health and social care bill 2011 factsheets
DESCRIPTION
Health Economics Online have compiled a series of factsheets published by The Department of Health. They aim to explain particular topics contained in the Bill, including its key themes. They include case studies of the policy in action, or answer frequently asked questions about the topic.TRANSCRIPT
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Health Economics Online has compiled a series of factsheets
published by The Department of Health. They aim to explain
particular topics contained in the Bill, including its key themes. They
include case studies of the policy in action, or answer frequently
asked questions about the topic.
HealthEconomicsOnline.com twitter.com/HealthEcoOnline Linkedin.com/HealthEconomicsOnline.com
Section A
A1. The Health and Social Care Bill
A2. The case for change
A3. Overview of the Healthcare Structures
A4. Scrutiny and improvements
Section B
B1. Clinically led commissioning
B2. Provider regulation to support innovative and efficient services
B3. Greater voice for patients
B4. New focus for public health
B5. Greater accountability locally and nationally
B6. Modernising health and care public bodies
Section C
C1. Improving quality of care
C2. Reducing health inequalities
C3. Improving integration of services
C4. Choice and competition
C5. The overarching role (NHS) of the Secretary of State
C6. Reconfiguring services
Ca
1.
2.
3.
4.
K
5.
6.
The Health and Social Care Bill
• y To safeguard its future the NHS needs to change to meet the challenges it faces – only bmodernising can the NHS tackle the problems of today and avoid a crisis tomorrow.
• The Health and Social Care Bill puts clinicians at the centre of commissioning, frees up providers to innovate, empowers patients and gives a new focus to public health.
se for change
The Government is committed to the NHS’s founding principles. However, there is a broad consensus that standing still will not protect the NHS. Modernisation is ess entialfor three main reasons.
Rising demand and treatment costs. The pressures on the NHS are increasing, in keeping with health systems across the world. Demand is growing rapidly as the population ages and long‐term conditions become more common; more sophisticated and expensive treatment options are becoming available. The cost of medicines is growing by over £600m per year.
Need for improvement. At its best, the NHS is world‐leading, but there are important areas where the NHS falls behind those of other major European countries. If we had cancer survival rates at the average in Europe, we would save 5,000 lives a year.
State of the public finances. Whilst the Government has protected the NHS budget, this is still among the tightest funding settlements the NHS has ever faced. Simply doing the same things in the same way will no longer be affordable in future.
e legislative changes
The Government’s proposals are designed to meet these challenges, by making the NHS more responsive, efficient and accountable. They draw on the evidenc
y
e and experience of 20 years of NHS reform.
Clinically led commissioning (Part 1). The Bill puts clinicians in charge of shaping services, enabling NHS funding to be spent more effectively. Previously clinicians in many areas were frustrated by negotiating with primary care trusts to get the right services for their patients. Supported by
the NHS Commissioning Board, new clinical commissioning groups will now directly commission services for their populations.
7. Provider regulation to support innovative services (Parts 3 and 4).The Bill enshrines a fair‐playing field in legislation for the first time. This will enable patients to be able to choose services which best meet their needs, including from charity or independent sector providers, as long as they meet NHS costs. Providers, including NHS foundation trusts, will be free to innovate to deliver quality services. Monitor will be established as a specialist regulator to protect patients' interests.
8. Greater voice for patients (Part 5). The Bill establishes new Healthwatch patient organisations locally and nationally to drive patient involvement across the NHS.
9. New focus for public health (Parts 1 and 2). The Bill provides the underpinnings for Public Health England, a new body to drive improvements in the public’s health.
10. Greater accountability locally and nationally (Parts 1 and 5). The Bill sets out clear roles and responsibilities, whilst keeping Ministers’ ultimate responsibility for the NHS. The Bill limits political micro‐management and gives local authorities a new role to join up local services.
11. Streamlined armslength bodies (Parts 710). The Bill removes unnecessary tiers of management, releasing resources to the frontline. It also places NICE and the Information Centre in primary legislation.
Factsheet A1 provides an overview of the Health and Social Care Bill. It is part of a wide range of factsheets, all available at: Web: www.dh.gov.uk/healthandsocialcarebillEmail: [email protected]
1.challenges it faces now and in the futur
2. Rising demand and treatment costs. Demand for NHS services is increasing rapidly as the population ages and long‐term conditions become more common. Despite living longer, we are becoming less healthy: obesity already costs the NHS £4 billion a year and this is set to rise to £6.3 billion within four years. The cost of medicines has been growing on average by nearly £600 million a year. While the NHS is, at its best, excellent a
The NHS needs to modernise to meet the e:
t treating illness, more needs to be done to prevent illness.
3. Need for improvement. Compared to other countries, the NHS achieves relatively poor outcomes in certain areas. For example, if we had cancer survival rates at the average in Europe, we would save 5,000 lives a year. A recent report by the Royal College of Surgeons found that among abdominal surgery patients thousands of lives could be saved if patients had better access to facilities such as X‐rays, scanners and
ative operating rooms, and better post‐opercare.
4. There are unjustified variations in the quality of care across the country. The chances of diagnosis and survival can vary hugely depending where you are treated. The chances of being diagnosed with dementia, recovering from a heart attack or
ncer, .
major operation, or beating breast cacan vary hugely on where you are treated
5. The experience of care for too many patients is fragmented between different parts of the health service and between the NHS and social care. Good examples of integrated services do exist, but there are huge opportunities to make services more integrated for the benefit of patients. While progress has been made, more still needs to
be done to embed quality at the heart of everything the NHS does.
6. The NHS also needs to be more responsive to the patients it serves. Too often, patients are expected to fit around services. Decisions about their care are taken at several removes from those who know them the best – the professionals who care for them. Public measures of performance bear little relation to what really matters to patients: how well the NHS is delivering their care.
7. For too long there has been a vacuum in NHS accountability. With no measures to hold PCTs and trusts locally to account, the notion that the Secretary of State is responsible for all clinical decision‐making in the NHS results in a less responsive and accountable service and a poo
. r deal for
patients. Clearer accountability is essential8. State of the public finances. Recent years
have seen improvements in services alongside growing budgets. However, we cannot afford to keep doing the same things in the same ways. Too much of the NHS budget is consumed by layers of bureaucracy that would be better spent on patient care. We need better value for money for what the NHS spends.
Factsheet A2 provides details regarding the
case for change behind the proposals within the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebillEmail: [email protected]
The case for change – The Health and Social Care Bill “Changing health needs and the challenges of managing care for people with long term conditions make it imperative to develop new health services. Alongside hospital turnarounds to ensure affordable high quality healthcare, integrated care services will have to be organized around patients outside hospital settings. […] When passed, the Health and Social Care Bill will create more pressures on hospitals to change, through stronger commissioning and extended patient choice”. Professor Paul Corrigan CBE (September 2011)
Ov s – The Health and Social Care Bill erview of health and care structure
The changes to the health and care system will: ers
• • ; Improve quality and choice of care for patients, and increase transparency for taxpay
• Give GPs and other clinicians the primary responsibility for commissioning health care; Create a coherent system of regulation for providers, to drive quality and efficiency;
• Limit Ministers’ ability to micromanage, while ensuring they remain ultimately accountable.
