1. Commissioning and the third sector the NHS NW perspective Seamus McGirr Associate Director, Commissioning & Strategy, NHS Northwest

2. summary We’ve moved beyond the idea that the third sector have a divine right to delivering more public services and that they are a panacea to the ills of those services. Commissioners - must have the aptitude and skills to be system leaders, getting the most out of their local provider markets for the best possible outcomes Providers - must learn to differentiate themselves from their competitors, ‘making the case’ in terms of quality and outcomes.

3. Stepping stones to transformation Inputs Money Leaders and workforce Structures Infrastructure Processes Commissioning Providers - competitive behaviours Regulation System management Outcomes Reducing inequality Increasing quality and safety Value for Money Improved health outcomes Patient experience aligned

4. More choice, greater voice for patients (demand side reforms) A framework of regulation & decision-making ensuring fairness, safety, quality.... (system management reforms) Better care, better patient experience & better VfM Money following patients (transactional reforms) Provider Diversification freedoms and scope to innovate (supply side reforms) NHS System Reforms

5. ‘demand-side’ reform: commissioning Most definitions of commissioning paint a picture of a cycle of activities at a strategic level including: Assessing the needs of a population Setting priorities and developing commissioning strategies to meet those needs in line with local and national targets Securing services from providers to meet those needs and targets, and Monitoring and evaluating outcomes

7. World class commissioning? What do you think of when you think of ‘the NHS’? ….your local hospital (the ‘provider’ of services)

8. World class commissioning? What do you think of when you think of ‘the NHS’? …. your local primary care trust? (the commissioners of services)

9. World class commissioning? We have a system that’s dominated by buildings- based, NHS providers of services – the hospital trusts, the Foundation Trusts, in-house primary care services But those services are expensive; they’re not always responsive to changing health need; they’re ‘one size fits all’; hospital-based services treat illness/the sick but don’t help people to stay well.

10. World class commissioning? Department of Health wants commissioning organisations to become the ‘face’ of NHS (NHS Local) – and for people have a choice of ‘provider’ Commissioners in the driving seat – ensuring that services are commissioned represent value for money, choice for patients, preventative options that are close to home.

11. World class commissioning - competences

12. Who are the commissioners (your customers?) The commissioning ‘function’ within our health care systems is changing. New levels of commissioning have been introduced: MACRO – Strategic commissioning – often happens in partnerships between organisations/sectors in a locality or a region MICRO – Practice Based Commissioning within GP practices, clusters and consortia INDIVIDUAL – Social care funding streams increasingly commissioned by end user through direct payments, individualised budgets

13. Who are the health commissioners? Providers shouldn’t just focus on existing PCT or Local Authority commissioners – these organisations are being encouraged to work as part of a ‘system’ of local partners – Local Area Agreements, Joint Strategic Needs Assessments, joint commissioning commissioning is being devolved to GP practices so potential providers should bear in mind how they sell your services to them and commissioning is increasingly expected to support individual choice and ‘voice’…so maybe providers need to be selling their services directly to service users/patients.

14. What does all this mean for you if you’re a third sector organisation? In many ways, the health and social care ‘market’ isn’t really ready for you yet. Commissioners (on the whole) don’t understand social enterprise – who they’re already commissioning in the sector; how social enterprise adds value in a market; how to contract effectively from social enterprise/3 rd sector service providers

15. All providers need to differentiate themselves from their competitors Provider organisations looking to break into health need to think about themselves in a ‘market’ situation – How do you sell your wares? How are you different to your competitors? And what are you providing that’s different and better than the other services? Do you have a clear understanding of how your services benefit the people using them?

16. What does all this mean for you if you’re a third sector organisation? We know that commissioning from the third sector needs to improve. It’s all about: 1.How they manage risk, and how we balance the need to manage risk with engendering innovative organisations. 2.Commissioning for outcomes - third sector organisations might deliver more in the way of outcomes for people using the services; social return on the investment. 3.Disinvesting in services and interventions that don’t work - most of our NHS resource is tied up in acute care, people with long term conditions who go unnecessarily in and out of hospital. What’s left for prevention, health and wellbeing?

17. What does all this mean for you if you’re a 3rd sector organisation? All this is changing, albeit slowly There’s a myriad of tool kits, guidance on how to procure/commission from social enterprise - which reflects central government’s commitment to make this happen. CSIP/NHS North West pilot for commissioners and social enterprise providers – trying to implement the guidance There’s an increased recognition that we have to support commissioners to change, otherwise nothing will change.

18. It’s not just about delivering health care services

19. Look again at the commissioning cycle - note the centrality of the patient/public

20. It’s not all about delivering services: commissioning and engagement The Local Government and Public Involvement Bill has just got Royal Assent. This has implications for how health and social care organisations involve their citizens. LINKS, new statutory duties to listen to views of LINKS, particularly for commissioners, refinement of Section 11 duty to consult. It’s not just about delivering traditional ‘health’ services to local commissioners – they are looking for better ways to involve and engage their patients/public in decision making – think about how can you help them with that.

21. “If managers or chief executives are in doubt, ask yourselves these three simple questions: will it benefit patients? Is it consistent with what the wider health economy is trying to achieve? Can I account for this to the public and their representatives? Don’t wait for guidance, if you can answer those three simple questions with a yes, get on and do it”. David Nicholson, NHS Chief Executive, NHS Confederation Annual Conference, 21 June 2007. Health commissioners looking ‘out’, not ‘up’

22. Specialist Intensive Services Acute Hospital Services Enhanced Primary Care Primary Care Social Care Self Care Voluntary Agencies Community Hospitals Care closer to Home CATs / uCATs / PBC 3 rd Sector Other providers Pre 8am OOH9-5 M-T, T-FPost 5pm / OOH L o n g i t u d i n a l a c c e s s – A c u i t y & N e e d s B a s e d Artificial Service Based Constructs

23. In the future the 3 rd Sector could / should provide A wide range of diagnostic services Rehab, falls, some beds etc Appropriate access An equivalent or enhanced level of service for some pathways compared to a DGH 7 day a week service ….. WiCs, Assessment units, Primary Care, Enhanced Primary Care, Support teams, Integrated Social care, Chiropody, CATs …..

24. Issues to address Tariff for community services Efficiency & productivity –Measurement metrics Definitions Bricks & Mortar V services & care Clinical reference groups –Pathway agreement –Strategic commissioning of 3 rd Sector services