0. NHS Commissioning Board- Clinical leadership The role of Local Dental Networks
Sam Illingworth
Dental, Pharmacy, Eye Care Lead
NHSCB Authority
21st May 2012
NHS | Presentation to [XXXX Company] | [Type Date]

1. Aim to cover Update on NHSCB
Key features of (proposed) NHSCB operating model for primary care
Concept and context of local professional networks
Focus on local dental networks
NHSCB strategic role
NHSCB operational/specific roles
NHSCB dental commissioning strategy – all dental services
Timescales for sign off and implementation 1

2. Primary Care Commissioning: a single operating model
New Public Health Service
The new architecture will take on many of the roles and responsibilities currently discharged by the Department of Health, Strategic Health Authorities and Primary Care Trusts
Responsibility for most commissioning with commissioning consortia, supported and supplemented by the NHS Commissioning Board
‘Design of the NHS Commissioning Board’, published January and supplement in May 2012.
Next NHSCB publication detailing local area office teams: Footprints, functions and senior structures within them
Primary Care Commissioning: as single operating model – due to be published soon after
The NHS Commissioning Board will be responsible for commissioning all NHS dental services, including primary, OOH, community and secondary services

3. Focus for the design and transition
The safe transfer of functions that must continue
Creation of a system capable of transforming primary care services (and ALL dental services)
Prioritising the single operating procedures needed on day 1
Ensuring effective alignment with critical interdependencies
Clear outcome measures, indicators and a single accountability framework
How to encourage and support the right behaviours for a new system to:
Be effective from the start
Mature over time through continued co-production, which will continue beyond April 2013
Develop in tandem with those around it e.g. CCGs, HWB, PHE, LETBs

4. Design challenge
The Department of Health has been responsible for negotiating the contracts, providing guidance to PCTs and high level strategic planning
These functions will transfer to the NHSCB
Primary Care Commissioning has been defined and delivered in different ways by PCTs. Some PCTs have had a strategic approach others have ‘managed contracts’
The NHSCB will define and deliver it in one way
Behaviour has ranged from mature, collaborative relationships through to adversarial
The NHSCB will define expectations of behaviour but it takes two to tango and behaviour change takes time
The new environment will be very different
CCGs as statutory bodies, Commissioning Support Organisations, no boards in a local office, more things done centrally, risk based approach, fewer managers than currently, more clinicians than currently with a different leadership challenge

5. Proposed operating model
Three elements
What happens locally (including regions)
What happens nationally
The interface and relationships between the two – key iterative relationship
Key features
Single system with a consistent operating model
Organising principle of quality and safety
Clinically led throughout system with local professional networks at more local level
Shared values and behaviours and productive relationships
Common policies and procedures
Clear outcome measures, indicators and a single accountability framework
But do not want to stifle local innovation in service and quality improvement

6. NHS Commissioning Board Structure

7. NHSCB local area teams
The local area teams will be responsible for contract management, service development and support functions leading to overall quality improvement.
CCGs anticipated to play major role in improving quality of primary medical care and will have a statutory duty to assist and support the Board in doing so.
For the other 3 independent contractor groups (dentistry, optometry and pharmacy) local professional networks will be embedded into the local teams to provide local intelligence and expertise into the quality improvement work for primary care
For dentistry, local professional networks will play a key role in the development of care pathways and could be the commissioning vehicle for the Board for dental services.