7. Monitor will temporarily also retain oversight of foundation trusts, while the NHS Trust Development Authority (not in the Bill) will help the rema
How the new system will work 1. From the point of view of patients and the
public, access to NHS services on the basis of need and not ability to pay will continue. The reforms are intended to improve quality and efficiency by reforming the
that commission,organisations regulate and support health and care services.
2. At local level, local authorities will have a much stronger role in shaping services, and
ake over responsibility for locawill t l population health improvement.
3. New Health and wellbeing boards will bring together local commissioners of health and social care, elected representatives and representatives of
to Healthwatch to agree an integrated way improving local health and well‐being.
4. Most NHS care will be commissioned by clinical commissioning groups, which will give GPs and other clinicians responsibility for using resources to secure high‐quality services.
5. NHS commissioners will be supported by a new body, the NHS Commissioning Board. The Board will authorise clinical commissioning groups, allocate resources, and commission certain services, such as primary care. It will also host clinical networks (to advise on single areas of
iding care) and clinical senates (provclinical advice on commissioning plans).
6. NHS providers will no longer be performance managed by Strategic Health Authorities. There will be a consistent system of regulation for all providers: the Care Quality Commission will ensure services meet safety and quality requirements, while Monitor will promote efficiency, with powers to set prices, ensure competition works in patients’ interests, and support service continuity.
ining NHS trusts achieve foundation status.
8. Health Education England (not in the Bill) provide oversight and leadership for essional edu
will prof cation and training.
9. The National Institute for Health and Care Excellence will continue to provide independent advice and guidance to the NHS, and will extend its role to social care. The Information Centre will continue to
l, authoritative source of act as the centrahealth and social care information.
10. Ministers in the Department of Health will still be ultimately accountable for the NHS. Instead of directly managing providers or commissioners, Ministers will transparently set objectives for the NHS through a mandate to the NHS Commissioning Board. It will hold to account all of the national bodies, with powers to intervene in the event of significant failure, or in an emergency.
11. Action to protect and promote the health of the population will be led nationally by a new public health service, Public Health England: an agency of the Department.
12. The overview on the next page provides an illustrative diagram of the structures established by the Bill. It does not feature changes to education and training, research or professional regulation.
Factsheet A3 provides details about the changes to the health and care system. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebillEmail: [email protected]
Overview of health and social care structures in the Health and Social Care BillApril 2013
NHS providers, including:•NHS foundation trusts and NHS trusts•Primary care providers•Independent and third sector providers
NHS
Ministers and the Department of Health including Public Health England
Adult Social CarePublic Health
Local Healthwatch [Formerly LINks]
Public health providers
Local authorities
Health and WellBeing Boards [Part of local authorities]
Local authorities
Clinical commissioning
groups
NHS Commissioning
Board
Care Quality Commissionincluding
HealthwatchEngland
Monitor
Social care providers
Local
National
Patients and the public
National Institute for Health and Care Excellence
Health and Care Information Centre
NHS Trust Development Authority
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Pr2.
3.
4.
5.
Bi6.
7.
8.
Scrutiny and improvements – The Health and Social Care
The r been subject to:
Bill
proposals in the Health and Social Care Bill have so faEquity and Excellen
•• ce: Liberating the NHS A consultation on the White Paper
l ing exercise and NHS Future Forum reports s of Public Bill Committee in the House of Commons
The isten• 40 sessionOctober 2011
The Government is committed to ensuring full, robust scrutiny of the Health and Social Care Bill. This has resulted in the Bill receiving an almost unprecedented level of scrutiny over its Parliamentary passage.
ior to the Bill’s introduction White Paper. The original Bill policy intentions were laid out in Equity and Excellence: Liberating the NHS (July 2010). The Government consulted from July to October 2010 on how best to implement the White Paper.
More than 6,000 responses were received from a wide spectrum of individuals and organisations, including: patients, clinicians, NHS staff, charities, local authorities, academics, professional bodies and Royal Colleges, think tanks and trade unions.
In response the Government made a range of changes, including strengthening the role of Health and Wellbeing Boards in local authorities and creating a more distinct identity for Healthwatch England.
The Government published full responses to the consultation in December 2010.
ll’s Parliamentary passage Initial Public Bill Committee. The Bill was introduced into the House of Commons on 19th January 2011. The Bill’s initial Public Bill Committee (January – March) was held
ill over 28 sessions – the longest Public BCommittee of any Bill in over nine years.
During the Committee, changes made included clarifying that competition could only be o rice. n the basis of quality, not p
Listening exercise and NHS Future Forum. Following Committee, the Government announced that it would take
time to pause, listen, reflect and improve. Whilst there was consensus about the aims of the legislation, there was significant
concern about how these aims were beingmet.
9. Over the course of the listening exercise, Ministers and members of the independent NHS Future Forum (see overleaf) attended over 250 events and meetings, in every region of the country, and over 8,000 people took part in providing their views.
10. The Future Forum made a number of recommendations to improve the Bill. All of the Forum’s core recommendations were accepted by the Government.
11. Second Public Bill Committee. Following the Future Forum, the Bill was recommitted to a second Public Bill Committee, the first Bill to do since 2003.
12. During Committee, the Government made a wide range of amendments to implement the Future Forum’s recommendations. These included involving a wide range of health experts in advising, and the governance of, clinical commissioning groups; clarification that Monitor’s core duty will be to protect and promote
further patients’ interests; and introducingsafeguards to stop ‘cherry‐picking’.
13. With 12 sessions in the second Bill committee, the Bill spent a total of 40 sessions in Commons’ Public Bill Committee– longer than any Public Bill in the period 1997‐2010.
Factsheet A4 provides details regarding scrutiny of the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebill Email: [email protected]
THE NHS FUTURE FORUM
Who are the Future Forum? The NHS Future Forum is an independent group of 45 health and social care experts drawn from all sectors. It includes medical practitioners; chief executives of hospitals, local councils, charities and healthcare organisations; patient representatives; voices from PCTs and SHAs; the Royal Colleges and many more.
The listening exercise and the work of the NHS Future Forum demonstrated the value of policy making in partnership. The approach the Future Forum took was widely welcomed and gave a wide range of people the opportunity to understand and influence the policy‐making process.
What have they done? Following a six‐week listening period, the Forum made a series of recommendations to improve the Bill based on what they had heard in their engagement with NHS staff, patients, the public and interested organisations. One set of recommendations, for example, focused on choice and competition. The Forum recommended that:
“Competition should be used as a tool for supporting choice, promoting integration and improving quality and must never be pursued as an end in itself. Monitor’s role in relation to competition should be significantly diluted in the Bill. Its primary duty to ‘promote’ competition should be removed and the Bill should be amended to require Monitor to support choice, collaboration and integration.”
