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NHS White Paper 2010 – Update on Consultation Papers Council of Governors Briefing Paper December 2010
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Background NHS White Paper: Liberating the NHS (July 2010) Further consultation papers (consultation closed 12 October 2010) Transparency in Outcomes – A Framework Regulatory Healthcare Providers Local Democratic Legitimacy in Health Commissioning for Patients
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Transparency in Outcomes – A Framework for the NHS Reasons for change Government targets over the last 10 years ‘did little to improve patients health’ Need to create an NHS that is transparent about outcomes it is achieving for patients What will the NHS Outcomes Framework do? Help patients, the public and Parliament understand how well the NHS overall is doing Allow the Secretary of State to hold the new NHS Commissioning Board to account Help drive improvements in patients health outcomes
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Transparency in Outcomes – A Framework for the NHS What will be included in the NHS Outcomes Framework? Five high level domains Preventing people from dying prematurely Enhancing the quality of life for people with long-term EFFECTIVENESS conditions Helping people to recover from episodes of ill health or following injury PATIENT EXPERIENCE Ensuring people have a positive experience of care Treating and caring for people in a safe environment and SAFETY protecting them from avoidable harm
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Transparency in Outcomes – A Framework for the NHS Each of these five domains would have: Overarching outcome indicator (or set of indicators) Small number of specific improvement areas Supporting Quality Standards (from NICE) pathways to deliver better care
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Transparency in Outcomes – A Framework for the NHS NHS Confederation Response Welcome the general principle Concerns about the three Outcomes Frameworks (NHS/Social Care/Public Health) – They need to overlap and cannot be separate Concerns about practical implementation Are there reliable methods for measuring outcomes? Substantial cost of data collection Timeliness of information for use by patients Difficulty of converting population-based outcome measures (e.g. national cancer mortality rates) into provider quality indicators (unable to assess the respective responsibility of different providers along the pathway)
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Regulatory Healthcare Providers Foundation Trusts – Increased freedoms: Repeal arbitrary income cap Remove statutory controls over FTs’ borrowing limits FTs able to change their own constitutions to meet local needs (no longer require Monitor approval) Easier for FTs to choose how to evolve and organise (Board approves merger etc) Flexibility for governance arrangements e.g. employee-led FTs Department of Health (or third party) to manage FT financial failures (not Monitor) Monitor’s Revised Role: Economic regulator for all health and adult social care in England Independent of Government Develop a stable, rule-based system Monitor (and CQC) license providers – streamlines process Regulate NHS prices – set efficient or maximum prices/set prices for individual providers if in the patient/public interest Promote competition Ensure continued access to key services New cost for FTs: Pay to be licensed – to finance new Monitor Fines if license breached Levies to create a ‘funding risk pool’ to allow for management of insolvent FTs
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Regulatory Healthcare Providers NHS Confederation/FT Network Responses Concerns: Competition could cause issues for viability of specialist services, emergency care and complex services – Safety net of hospital Public Consultation can no longer be as slow and commissioner-led if a dynamic market is to operate – providers need to lead and process needs to be streamlined A banking facility is needed to provide long-term restructuring loans Difficult to deliver major structural change and £20bn cost savings simultaneously Concept of staff-led only organisations seems counter-intuitive to the NHS being accountable to the public FTs need greater freedom to withdraw from the provision of loss making services Review current incentive structures to encourage hospitals to create more integrated care between primary and secondary care GPs are commissioners and providers – need to ensure they are not acting anti-competitively Benefits Removal of arbitrary limits – capital and working capital Ability to change constitution Mergers/Acquisitions – Local Board decisions
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Local Democratic Legitimacy in Health Reasons for change Commissioning has been to remote from patients GP-led commissioning will ensure decisions are underpinned by clinical insight and knowledge of local healthcare needs Areas covered by the consultation Responsibilities (GP Consortia/NHS Commissioning Board) Commissioning GP Consortia – Elective hospital care, rehab, urgent and emergency care (including out-of- hours), community services, mental health, learning disabilities plus prescribing NHS Commissioning Board – Primary Care (GP practices), other family heath (e.g. dental), specialised services, maternity and prisons Finance Finance NHS Commissioning Board - calculate practice-level budgets/allocate to consortia Designing guidelines/contracts/tariff structures/data standards Financial stability of commissioners
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Local Democratic Legitimacy in Health Establishment of GP Consortia Statutory public bodies held to account for outcomes Shadow form from 2010/11 (Pathfinders being sent) Fully operational 2013/14 Freedoms, controls and accountabilities GP Consortia : Free to decide commissioning priorities Maximum allowance to cover management costs Manage resources to breakeven on commissioning budgets Commission services using any willing provider (Choice) Cannot provide services in their own right NHS Commissioning Board Significant role in managing financial risk Intervention powers in the event of poor financial management Develop a commissioning outcomes framework Decide proportion of GP income linked to achieving commissioned outcomes and financial risk Partnerships GP Consortia to work with local authorities – potentially via health and wellbeing boards
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Local Democratic Legitimacy in Health NHS Confederation Response Key Areas of Concern: Scale of change and resource implications Loss of short term focus during transition (particularly money) Potential loss of organisational memory Risks around splitting-up current PCT functions Likely running costs of GP Consortia How the system will work in practice i.e. GP commissioning and the role of competition versus local political influence on services provided Other issues: Why is maternity not commissioned at local level? Need to ensure consortia are not just GP-led but involve other professionals e.g. nurses, AHPs, etc Potential for competition to destabilise core local secondary care services How do consortia commission extended primary care from constituent practices ?
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Democratic Legitimacy in Health Strengthening public and patient involvement A strong local voice for patients via local democratic representation Patients/public have a clear route to influence services they receive Individuals have greater say in decisions Create local HealthWatch (replace LiNKS) – more like a ‘citizen’s advice bureau’ for health and social care – the local consumer champion Improving Integrated Working Local authorities have greater responsibility in: Leading joint strategic needs assessments Supporting local voice Promoting joined-up commissioning- NHS, social care and health improvement Leading on local health improvement and prevention activity Above gives local authorities influence over NHS Commissioning Local health and wellbeing boards (joint strategic needs assessments/promoting partnership working and integration)
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Democratic Legitimacy in Health NHS Confederation Response Supportive of many of the aspirations Key areas of concern: HealthWatch – Will it be properly resources and have relevant capacity? Health and Wellbeing Boards – Don’t necessarily increase legitimacy or local accountability Monitor – Unclear how it relates to health and well-being boards to ensure service continuity Public health and health improvement – Which tiers of local government are responsible for which functions? Scrutiny of major strategic changes – Inadequate attention to potential for provider- led service change
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