8. NHSCB central CCGs PC providers/ Contractors LPNs
NHSCB local teams (contracting relationship with individual practices)
CCGs
MICRO COMMISSIONING SYSTEM
Implementation and development plans to reflect local circumstances
Strategy, policy, contract, procedure and assurance of achievement of outcomes
Aggregation of need and assurance of performance
Peer review, benchmarking and development to deliver the contract
Maximising performance
Local intelligence, clinical expertise, innovation and development of integrated care pathways
Informing needs, demand, supply in primary care
LETBs (Local Education & Training Boards)
Health and wellbeing boards
Patients, carers and the Public
Local representative committees
PC providers/
Contractors
LPNs 8

9. Interdependencies and wider system
Intelligence for commissioners
CQC concordat
PHE concordat
HWB/LA – local memorandum of understanding/agreement
Commissioning support service requirements – BSA and CSUs
Transition programme
Testing the LPN concept – learning is refining our proposals and will inform transition planning

10. Local dental networks – learning from testing and wider system establishment

11. NHSCB: Commissioning Dental Services
The NHSCB will be responsible for commissioning all dental services, primary, community and secondary (inc urgent care and OOH)
Single operating model provides a unique opportunity for consistency where it is required (but must maintain flexibility where it is justified)
Opportunity to commission dentistry in an integrated way – concentrating on care pathways not care settings
Key to this is to maximise quality and performance across pathways against consistent measures
Quality and consistency of primary and community care dental services key driver for transformation agenda of the future – significant move to a preventative approach (dental contract pilots) and consistent care pathway (advanced care)
Clinical leadership key to our model to deliver continuous quality improvement, consistency and transformation (innovation!)

12. Local professional networks: Context and concept
An integral part of the NHS CB local offices (NOT an external body or network)
No independent status or constitution – part of NHSCB local area teams
Accountable to most senior clinician/ commissioner in NHSCB local office with professional accountability to CPO
Ensure clinical leadership at the heart of the local operating model
Delivering functions where clinical expertise and leadership can add most value
Commissioning managers and clinicians delivering NHS CB (and wider) vision together
Common purpose grounded in national and local priorities
Local dental network role far greater in commissioning agenda than pharmacy and eye care – potential future vehicle for delivering NHSCB dental commissioning agenda

13. Our testing has shown that we need to support LDN development within clear framework…

14. What some testing the concept have attempted…

15. Local dental networks overarching objectives
An NHSCB vehicle for clinically led and clinically owned delivery of;
Local implementation of NHSCB strategy – turning national mandate and local priorities into a deliverable implementation plan (within finite resources)
Improving and assuring quality and performance – CQC, local offices (networks rather than isolated clinical advisors), performance and links to performer list management
Planning and designing local care pathways and dental services - Best use of NHS resources and advocacy for patients on consistency of NHS offer
Oral health strategy and oral health improvement for dental services - Best outcomes for patients that reflects local need via JSNA, oral health strategies – turning national and local strategy into local commissioning and improvement plans.
Clinical and professional leadership and engagement – ensuring engagement across all providers, performers and LDCs.
Local Professional Networks: What are they
There are a number of key common areas that the LPNs for dentistry, pharmacy and eye care will work on.
It is important that we have clinical leadership to lead the delivery of these things because;
Clinicians have a real understanding of local need and an understanding of how, where and why local people access services in the way that they do
True clinical engagement from front line staff in dentistry, pharmacy and eye care will ensure clinical ownership of continuous quality improvement by the profession
Effective relationships so commissioning of services integrated and personalised for the patient.
Local intelligence – recognising and sharing what is good and supporting poor or deteriorating practice to turn around
Peer review and peer support – developing a new culture where this is the norm
Supporting innovation and making sure what works informs national policy
Underpinned by strong professional and clinical leadership and engagement

16. What have we have learned from the past?
The evidence over the past few years suggests that ‘commissioning’ primary and community care as opposed to contract management leads to better services and outcomes for patients.
Strong commissioners have improved services for patients and achieved greater value for money through the removal or remediation of poor performance and inefficiency, but...
Commissioners who have engaged clinicians and patients have come up with innovative solutions to local problems and some of those innovations are now influencing at a national level e.g. new primary care contracts
That a pre-occupation with the contract as opposed to the relationship with contractors can stifle quality improvement.
That a sound evidence base of causes and consequences and a fair and transparent process is required if poor performance is to be addressed.
That a clinician has greater impact in conversations with a contractor than a manager and can evidence change as a result of their intervention.