The Bill was amended to incorporate these recommendations at recommitted Bill Committee. Following the Government response to the Future Forum Report, the Forum’s chair Professor Steve Field said: “…it is remarkable how the Government have listened to what are a lot of recommendations from us and have come back with more ideas and suggestions in the amendments than we have asked for.” What will be their role going forward? Building on the success of the first phase of the Forum’s work, the Department have asked the Forum to continue listening to the views of others and to provide advice to the Government in four areas of detailed policy development and implementation. The Forum will base its advice to the Department on the results of extensive engagement exercises, involving a wide range of interested parties, and will report back towards the end of 2011. Further work on integration is taking place, with the Forum considering how we can take advantage of the health and care modernisation programme to ensure services are better integrated around people's needs. It will focus on what best practice looks like and how to achieve it, who should be involved to progress integrated services in a sustainable way, and how innovation in integrated care can be identified and nurtured. The Forum’s work will link with the listening exercise on social care, which will also consider the integration of NHS and social care.
FURTHER INFORMATION
Further information about the work of the Future Forum Briefing notes for amendments laid in the House of Commons The White Paper, Command Paper and consultation responses
Clinicallyled commissioning – The Health and Social Care Bill
“Clinical commissioners have a crucial role to play in ensuring that care is integrated and delivered in the community, with maximum input of local people and patients. Also, by working to overcome the barriers between the NHS and social care, they will be able to provide patients with better, seamless and more accessible care.” Dr Michael Dixon, Chairman of the NHS Alliance (18 June).
Context 1. Clinical commissioning will empower NHS
professionals to improve health services for the benefit of patients and communities. It will remove political interference and micromanagement in decisions about people’s care.
2. Most NHS services will be commissioned by clinical commissioning groups (CCGs). GPs are ideally suited to lead on commissioning
eds .
based on their understanding of the neof their patients and local communities
3. Unlike previous approaches to GP‐led commissioning, such as practice based commissioning, this will be a universal system involving all practices. CCGs will hold real budgets and be able to reinvest any savings they generate in patient care.
4. An autonomous NHS Commissioning Board will help develop and support capable CCGs and hold them to account for improving outcomes for patients and getting the best value for money from the public’s investment.
Ke legislative changes 5. Responsibility where it belongs. The Bill
makes CCGs directly responsible for commissioning services they consider appropriate to meet reasonable local needs. The Board will support them by providing guidance and tools, based on the best available evidence, to enable them to commission effectively. It will also pick up those services it would not be possible or appropriate for CCGs to commission – such as primary care services, although CCGs will play a ke ity
y
y role in driving up the qualof primary medical care locally.
6. Core duties. CCGs and the Board will be subject to a number of duties that did not previously apply to PCTs or SHAs, which put patient interests at the heart of everything they do. These include new duties in relation to promoting the NHS Constitution; securing continuous improvements in the quality of services commissioned; reducing inequalities; enabling choice and promoting patient involvement; securing integration; and promoting innovation and research.
7. A collaborative approach. CCGs will have
to work with each other, and with local partners to be effective. Both CCGs and the Board will be required to obtain advice from a people with a broad range of professional expertise. This should include working closely with clinical senates and networks. They must also work with the local health and wellbeing boards, in assessing local needs, and developing commissioning plans to meet them.
8. Focus on outcomes. The Secretary of State will set the strategic direction through the mandate for the Board and the NHS Outcomes Framework. This will inform the Commissioning Outcomes Framework which the Board will use to assess the performance of CCGs. CCGs will have the freedom to pursue innovative approaches to delivering care that will deliver improved outcomes for patients.
9. Accountability and assurance. The Board will be responsible for ensuring an effective and comprehensive system of CCGs. The Board will only authorise a CCG if it meets certain criteria, including: having an appropriate accountable officer; a governing body with both lay and wider clinical membership; a constitution which sets out arrangements for making decisions, ensuring transparency and for managing potential conflicts of interest; and that it is able to take on its commissioning functions.
10. Financial management. The Secretary of State will set an overall budget for the Board through the mandate, with the Board doing the same for CCGs. The Secretary of State will also set an overall limit on the amount that can be spent on administrative costs in the system. The Board will hold CCGs to account for their financial management. The Chief Executive of the Board, as Accounting Officer, will be accountable both to the Department of Health and to Parliament.
Factsheet B1 provides details regarding the commissioning changes within the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebille‐mail: [email protected]
BACKGROUND ON PATHFINDER PROGRAMME
• There are already 253 pathfinder commissioning groups in place covering around 95% of GP practices and the vast majority of the population. Pathfinders are groups of GP practices, who see themselves as emerging clinical commissioning groups and want to move quickly to take on additional roles using powers and budgets delegated to them by PCTs within the current statutory framework.
• The aim of the programme is to enable GPs and other health and care professionals to test different design concepts of clinical commissioning and identify any issues and areas of learning early so that these can be shared across the clinical community. They will create learning networks across the country to ensure that best practice is spread and specifically that pathfinders support other local groups who are less developed.
CASE STUDY – EXAMPLES OF CLINICAL COMMISSIONING IN ACTION
• By empowering clinicians to commission services directly, working closely with their local partners, results for patients can be improved alongside more efficient use of NHS resources. The Bill creates an environment where this can become the norm.
• Clinically led commissioning in pathfinder areas is already having an impact by inspiring new and innovative solutions to local health care issues, such as supporting patients in the
community and reducing avoidable admissions to hospital.
• Responding to an increase in the number of emergency admissions to hospital from care homes in Bedfordshire, local GPs implemented a multidisciplinary care team to deliver more intensive care to patients in nursing and residential homes. The team, consisting of GPs, pharmacists and nurses, focuses on care homes with higher than average use of urgent care services. This proactive care planning and risk identification has resulted in significant improvement in experience and confidence of patients and their families and has led to a 38%
decrease in hospital admissions from the care homes. • Clinical‐led commissioning has driven a scheme in Swindon to help patients with life‐long or
long term conditions remain at home. Telehealth technology alerts health professionals when patients need intervention and means patients can live independently in the familiar surroundings of their own home. The NHS can spend its money more efficiently: avoided A&E attendances and admissions for one patient alone are estimated to have saved the NHS £13,000 in three months.
• As part of a pilot, in Newcastle, GP practices were given the opportunity for a specialist company to run a search software programme on their patient database, which identified patients at risk of a serious chronic obstructive pulmonary disease (COPD) episode. These patients were invited in for tests and treated according to the Newcastle COPD guidelines, and will now receive ongoing education and support to help them to manage their condition. The pilot project has reduced unplanned admissions for COPD by around 70 per cent, resulting in cost savings of around £50,000. This is now being rolled out to other practices in the area.
FURTHER INFORMATION
• More information on the pathfinder progr le on a special website on the amme is availabModernisation of Health and Care
• Developing the NHS Commissioning Board (July 2011) and Developing Clinical Commissioning Groups: Towards Authorisation (Sept 2011) are also available on the DH website. These set out initial proposals about how the Board, and the authorisation process for CCGs may operate, as well as forming the basis for ongoing engagement.
