1. Commissioning and System Management NHS Contract for Community Services Third Sector Learning Event Welcome & Introduction Melinda Letts OBE

2. Commissioning and System Management Strategic context for the Standard NHS Contracts Anthony Kealy – Contract Development Lead

3. Commissioning and System Management 3 Why do we need new contracts? To strengthen commissioning To improve NHS business processes To strengthen accountability and improve performance

4. Commissioning and System Management 4 ‘Failure of Commissioning’ NHS has ‘commissioned’ for over a decade, but … ‘Command & control’ model has consistently reinforced the ‘provider line’ Commissioners have lacked robust levers Not all available levers have been used Inadequate regulatory regime Low investment in developing commissioners Highly variable & fragmented practice Lack of legitimacy (linked to ‘voice’ & patient /public engagement) Very limited range of providers

5. Commissioning and System Management 5 Re-launching commissioning –Commissioning Framework (July 06) –Third Sector Commissioning Task Force – (July 06) –Practice-Based Commissioning Guidance (November 06) –Interim New NHS Contract (December 06) –Commissioning Framework for Health & Well-being (March 07) –A Vision for World Class Commissioning (December 07) –New standard acute contract (December 07) –New standard community, mental health & ambulance contracts (December 08)

6. Commissioning and System Management 6 A new approach to contracting The need for new NHS contracts was introduced with in the Commissioning Framework, July 2006 This was reinforced by the Third Sector ‘No excuses…’ report Contracts becomes the main tool for achieving accountability and improving performance in a system with more autonomous providers The final version of the acute contract was published with the 08/09 Operating Framework New contracts are now being developed for –Ambulance –Community –Mental Health

7. Commissioning and System Management 7 Structure of the Contract ‘Must have’ elements for local negotiation 1.Are contractual or legal requirements 2.Are defined centrally 3.Require local detail so local agreement is necessary 4.Provide flexibility within a framework 5.Co-ordinating Commissioner defines consortium rules (by agreement) 6.Must be completed to make contract executable Elements for local agreement 1.Are locally defined, with no national or legal requirement 2.Must be internally consistent and not ‘trump’ required elements 3.Could cover any issues, but typically might cover care pathways, treatment protocols, quality standards Nationally Applicable Standard Terms 1.Are set centrally 2.Can be changed generically only through the NHS Operating Framework 3.Could be considered as “Standard NHS Terms and Conditions”

8. Commissioning and System Management 8 Main features A standard – not a model contract A new model of co-ordinated contracting Activity planning and review Demand management requirements National and locally-agreed quality standards Requirements on information flows and provision Dispute resolution arrangements Contractual Control mechanisms. Sanctions and / or incentives for performance on a small number of priority issues Locally-defined service specifications

9. Commissioning and System Management 9 Stakeholder Principles The contract should: Reflect vision, long term planning and change Recognise the community interest Provide clarity on commitments that need to made to stakeholders Clarify and define respective roles and responsibilities Recognise that open information is required from both parties to manage the contract Underpin a relationship between equals Understand mutual dependency and benefit of the parties in aiming for a partnership approach Support co-operation and collaborative behaviours that benefit both parties and cement the positive relationship between them. Be based on terms that are deliverable in practice

10. Commissioning and System Management 10 Expected behaviours Find and support win-win solutions Achieve appropriate risk sharing, and sharing of any benefits that are realised by mutual effort Maintain mature, regular dialogue within a professional code of conduct Ensure flexibility where there are genuine problems in delivery Provide incentives as well as penalties Recognise investment required to achieve requirements over a reasonable time period Support providers to change their service offer over time in relation to changes brought about through patient choices Maintain honesty and transparency – across both parties and with patients and the public

11. Commissioning and System Management 11 Project management Mark Britnell Contract National Steering Group Stakeholder Reference Group Mental Health Project Group Ambulance Project Group Community Services Project Group Task Sub-Groups DH Contract Project Support Group Task Sub-Groups Task Sub-Groups

12. Commissioning and System Management Developing a new Standard NHS Contract for Community Services - Overview of scope and structure Tracy Cannell System Management and New Enterprise Directorate

13. Commissioning and System Management 13 Aims, Strategic Links and Potential Barriers of Community Services Contract Strategic Links Next Stage Review including Primary & Community Services Strategy System Management 3rd sector & SE Programme Wider programme re. community services development Links to CQC re standard setting, monitoring and response to failure. Aims Flexibly support innovative commissioning approaches Improve care outcomes, Catalyst to maximise quality and productivity Support both joint commissioning & pathway based care Develop benchmarking. Potential Barriers Wide scope of coverage Cross-departmental approach for Section 75 agreements Joint approach to be agreed with DCSF re. childrens’ services, Legal agreements already in place with non-NHS bodies may delay implementation Current lack of standards/ targets in relation to quality and activity Community MDS not in place, metrics not yet available for majority of services