17. Local dental networks operating model
Core LDN Team - led by clinicians, with priorities focussed in national and local delivery. Driver should be oral health and oral health improvement plans as priorities.
LDN Networks – opportunities to engage clinicians to lead specific areas of LDN programme. Delivering short or longer term objectives within and between local office areas. Wider opportunities for other interested clinicians to be involved in projects.
Wider engagement – opportunities for all providers, performers and wider teams to engage with LPN work, two-way communications, implementation across all providers, learning and sharing best practice.
All dental providers and performers
(influence, communications, roll out, embedding)
Clinical Networks
(clinical expertise for ‘task and finish’ projects, quality improvement, pathway re-design, strategic development and planning)
Core Local Dental Network Team (commissioning managers, clinical quality and network leaders, public health)

18. All dental providers and performers, stakeholders
Local dental networks: Core team
Core LDN Team
Small team with ownership of LDN agenda across a local area team and links into national and across other NHSCB areas
Clinicians and commissioners delivering NHSCB agenda – admin and financial support from local team and CSS where required
Accountability at local and national level for dental delivery – to senior local area likely via a direct commissioning forum
Employed/contracted clinical time to NHSCB local area team to deliver NHSCB dental agenda within a clear operating framework
Professionally accountable to CDO and links to national dental development agenda, including clinical senates and national networks
NHSCB likely to formally appoint clinicians to LDN, so current ‘testing’ arrangements are interim
Role and clinical leadership will evolve and develop over time
Key priority is quality and performance assurance and improvement
Need to clearly distinguish LDN and LDC role – they are not the same. LDC invited stakeholder/partner not key core member
All dental providers and performers, stakeholders
Clinical Networks
Core Local
Dental Network Team

19. All dental providers and performers, stakeholders
Local dental networks: Network delivery models
Dental Networks – example models being collected
Many models emerging from testing have common key themes
Focus and capacity requirements will depend on national and local priorities – networks managed by core team
Allows flexible and efficient approach to progressing specific areas of programme – some networks may be time limited project specific
Opportunities for other clinicians and interested professionals to get involved
Networks feed other strategic and operational interdependencies via core team
All dental providers and performers, stakeholders
Core Team
Clinical Networks
Core Local
Dental Network Team
Restorative
Oral
Surgery
Special Care
Dentistry
Specialist
areas
Quality
Assurance
And Imp
STRATEGIC AND OPERATIONAL INTERDEPENDENCIES
Patients, Providers, Workforce, Engagement, HWB, JSNA, Commissioning Priorities

20. All dental providers and performers, stakeholders
Local dental networks: Wider engagement
Clinical and Professional Leadership & Engagement
NHSCB local area teams and national support centre will want to establish efficient and effective engagement with all providers and performers and wider dental provider teams
Testing has provided some innovative examples of this – local web-based networks providing updates and means to engage for wider clinical community
Clinical leaders employed within NHSCB local dental networks need ability to bring the profession with them
Clinical consensus (as far as possible) on standard and quality of patient care
All dental providers and performers, stakeholders
Clinical Networks
Core Local
Dental Network Team

21. Clinical leadership
What we will need from clinicians in local dental networks
A progressive approach in thinking, culture and behaviour
A commitment and desire to improve quality and services for patients
Population view - public health specialists
Evidence – based approach to clinical effectiveness
Strategic and operational skills
Objective advisory and decision making
Willingness to take action and responsibility
Engaging the local profession and local representative committees
Ensuring success in new relationships, behaviour and culture