C1
P2
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4
5
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Provider regulation to support innovative and efficient services – The Health and Social Care Bill “We are pleased to see the that the government has recognised the importance of promoting integration but believe it is also important to recognise that for some services the use of choice and competition is also an essential route to deliver the best patient care” Mike Farrar, NHS Confederation (June 2011).
ontext . The Government wants to see patients being able to access a range of providers who can offer services which are tailored to their particular needs. The Health and Social Care Bill contains a range of measures to create an environment in which providers can flourish.
art 3 Monitor . Monitor will regulate providers of NHS services so that NHS healthcare services are operated in the best interests of patients. In exercising its functions Monitor must obtain advice from health professionals, as well as securing the involvement of patients. It must also have regard to a range of factors, including the desirability of cooperation to improve quality, and the promotion of research.
. Competition. Fair and effective competition is a means to give greater choice and control to patients to access high quality care.
. Monitor will be able to address abuses and restrictions that prevent competition and could lead to poorer care for patients. The Bill does not change EU or UK competition and procurement legislation. What the Bill does do is create a framework in which competition (on quality, not price) can operate, including appropriate safeguards.
. Monitor will be a sector specific competition regulator for healthcare, allowing it to develop a bespoke approach for health. It is the Government’s view this is the best way to protect patients’ interests; this approach was strongly supported by the NHS Future Forum. The Bill also provides powers for the Secretary of State to rs make regulations on commissioneof NHS services which Monitor would enforce.
. Licensing. Monitor will license providers, so there is no “free‐for‐all” to deliver NHS services. Through licensing conditions, Monitor would be able to prevent potentially anti‐competitive behaviour and identify at an early stage if a provider was at risk of financial distress and,
insofar as legislation provided for this, require the pro l vider to take action to address potentiaproblems.
7. Pricing. Monitor, in conjunction with the NHS Commissioning Board, will regulate prices for NHS services through a national tariff. By doing so, Monitor and the Board will be able to safeguard against cherry picking, encourage efficiency (for example, through best practice tariffs) and integration (by setting tariffs for whole pathways of care).
8. Continuity of Services. The new continutiy of services regime would enable Monitor to support commissioners securing continuity of NHS services. The Bill places a duty on Monitor to establish financial mechanisms to secure continued access to NHS services.
Part 4 – NHS foundation trusts (FTs) 9. The changes will ensure that FTs are
accountable, transparent and autonomous in the way they operate, so they can better
s.
support innovation and provision of highquality, locally responsive care to patient
10. Local accountability will be increased by clarifying the roles of FT governors and directors, strengthening the governors’ role in holding the directors to account, and requiring public board meetings.
11. FT autonomy will be increased, for example by the repeal of private patient income cap and completing legislation on organisational changes such as mergers, acquisitions and separations, and increasing the transparency in Secretary of State’s use of powers to give financial assistance.
Factsheet B2 provides details regarding the changes to provision of NHS services within the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebillEmail: [email protected]
CASE STUDIES – AUTONOMOUS AND ACCOUNTABLE FOUNDATION TRUST
The Bill will ensure that public NHS providers are autonomous and become more accountable and transparent in the way they operate, so they can better support innovation and the provision of high‐uality, locally responsive care to patients. Examples of how NHS Foundation Trusts are today using their tatus and autonomy to deliver improved NHS services include:
S
qs 1. Gloucestershire Hospitals NHS Foundation Trust innovation for patients The foundation trust has pulled off a national first in a partnership deal with a local charity to provide a mobile chemotherapy team across three counties where many residents live in isolated communities. The trust was free to make the decision when the charity approached it ‐ proving that good ideas can happen quickly in a foundation trust. This innovation was about looking at the way the foundation trust provided ervices from the standpoint of the patient and then finding ways to do things differently without added ureaucracy. sb 2. Salisbury NHS Foundation Trust innovation to increase resources to support NHS services Salisbury NHS Foundation Trust set up a company, Odstock Medical Limited, to develop and market electronic devices that help disabled patients to walk by stimulating paralysed muscles. The company is the first 'spin‐off' company to be created and owned by the NHS. The foundation trust holds 68 per cent of he shares, with staff and Bournemouth University also holding shares. The company is profitable and is ow developing trade overseas. tn 3. Chesterfield Royal Hospital NHS Foundation Trust giving a voice to patients At this trust, governors are putting the patients' voice at the heart of their organisation. They have unfettered access to the wards and their recommendations have resulted in changes to cleaning regimes nd food quality, for example. Governors have also set up a new liaison role to give practical support and rivacy to vulnerable patients waiting to leave hospital. ap 4. Heart of England NHS Foundation Trusts collaboration with Boots to innovate and improve access and patient experience Heart of England NHS Foundation Trust has launched an outpatients clinic in the Solihull branch of Boots to take healthcare services into the community and give patients more choice about where they receive their treatment. The clinic provides walk‐in blood testing and outpatient facilities for dermatology, children's ophthalmology, physiotherapy, and pain management. Patients see the same NHS consultants, nurses and clinical staff and receive the same high level of care as they would have at the hospital. The centre is open in the evenings and at weekends. It is cost neutral to the foundation trust because of the collaboration with Boots.
FURTHER INFORMATION
• Securing continued access to NHS services narrative published to support the amendments tabled to the Bill ahead of House of Commons Report stage (Aug 2011).
Context 1. The Government aims for there to be “no
decision about me, without me” for patients and their own care. The same goes for the
t design of health and social care services aboth a local and a national level.
2. A key part of patient empowerment is to offer increased choice about their care. For more information on this, see the ‘Choice and Competition’ factsheet (factsheet C4).
3. We have recognised from previous changes in public and patient involvement in England, like the abolition of Community Health Councils and Public and Patient Involvement Forums that it is important to build upon current structures to ensure lessons and momentum are not lost. The Government’s approach is, therefore, about continual improvements, and changes need to build on the work currently undertaken by Local Involvement Networks (LINks), rather than reinventing them.
4. It is important to provide a strong forum where the views and experiences of patients, carers and the public can influence the commissioning process and improve the quality of health and social care services. All sources of user feedback enable providers to assess the quality of their services.
Ke hanges 5. The Bill strengthens the collective voice
of patients. It is important that this is reflected at all levels of the system; service providers and commissioners should welcome all sources of feedback as a means through which to assess the quality of their services. We want to avoid the experience of Mid‐Staffordshire, where patient and staff concerns were continually overlooked while systemic failure in the quality of care went unchecked.
y legislative c
6. The NHS Commissioning Board, Clinical Commissioning Groups, Monitor and Health and Wellbeing Boards will all have duties with regards to involvement of patients, carers and the public. Commissioning Groups will have to consult the public on their annual commissioning plans and invo hat lve them in any changes taffect patient services.
7. HealthWatch. The Bill provides for the establishment of HealthWatch England (clause 178) as a statutory committee of the Care Quality Commission. HealthWatch England will be a new national body representing the views of users of health and social care services, other members of the public and Local HealthWatch organisations. It will advise and provide information to the Secretary of State, the NHS Commissioning Board, Monitor, English local authorities and the Care Quality Commission on the views of users
s and their of health and social care serviceexperience of such services.