14. Commissioning and System Management 14 Out-Patient careIn-Patient CareCommunity drop- in Domiciliary Care 2143 Includes Rehabilitative and palliative care in community hospitals, hospices, nursing or residential homes Includes therapy services such as physiotherapy and podiatry as well as district nurse clinics. Includes specialist services such as family planning & health visiting Includes home visits by district nursing, occupational therapy, community midwifery and health visiting. Community Services Scope of community services contract

15. Commissioning and System Management 15 Potential Contract Routes for Community Services (1 of 2 ) Commissioner Benefit: Reflects most common current practice with commissioner contracting on an organisational basis with each provider therefore easy to implement Option 1 Option 2 Commissioner Lead provider for geographical area Benefit: Could reflect PBC or local approach with Local Authority with one provider accountable to commissioner

16. Commissioning and System Management 16 Potential Contract Routes for Community Services (2 of 2) Commissioner Strong Commissioning Commissioner Lead provider Benefit: One provider retains clinical and financial responsibility for the patient, as well as accountability to the commissioner Benefit: Commissioner / provider split is maintained, and commissioner retains full control of commissioning care Option 3 Option 4 SINGLE CARE PATHWAY

17. Commissioning and System Management 17 Core Requirements Heads of TermsLocal Issues Supporting Guidance 2143 Standard section containing nationally mandated approach with no local variation Contains standard legal requirements National core standards applicable to all community services, e.g. this could include HCAI targets, minimum data collection requirements Nationally identified issues but local targets, e.g. Could include stretch targets for performance information and quality standards. Service specification template to support locally determined commissioning To include guidance re. liabilities Community Services Contract Structure of community services contract For local determination

18. Commissioning and System Management 18 Performance and quality issues being considered for inclusion Patient held records Patient based use of NHS number Use of national MDS (to be developed) Assessment & care plan Diagnosis & Treatment codes Outcomes Communication between professional/services Infection control Choice/convenience - appointment times, transport and location Waiting times – 18 weeks, 1st & follow up, referrals Patient satisfaction Patient information re service

19. Commissioning and System Management 19 Key Policy Issues to address The role of sanctions and incentives Minimum information requirements and flows Mandatory performance and quality requirements Anticipating outcome of community metrics work and development of tariffs Compact Compliance e.g. Flexible payment arrangements Transition and adoption requirements for very small providers Relationship with primary care contracts

20. Commissioning and System Management 20 Key timescales & milestones March- Collation of current best practice completed April - Outline heads of terms available - Stakeholder workshops - Initial testing with stakeholders commences June- Identification of test sites & initial workshops - 3 rd Sector Learning Event September- Test sites complete Final Report October - Impact assessment processes Nov - Contract published & Transitional guidance issued, Dec- Implementation support programme Feb 2009- Contracts agreed and signed

21. Commissioning and System Management Further Information Tracy.Cannell@dh.gsi.gov.uk Monthly Bulletin available via ‘The Week’ (www.dh.gov.uk/en/managingyourorganis ation/commissioning/DH_085048)

22. Commissioning and System Management 22 Performance and quality issues being considered for inclusion Patient held records Patient based use of NHS number Use of national MDS (to be developed) Assessment & care plan Diagnosis & Treatment codes Outcomes Communication between professional/services Infection control Choice/convenience - appointment times, transport and location Waiting times – 18 weeks, 1st & follow up, referrals Patient satisfaction Patient information re service

23. Commissioning and System Management 23 Workshop Discussions Each group to consider how the contract can provide a sound approach and clarity for both commissioners and providers re. responsibility and accountability, performance management, risk management Identify any barriers/enablers/vital links Consider what support will be required to implement the contract And also specifically: –Performance Management –Contract Terms –Service Specification –Quality Standards –Flexibility

24. Commissioning and System Management Workshop Topics Group 1- Performance Management What are the key performance measures that should be incorporated into the contract as a baseline platform? Are/should these be duplicated by regulation? What measures should have incentives or penalties attached? Group 2 – Contract Terms Are the generic heads of terms appropriate in both its scope and detail? Can/should we scale the documentation according to contract value? Should block contracts be permitted? Is there sufficient understanding in the use of contracts vs grants? What if any variation or flexibility be given to the contract duration and notice periods? Group 3 - Service Specification Will the proposed specification guidance be sufficient to support local commissioning? Is it structured appropriately? What supplementary guidance would be helpful? Group 4 – Quality Standards What are the key generic standards that should be incorporated into the contract as a baseline platform? Are/should these be duplicated by regulation? What standards should have incentives or penalties attached? Group 5 – Flexibility of Contract Is the contract appropriately structured to support both commissioners and providers of:- Differing Organisations Care pathways Umbrella or lead provider arrangements Section 75 arrangements Co-ordinated commissioner arrangements If not how should this be changed and/or what’s missing?