialist/shared/back office support services to multiple CCGs THE MAJORITY OF THE CHANGES WILL HAVE BEEN COMPLETED BY APRIL 2013 (Information on this slide is supported by the “Fact Sheet” handout)

Changes in Commissioning National Regionall Local April 2010 April 2013 Department of Health Strategic Health Authorities Primary Care Trusts, working with practice based commissioners Local authorities (for elements of public health) NHS Commissioning Board (NHS CB) Local Area Teams (LATs) of the NHS CB Clinical commissioning groups for NHS services Local authorities (for public health improvement) Public Health England (for public health protection)

Who commissions in the new health system? NHS Commissioning Board Primary care GPs Dentists Pharmacists Optometrists Specialised commissioning Prison health Immunisation Public Health 0-5yrs Screening Clinical Commissioning Groups Most commissioning of healthcare services locally Local government Health and Wellbeing Board Public health Health improvement Health protection Healthcare PH JSNA Joint health and Wellbeing Strategy (with CCGs) Promote integrated commissioning Public Health England Health Protection Emergency Preparedness National Treatment Agency functions Evidence and information Cancer registries Advocacy National campaigns Observatories Health and Wellbeing Board

The Role of Local Authorities Democratic accountability in health Public Health Commission Local Healthwatch Health and Wellbeing Boards Scrutiny Functions Relationships with Districts and Borough Councils

Role of Health and Wellbeing Boards Improve local democratic accountability Promote integration and partnership working between the NHS, Social Care, Public Health and other local services Publish joint strategic needs assessments Develop and deliver a joint health and wellbeing strategy Engage with local people about health and wellbeing In order to….improve outcomes for health and wellbeing in the local population

Example of Board Composition - Leicestershire Cabinet Lead Members for: –Health (Chair) –Adult Social Care and Communities –Children and Young People 2 representatives of each Clinical Commissioning Group Local Authority Directors of: –Public Health –Adults and Communities –Children and Young People 2 LINk representatives (later Local HealthWatch Chief Executive NHS Commissioning Board Local Team 2 District Council representatives 1 Police representative

The Role of the NHS Commissioning Board Improve Outcomes Deliver the Mandate Develop Clinical Commissioning Groups Commission Primary Care Services, Specialist Services, (plus some public health functions and prison healthcare) Operate nationally and through Local Area Teams (LATs) - single operating model Concordat with Local Government

NHS Commissioning Board Mandate April 2013-March 2015

Development of Clinical Commissioning Groups (CCGs) One of the main aims of the NHS reforms is to ensure clinical leadership is at the heart of commissioning. The NHS CB’s role is to support CCGs to develop locally and provide assurance that CCGs are able to: –Commission safely –Use the their budgets responsibly –Exercise their functions to improve quality, reduce inequality and deliver improved outcomes within the available resources.

The Role of Healthwatch England Healthwatch England was created in October The role of Healthwatch England is to: –Assist in the creation of Local Healthwatch organisations and provide them with a coordinating network. –Make sure the voices of people who use health and social care services are heard by the Secretary of State for Health, the Care Quality Commission (CQC), the NHS Commissioning Board, Monitor and every local authority in England.

The Role of Local Healthwatch - 1 The role of Local Healthwatch is to:- –Engage with local people about local NHS and social care commissioning and provision –Involve patients, services users and the public to ensure the voice of local people plays a central and active role in the planning and delivery of local services, including through representation at the local health and wellbeing board.

The Role of Local Healthwatch - 2 They will: –Have the power to enter and view services. –Influence how services are set up and commissioned by having a seat on the local health and wellbeing board. –Produce reports which influence the way services are designed and delivered. –Provide information, advice and support about local services. –Pass information and recommendations to Healthwatch England and the Care Quality Commission.

Implications for Provider Trusts Foundation Trust Status – requirement by 2014 Monitor - the new economic regulator –Licensing (with CQC) –Prices –Integration –Competition –Service continuity NHS Trust Development Authority Complexities for providers interacting with the new landscape

What’s Happening Locally? All 3 local CCGs are in shadow form applied for authorisation in the first wave (June 2012). Decision expected December. Shadow Health and Wellbeing Boards are now in place across LLR There is likely to be a Commissioning Support Service covering CCGs in the Greater East Midlands area (this will include Leicester, Nottingham, Lincoln, Derby, Northampton, Milton Keynes) Public Health transition plans are progressing in line with national requirements The NHS Commissioning Board Local Area Team was established in shadow form in October 2012 and covers Leicestershire and Lincolnshire Leicestershire Partnership Trust is currently applying for Foundation Trust Status University Hospitals of Leicester intends to apply for Foundation Trust Status in line with national timescales (by April 2014)

Some of the challenges in the new system… Overlaps in roles and accountabilities? Fragmentation of commissioning? The tension between integration and competition? Spotlight on contracts, efficiencies and specifications New markets and mechanisms e.g. any qualified provider

 Ageing population requiring greater levels of integrated “wrap around” care  Consumer expectations – e.g. on quality, involvement, choice, and the channels by which care will be planned and delivered in the future  Funding flatlined in public sector / Nicholson Challenge  Monitor efficiency target for FTs  Scale of enterprises that might be needed to withstand market conditions and tariff efficiencies 20 Burning platform for integration?

 “Health and social care provision that is seamless, personalised and flexible” Jennifer Dixon, Nuffield Trust  “Smoothness with which a patient or carer can navigate the NHS and social care systems in order to meet their needs” Frontier Economics  “Care organised around the needs of individuals” National Voices  “A tool to improve outcomes for individuals or communities” Health Select Committee  “People want care and coordination, not necessarily organisational integration, where it comes from is secondary” The Richmond Group of Charities 21 Some Integration Definitions

 Health and Social Care Act places duties on CCGs, Health and Wellbeing Boards, Monitor and the NHS Commissioning Board to promote integration  Monitor’s role is defined as supporting integration of services where it improves care (at the same time as taking action against anti-competitive behaviour)  Integration therefore will be delivered by commissioners and providers operating in an increasingly complex market for healthcare 22 Integration in the reformed NHS

23  Competition for the market – where providers are invited to tender for the provision of integrated services  Competition within the market – where patients are offered a choice from a menu of providers, and (soon) where patients commission for themselves through holding personal healthcare budgets What do we mean by competition?

 Understanding what consumers need and want in terms of integrated care  More definition / guidance / regulation? – what are the boundaries to avoid collusion and conflicts of interest in the new commissioner / provider landscape?  Understanding the implications and differences between organisational level / transactional integration and integration at care pathway levels  New tariffs to promote integrated pathways  Learning Lessons –the UK’s Integrated Care Organisation (ICO) pilots, Accountable Care Organisations and vertical integration models (such as Kaiser) in the USA, and from healthcare mergers 24 Issues, risks and concerns

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