8. In addition, Local HealthWatch organisations (clause 179), based in and funded by Local Authorities, will carry out the functions currently carried out by Local Involvement Networks’, and take on additional functions. They will help ensure that the views and feedback from patients and carers are an integral part of local commissioning across health and social care. Their activities will also include providing information about local care services a t
nd choices to be made in respec
of those services. (Clauses 180 and 181.) Factsheet B3 provides details regarding the changes to increase patient voice within the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebille‐mail: [email protected]
Greater voice for patients – The Health and Social Care Bill
“If the fundamental purpose of the Government’s proposed changes to the NHS – putting the patient first – is to be made a reality, the system that emerges must be gr stematic patient involvement to the extent that shared decision making is the nor
ounded in sym.”
NHS Future Forum Patient Involvement and Public Accountability Report (June 2011).
HEALTHWATCH DEVELOPME
The Department of Health has set up a HealthWatch Development Programme Advisory Group. The objectives o
NT PROGRAMME
f the HealthWatch programme are to:
• h HealthWatch England as a sub‐implement the White Paper commitments to establis
• committee of CQC; evolve LINks into Local HealthWatch organisations;
• elop and refine consulting and engaging with NHS and Local Authority partners to devthe organisational model; and
• set clear roles and responsibilities for national and local HealthWatch.
Underlying principles of the programme are that it adopts a partnership approach between the Department of Health, Care Quality Commission and local authorities, and that it engages people who use health and social care services and their representative organisations in all stages of the development.
BACKGROUND ON PATHFINDER PROGRAMME
Seventy‐five local HealthWatch pathfinders were announced on 3 August. The pathfinders will pioneer plans ahead of the full establishment of local HealthWatch across the country in October 2012.
Guidance on developing local HealthWatch is also available, along with a timetable for the transition from the current patient involvement groups,. The guidance is aimed at local authorities and Local Involvement Networks (LINks) to help them and other key stakeholders prepare for the introduction of HealthWatch.
The guidance describes the vision for HealthWatch, sets out what the current arrangements should look like when they are working really well, and outlines the building blocks being put in place to support the transition. It is the first in a series of transition documents to support the move from LINks to local HealthWatch.
FURTHER INFORMATION
• HealthWatch Transition Plan ‐ this document highlights key issues for Local Involvement rior toNetworks (LINks), their host organisations and local authorities during 2011/12, p
the establishment of HealthWatch. • HealthWatch programme board minutes – access records of previous and current
discussions and decisions made at the HealthWatch programme board. • HealthWatch Pathfinders – further information on the pathfinders programme including
the list of participating areas.
New focus for public health – The Health and Social Care Bill
“The Government’s commitment to put the public’s health centre stage has been applauded by thosewe have heard from.”…“At a local level, the move of public health services into local authorities is widely supported.” NHS Future Forum Report (June 2011).
Context 1. There are huge opportunities to improve
health and wellbeing in England. People living in the poorest areas die on average seven years earlier than people living in richer areas, and have higher rates of mental illness; disability, harm from alcohol, drugs and smoking.
2. We are pulling together every aspect of Government to improve our nation’s health. At the national level, this will be through Public Health England, which we have proposed should be established as an executive agency of the Department of Health, and by delivering concerted cross‐government action through the dedicated public health cabinet sub‐committee that we have established. At the local level, this will by putting local authorities in charge of driving health improvement, pulling together the work done by the NHS, social care, housing, environmental health, leisure and transport services.
Key legislative changes 1. The reforms give Secretary of State a duty
to take steps to protect the health of the people of England. (Clause 8)
2. At the national level there is a clear rationale for accountability for health protection to rest with central Government, as the nature of various threats to health (ranging from infectious disease to terrorist attacks) are not generally amenable to individual or local action. Instead, they require clear “command and control” arrangements, resting on a clear line of sight from the centre of Government down to local services.
3. To do this the Bill abolishes the Health Protection Agency (HPA) and transfers its functions to the Secretary of State. (Clause 53) Abolishing the HPA is part of a wider programme of reform that abolishes several other public health organisations in
order to streamline a fragmented public health system. The aim of the reform is to exploit synergies across services and reduce inefficiencies due to overlapping responsibilities. Public Health England will bring together a range of organisations into one organisation in a public health system
State. directly accountable to Secretary of
4. At the local level, the Bill gives local authorities the responsibility for improving the health of their local populations. The Bill says that local authorities must employ a director of public health, and they will be supported by a new ring‐fenced budget. The Bill requires directors of public health to publish annual reports that can chart local progress. (Clauses 9, 27,28)
5. The Government believes that many of the wider determinants of health (for example, housing, economic development, transport) can be more easily impacted by local authorities, who have overall responsibility for improving the local area for their populations. Local authorities are well‐placed to take a very broad view of what services will impact positively on the public's health, and combine traditional "public health" activities with other activity locally to maximise benefits.
6. The NHS will continue to have a critical part to play in securing good population health. The public health system will support the NHS at every level to do this, for example by supporting and encouraging GP practices to maximise their impact on improving population health. .
Factsheet B4 provides details regarding public health changes in the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebille‐mail: [email protected]
CASE STUDY 1 – HEALTHY LIVING PHARMACIES, PORTSMOUTH
Healthy Living Pharmacies (HLPs) are making a real difference to the health of people in Portsmouth, with 10 pharmacies awarded HLP status by NHS Portsmouth. HLPs have to demonstrate consistent, high‐quality delivery of a range of services such as stopping smoking, weight management, emergency hormonal contraception, chlamydia screening, advice on alcohol and reviews of the use of their medicines. They proactively promote a healthy living ethos and work closely with local GPs and other health and social care professionals.
Early indications show that HLPs have greater productivity and offer higher‐quality services. Early evaluation results include a 140% increase in smoking quits from pharmacies compared with the previous year; and 75% of the 200 smokers with asthma or chronic obstructive pulmonary disease who had a medicines use review accepted help to stop smoking.
In the future system, we expect to see local authorities leading on more innovative public health improvement schemes such as this one in close collaboration with local partners from all sectors.
www.portsmouth.nhs.uk/Services/Guide‐to‐services/resources‐for‐professionals.htm
CASE STUDY 2 – THE BIG BOLTON HEALTH CHECK
The Big Bolton Health Check was launched in 2008. It is commissioned and managed by NHS Bolton and supported by the local council. The programme was set up to address high rates of cardiovascular disease in the local area.
The scheme is still running today and is made available in a wide range of community venues, from supermarkets and betting shops to pubs and places of worship to capture those people who do not usually frequent their GP surgery. This offer supplements the offer from local GPs. Feedback from patients and the public is overwhelmingly positive.
Results have shown that take‐up of the scheme was high in its first years (approximately two thirds of the target population). Moreover, nearly 30% of those assessed were found to be at high risk (i.e. with a risk score of over 20% in the next 10 years) of CVD. One estimate suggests that the check revealed 900 cases of diabetes, 2,000 people with reduced liver function and 2,000 people with blood pressure problems.
For the people who are diagnosed as part of this scheme, the action taken as a result was and is potentially life‐saving. For the local community the return on investment, in terms of preventing circulatory events, is expected to be considerable over the long term.