22. Clinical and professional partnerships
Emerging local dental networks have involvement and engagement from a wide range of stakeholders and partners;
Primary and Secondary Care Commissioners
Dental Public Health
Quality and Performance Improvement Leads – clinical and managerial
Clinical and Professional Expertise
Specialist Clinical Input – secondary and community care
PC clinicians with a specialist interest
Clinical Skill Mix (e.g. dental nurses)
Health and Wellbeing Board representation
Local Dental Committees
Workforce and Development – deaneries, CPPE (LETBs)
Patient and the Public Representation
CCG Representation
Interdependencies to support as appropriate – e.g. Informatics, Finance, PC regulatory experts

23. Governance and conflict of interest
Using Towards Establishment of CCGs as outline framework
Recommendation that NHSCB will formally appoint clinical resource to LPNs
Learning from governance frameworks of testing and existing best practice PCT arrangements
Single organisation means working across local office boundaries to support governance can be hard-wired
Consistent and robust approaches to things like procurement, decision making and reviews
The single operating model is a key driver in ensuring self governance and spotlighting issues

24. Local dental networks: measures of success success
Delivery of clinically owned quality and performance improvement
Clinically owned care pathway approach to commissioning dental services
A consistent NHS dental offer for patients
A consistent experience for all providers in their contractual relationship with NHSCB
Clinical ownership and relevance to commissioning agenda across dentistry
Iterative, clinically developed strategy and policy at national level developed through experience and needs of local area teams
Strong governance, transparency and management of any conflicts of interest

25. Next steps
Socialising the operating model – we will do this through Primary Care Commissioning: a single operating model
Continue to refine the proposals and added value of local dental networks – currently extracting learning and alignment to wider system requirements
Continue to refine detail of dental commissioning through co-production of ‘Dental Commissioning Framework’ document
Contributing to central and local structures and ensuring the integrity of the single operating model and the strength of clinical leadership is preserved
Working with Operations to develop a very clear transition plan and support for PCT clusters
Continuing to test assumptions and adapt/refine
Contribution to the OD programmes

26. NHSCB: care pathway approach to commissioning dental services: Community and secondary care services

27. NHSCB: Commissioning Dental Services
The NHSCB will be responsible for commissioning all dental services, primary, community and secondary (inc urgent care and OOH)
Single operating model provides a unique opportunity for consistency where it is required (but must maintain flexibility where it is justified)
Opportunity to commission dentistry in an integrated way – concentrating on care pathways not care settings
Key to this is to maximise quality and performance across pathways against consistent measures
Quality and consistency of primary and community care dental services key driver for transformation agenda of the future – significant move to a preventative approach (dental contract pilots) and consistent care pathway (advanced care)
To ensure traction to NHSCB, we are developing an NHSCB dental commissioning framework – future facing vision and strategy

28. Dental Commissioning Task Group Developing Proposals for NHSCB
Aims of the group;
Articulate NHSCBs strategic approach and vision for commissioning all dental services
Describe the care pathway approach to commissioning and the ‘ingredients’ required to make this a reality
Identify the enablers and levers required to deliver this and where in the system they need to be developed and delivered
Outline how the NHSCB will align it’s Directorate resources, skills and commissioning support requirements to deliver this
Describe the key strategic and operational relationships that the NHSCB will need to deliver the strategy and vision
Like our primary care work must have two parallel aims;
Safe and robust transfer of current arrangements, but;
Designed as a system capable of transforming and improving services

29. NHSCB Dental Commissioning Strategy
To be an exemplar commissioner we have established that NHSCB will require;
Consistent care pathway design across all specialties encompassing procedures, levels of complexity, standards and criteria, costs and coding, specifications and KPIs, including outcome measures
Consistent method to capture need/diagnosis and level of complexity for all specialties and referrals
Consistent information and intelligence for performance management and financial control
National (clinical and commissioner) consensus on these elements, for local translation into implementation

30. Ingredients for pathway commissioning
NHSCB skills and resources in right place
Vision and strategy: Commissioning Development/Operations/Clinical of NHSCB
Enablers: clinical and commercial
(advanced care, contract pilot, PbR, tariff etc)
Aligning Interdependencies
e.g workforce, market management