By protecting the public health budget, local authorities will be able to carry out more preventative projects such as this one to improve the health of the public on a long‐term basis.
FURTHER INFORMATION
• “Healthy lives, healthy people – our strategy for public health in England” – The Public Health White Paper sets out the Government’s long‐term vision for the future of public health in England (November 2010).
• “Healthy lives, healthy people – update and way forward” ‐ This policy statement reaffirms the Government's bold vision for a new public health system. It sets out the progress we have made in developing our vision for public health, and a timeline for completing the operational design of this work through a series of Public Health System Reform Updates (July 2011).
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Greater accountability locally and nationally – The Health and Social Care Bill
The Health and Social Care Bill will: Strengthen and clarify accountability for and within the NHS nationally
• Improve and introduce new mechanisms for local accountability within the health system•
ntext The Secretary of State will remain ultimately accountable for the NHS. The Bill does not change the Secretary of State’s duty to promote a comprehensive health service, which is set out in section 1 (1) of
o the NHS Act 2006, and which dates back tthe founding Act of 1946.
Currently many important health service functions (such as commissioning services, and ensuring that competition works in the interests of patients) are carried out under the functions of the Minister of the day, who can delegate responsibility to Strategic Health Authorities, Primary Care Trusts, Special Health Authorities and NHS Trusts. The Secretary of State has wide ranging powers to direct those organisations.
Under the Bill, functions will be conferred directly by Parliament on specific organisations. This will strengthen accountability, by making it clearer who is responsible for what. The Secretary of State’s powers to micromanage will be limited.
Ministers will continue to set, and will remain accountable for, the design and strategic direction of the system.
e legislative changes Greater autonomy for NHS bodies will be matched by increased accountability to patients, democratic legitimacy and a transparent system for achieving
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value for money and quality inspection.
The NHS Commissioning Board (NHSCB) will be accountable to the Secretary of State for meeting the objectives and outcomes set out in the mandate (Clause 20), which will be consulted on, published and laid before Parliament. The NHSCB will report publicly on how it has performed.
Clinical commissioning groups (CCGs) will be held to account for their decisions
by the NHSCB against a Commissioning Outcomes Framework, which will ensure transparency and accountability for achieving quality and value for money.
8. Health and Wellbeing Boards (Clauses 191‐196) will introduce real local democratic legitimacy by bringing together locally elected and accountable councillors, directors of adult social services, children’s services and public health, CCGs and patients’ views through local HealthWatch.
9. Providers of health and care services will be more accountable to patients, who will have the ability to choose their provider based on quality of services and their experiences.
10. Local HealthWatch organisations (Clauses 179‐186) will provide advice and information about access to local care services and choices available to patients and a stronger voice for patients, with a seat on the local Health and Wellbeing Board (Clause 191).
11. HealthWatch England (Clause 178) will receive local HealthWatch organisations’ views on standards of providers’ services and will be consulted by the Secretary of State on the mandate to the NHS Commissioning Board.
12. Foundation Trust Governors’ roles will be clarified (Clause 148) and they will have a strengthened role in holding the directors of FTs to account. To strengthen local accountability further, foundation trusts will be required to hold public board meetings.
Factsheet B5 provides details regarding accountability and the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebille‐mail:[email protected]
IMPROVING LOCAL ACCOUNTABILITY
Health and Wellbeing Boards will strengthen joint working between local government and the NHS. The Bill will establish Health and wellbeing boards in all upper tier local authorities, to promote integrated health and care services and increase accountability. The boards will significantly increase local democratic legitimacy in the commissioning of health and care services, bringing together locally elected councillors, clinical commissioning groups, local HealthWatch and irectors of Adult Social Services, Children’s Services and Public Health to jointly assess local D
needs and develop an integrated strategy to address them. Elected councillors will be involved in this process and will be held to account by the local electorate if they are ineffective. Local HealthWatch will ensure patients and the public have a irect say in their health and wellbeing board and so in the strategic planning for meeting the dhealth and care needs of their area. Early implementers have identified benefits such as an increased “profile of the patient and user voice in redesigning care pathways” (Herefordshire) and welcomed “the role of the elected member and HealthWatch to ensure that services commissioned and delivered reflect the needs, voice and aspirations of local communities” (Doncaster).
IMPROVING NATIONAL ACCOUNTABILITY
The reforms will increase Parliament’s power and limit Ministers’ power to interfere in day‐to‐day operations.
Power will be transferred from Ministers to Parliament. In the current system Ministers are able to set up new organisations, create permanent quangos and change the responsibilities of existing bodies through directions which are not subject to the control or scrutiny of Parliament.
The Bill enshrines a new approach. It sets out the responsibilities of the different bodies clearly and on its face. For the first time Parliament and not the Secretary of State will have the power to define the role of organisations within the NHS. Roles and responsibilities will be clearer and more democratically determined.
In future it will be harder for Ministers to make significant changes to the health system without the support of Parliament. New permanent quangos will only be able to be created by primary legislation passed by Parliament. Political expediency for the Minister of the day will no longer be able to affect the NHS to the same extent. There are many instances under the Bill where regulations in relation to the NHS must be made through the affirmative procedure, for example any regulations pursuant to Clause 61 to extend the functions of Monitor to adult social services will have to be actively approved by Parliament in future.
FURTHER INFORMATION
• Further information for legal professionals on clause 1 of the Health and Social Care Bill.
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Modernising health and care public bodies – The Health and Social Care Bill
The Bill modernises the public body infrastructure required to deliver high quality and efficient health and care services. Parts 7 to 10 of the Bill make a number of changes to create fewer, better organisations and to release more money to the frontline.
ntext The Health and Social Care Bill contains provisions to restructure the health and care public bodies sector, carrying forward
ort 0).
policy set out in Liberating the NHS: Repof the armslength body review (July 201
Change is necessary in the arm’s‐length bodies (ALB) sector for two reasons:
Firstly, to create better organisations. The Government’s modernisation plans will create organisations with greater freedoms in , clear duties and transparencytheir responsibilities to patients.
Secondly, to increase the proportion of money going to frontline services. This means that we need to make significant cuts in the costs of bureaucracy. Over the
next four years, the Government will reduce NHS administrative costs by a third.
The Government’s plans focus on ensuring necessary functions are delivered at the
right level, by the right body. As such, the Bill makes changes both to transfer functions, and to abolish bodies. These fit under three categories: professional regulation; safeguarding NICE and the Information Centre; and streamlining the number of bodies.
Professional regulation (Part 7 of the Bill) ‐ The General Social Care Council will be abolished, and the regulation of social workers in England transferred to the Health Professions Council (renamed, the Health and Care Professions Council). As the Health Professions Council operate on a model that is funded by its registrants
ill deliver significant year on year gs.
this wsavin
The Council for Healthcare Regulatory Excellence will be made self‐funding through a levy on the regulators it regulates. It’s remit will be extended to
include the quality assurance of the Health and Care Professions Council regulation of
l workers and the setting of standards nd assu
sociafor, a ring of, voluntary registers.
9. The Office of the Healthcare Professions Adjudicator will be abolished. Existing systems within the General Medical Council will be modernised to deliver substantially similar benefits for the medical profession.
10. Safeguarding NICE and the Information Centre (Parts 8 and 9) NICE and the Information Centre currently play important roles. The Bill re‐establishes them in primary legislation– giving them greater autonomy to serve patients and professionals through the provision of clinical advice and information.
11. NICE’s roles include the production of quality standards, which the NHS Commissioning Board will use to produce commissioning guidance for clinical commissioning groups. In addition the Bill exte ICE's remit to social care. nds N
12. Streamlining the number of bodies (Part 10) The Alcohol Education and Research Council will be abolished, with its research fund transferred to a new charity. The National Patient Safety Agency, NHS Institute for Innovation and Improvement, and National Information Governance Board will be abolished with key functions transferred to other bodies. The Appointments Commission will be abolished as, following PCT and SHA abolition, it will no longer be required.
Factsheet B6 provides details regarding the
changes to public bodies within the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebillEmail: [email protected]
CASE STUDY 1 – NHS INFORMATION CENTRE
he Bill will pave the way to help make our vision for an information revolution a reality by giving Tthe Information Centre clearer powers to make information more open and transparent. The Information Centre will become a national focal point for information collections across health and social care, joining up information so that we can better understand issues like how treatments lead to outcomes. Information will generally be made publicly available in anonymised orm, benefiting everyone. The Information Centre will also help to improve the quality of finformation and minimise information burdens across the sector. The Bill contains important safeguards to ensure the positive benefits of unleashing information are balanced by the imperative to protect patient confidential information. We continue to work ith the BMA to ensure information is protected in ways that enable information to be joined up w
to support seamless, integrated care. Tim Straughan, Chief Executive of the Information Centre, said: “The Bill will enable the Information Centre to strengthen its focus on ensuring the full potential of data to improve patient care is achieved; expanding the breadth and accessibility of information in support of transparency, while ensuring patient confidentiality is at the heart of everything we deliver.”
CASE STUDY 2 – FUTURE OF SOCIAL WORK REGULATION
The Bill will transfer the regulation of social workers in England from the General Social Care Council (wh uncil. The Council is an experienced professiona l worker stakeholders, including ‐
ich will be abolished) to the Health Professions Col regulator and is already engaging with key socia
• representation on the Social Work Reform Board; • of establishing a professional liaison group, with key stakeholders, to draft standards
proficiency for social workers in England (currently subject to consultation) ; • working with the Care Councils of Scotland, Wales and Northern Ireland to agree a
memorandum of understanding; and • working closely with the General Social Care Council to support a smooth transfer.
The changes will help ensure that public protection and confidence is maintained. There will also be significant year on year savings to the public as the Health Professions Council is funded by its registrants. Social workers will benefit from, being regulated on the same basis as other health professionals; standards of proficiency tailored specifically for their profession; and being subject to a fitness to practise process.
FURTHER INFORMATION
• iewLiberating the NHS: Report of the arms‐length body rev (July 2010) • Developing the NHS Commissioning Board (July 2011) The Bill transfers a number of
functions from the NHS Institute and the National Patient Safety Agency to the NHSCB • essing different mechanisms Fitness to Practise Adjudication for Health Professionals: Ass
for delivery (December 2010) Sets out the reasons for abolish• nical Excellence
ing OHPA National Institute for Health and Cli website
• NHS Information Centre website • Health Professions Council website • Council for Health and Regulatory Excellence website
Improving quality of care – The Health and Social Care Bill
“The Government's plans build on the reforms initiated by Ara Darzi's review of the NHS which put quality centre stage in a way everyone could understand. The current Bill is a natural progression aimed at ensuring, that firstly, our understanding of quality is enshrined in law; secondly, clinical results become the currency of the NHS; thirdly, clinicians play a greater role in setting direction for the delivery of clinical services and are accountable for that freedom; and, above all, patients are given the opportunity to take greater control over how they receive their care.”
Professor Sir Bruce Keogh, NHS Medical Director
Context 1. In his report of 2008, Lord Darzi set out
that continuous improvement in care quality should be the organising principle of the NHS. This Bill builds on this approach.
2. At its best, the NHS leads the world in making the highest quality care available to all. In many cases, the NHS not only meets these expectations, but exceeds them.
3. However, there are important areas where NHS services fall behind those of other major European countries. For example, a recent OECD report found that if the NHS were to perform as efficiently as the best performing health systems, we could increase life expectancy in the UK by 3 years. In their February 2011 report on cancer, the Public Accounts Committee found that “Early diagnosis is still not happening often enough and this is reflected in poor one year survival rates for most cancers compared to other countries”.
Ke legislative changes 4. The Government’s modernisation plans
centre on achieving continuous quality improvement for patients, and making services fairer and more efficient. This will be achieved by the NHS frontline – not through central diktat. The Bill therefore is about liberating clinical teams to let them
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deliver high quality care ‐ in four key wayi. Clinicallyled commissioning. The Bill puts clinicians in charge of shaping services. This will enable NHS funding to be spent more effectively. Previously clinicians in many areas were frustrated by negotiating with primary care trusts to get the right services for their patients. Supported by the NHS Commissioning
Board, new clinical commissioning groups (CCGs) will now directly commission the majority of services for their local populations. In addition, clinical senates and networks will be able to provide ditional expertise to improve the design d delivery of pa
adan tient care. ii. Enabling patients to choose the best services for them. The Bill promotes patients choice of services, and for the first time enshrines in legislation a level playing field. This enables patients to choose between innovative new providers, such as cial enterprises, that can better meet eir needs.
soth iii. Outcomes framework and quality standards. The Bill creates tools that will support continuous quality improvement. The Outcomes Framework defines the NHS’s accountability – and its inception was welcomed by the clinical community. NICE will provide evidence based quality standards, defining what high quality care oks like. Again, this is an inlo novation
supported by clinicians and patients. iv. New duties of quality. The Bill places Lord Darzi’s quality domains – effectiveness, safety, experience ‐ in legislation. The Secretary of State, the NHS Commissioning Board and CCGS will now have positive duties in relation to securing ontinuous improvement in the quality of ervices across these domains. cs
Factsheet C1 provides an overview of how the Health and Social Care Bill contributes to improving the quality of NHS care. It is part of a wide range of factsheets, all available at: Web: www.dh.gov.uk/healthandsocialcarebillEmail: [email protected]
CLINI ALITY STANDARDSCALLY LED QUALITY IMPROVEMENT – NICE QU
• The Bill puts Quality Standards firmly at the heart of the NHS. • rd to Both the Secretary of State and the NHS Commissioning Board will have to have rega
Quality Standards, prepared by NICE, as they discharge their duty of quality. • Clinical commissioning groups will have to have regard to commissioning guidance
produced by the Commissioning Board, which will be based on NICE Quality Standards. • lly NICE ‘s worldwide reputation for excellence and proven independence make them idea
placed to take on this role. • For the first time, therefore, evidence based quality improvement will be central to the
of delivery of NHS funded care and its management. The Bill puts this firmly at the heartthe health system.
• Breast Cancer Campaign has said: “We support the Government proposal for NICE to develop quality standards”.
• The Royal College of Nursing (RCN) has said: “NICE does an important and sometimes unpopular job in difficult circumstances and remains widely respected within the UK and abroad.”
CLINICALLY LED QUALITY IMPROVEMENT – LEADING THE WORLD IN OUTCOMES MEASUREMENT
• The Bill enshrines a focus on outcomes. • The first NHS outcomes framework sets out the outcomes and corresponding indicators
that will be used to hold the NHS Commissioning Board to account for the outcomes it delivers through commissioning health services from 2012‐13. The framework sets direction of travel in the journey towards improving outcomes, and offers an opportunity for the NHS to begin to understand what an NHS focussed on outcomes means for individuals, organisations and the NHS itself.
• The Bill (Cl. 20 inserts S 13 E 4 (b) into the 2006 Act) envisages the publication by the Secretary of State of an outcomes framework and makes it central to the delivery of care.
to When fulfilling its duty in relation to quality improvement, the Board must have regard the outcomes in this framework.
• When the first NHS Outcomes Framework was published last year, the Organisation for e Economic Co‐operation and Development said it “…strongly applauded the decision by th
Department of Health to move towards international benchmarking for outcomes.” • And UCL partners said “…we do not know of a sizable health system internationally with
such a comprehensive framework for outcomes”.
FURTHER INFORMATION
• NICE Quality Standards – Access published Quality Standards via the NICE websitas updates on plans to produce further Quality Standards in the near future.
•
e, as well
The NHS Outcomes Framework ‐ The first NHS outcomes framework sets out the outcomes and corresponding indicators that will be used to hold the NHS Commissioning Board to account for the outcomes it delivers through commissioning health services from 2012/13. (Dec 2010)
• High Quality Care for All – Publication following the culmination of the Next Stage Review, led by Lord Darzi (June 2008).
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Reducing health inequalities – The Health and Social Care Bill
“The Government’s focus on inclusion health and reducing health inequalities has been warmly welcomed.” NHS Future Forum, Summary Report, (June 2011).
ntext The fundamental principle of the NHS, to be open to all based on need not ability to pay, is one based on reducing inequalities in
s healthcare. The Government fully endorsethis principle and seeks to strengthen it.
Currently, there is unjustified variation in many spheres of the health service including access, quality and outcomes of care, and relative to particular social determinants of health.
The plans for modernisation address these challenges head on. The Government recognises the causes of inequalities in health are wide and diverse. As such, actions to reduce inequalities are being taken across the system.
e Public Health England. The White Paper Healthy Lives, Healthy People set out the practical steps we intend to initiate to tackle health inequalities across the life
inants
y legislative changes
course, and across the social determof health that shape people's lives.
A key aspect of this strategy is the establishment of Public Health England, a dedicated body to improve the nation’s health. Public Health England will streamline the disjointed system of public health that currently exists. It will have an important role in reducing inequalities, enabling and supporting individuals and communities to improve their own health. It will work with the NHS and local government and other agencies to address the wider determinants of health.
Placing inequalities at the heart of the NHS. The Bill enshrines in legislation for the first time, explicit duties on the Secretary of State, NHS Commissioning Board and clinical commissioning groups (CCGs) to have regard to the need to reduce
inequalities in the benefits which can be obtained from health services. The duty on the Secretary of State extends to functions in relation to both the NHS and public health. The duties on the Board and CCGs incorporate both access to, and benefits from, healthcare services.
7. Clinicallyled commissioning. The Bill puts clinicians in charge of shaping services. A number of CCGs key responsibilities are directly designed to help rin
educe health equalities:
i. Promoting integration. The Board and CCGs, will be responsible for promoting better integration of health services with health, social care and other health‐related services, where this would improve service quality or reduce inequalities.
ii. Quality reward. The NHS Commissioning Board will be able to reward CCGs for providing high quality services, for improving outcomes and reducing inequalities.
iii. No decision about me, without me. The Board and CCGs will be required to involve the public in the planning of commissioning arrangements and proposals to change those arrangements and decisions affecting them.
8. New innovative services. The Bill enables providers – including the independent and 3rd sector – to develop innovative services to tackle complex problems such as health inequalities.
Factsheet C2 provides details regarding health inequalities and the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: web: www.dh.gov.uk/healthandsocialcarebille‐mail: [email protected]
CASE STUDIES – COLLABORATION AND INNOVATION TO HELP THE VMOST ULNERABLE
The Bill encourages greater collaborative working between health bodies, and also provides
greater freedoms for providers to develop new services and innovative approaches to improving
quality and reducing inequalities. There are many examples in the NHS at present of services
which are working well to help those most in need – such as the two below. The Government’s
odernisation plans seek to make these exceptions the norm. m
St Mungo’s and Marie Curie Cancer Care (both charities) have been working in partnership
since 2008 to explore ways to improve end of life care for homeless people. People who are
homeless often have a range of difficulties to face, and appropriate care at the end of life for them
is as important as it is for any other group. This partnership between the charities has focused on
better understanding the key signs of deterioration in homeless people with advanced liver failure
and supporting staff to recognise these signs. By working together they can strive to ensure that
all homeless people who are terminally ill experience the best possible care at the end of their
ives: care that respects their wishes and is available in a place of their choosing. l
Walsall Integrated Learning Disabilities Service, in partnership with the Department of
Health’s Pacesetters programme, has successfully addressed the historically low take‐up of breast
screening by women with learning disabilities. Through a combination of user engagement and
raising staff awareness of the needs of this group, the project has improved screening rates from
62% to 100% for those women who are able to be screened. When the project began in August
2006, only 17 women with learning disabilities had attended breast screening in recent months.
By August 2009, this had risen to more than 140 women who attended screening as part of a
olling programme." r
FURTHER INFORMATION
Government Response to The Health Select Committee Report on Health Inequalities
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Improving integration of services – The Health and Social Care Bill
“It is clear the health service now needs to drive integration in a way that has simply never happened to date. In practice, current contracting processes, funding streams and financial pressures can actually discourage integration. There needs to be a service that both encourages innovation and supports collaboration. We also believe competition will play an important role driving change.” NHS Future Forum Forum ‘Choice and Competition’ Report (June 2011).
ntext Improving quality of care is at the heart of the Health and Social Care Bill. One key means to achieve this is to ensure care is integrated around the needs of patients. Typically the NHS has not managed handovers well between different parts of the NHS, or with social care. As such, the Bill seeks to encourage and enable more integration between services.
The Future Forum made recommendations as to how we could strengthen integration in the Bill. We accepted these in full and have made amendments. The Future Forum are continuing to look at integration in terms of what non‐legislative action can be taken to further promote integration.
e legislative changes The Bill contains a number of provisions to encourage and enable the NHS, local government and other sectors, to improve patient outcomes through far more effective co‐ordinated working. The Bill provides the basis for better collaboration, partnership working and integration across
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local government and the NHS at all levels. Commissioners take the lead. The drivers of integration in the modernised NHS will be clinical commissioning groups (CCGs) and the NHS Commissioning Board. Both have new duties to promote integrated
secure nts).
workings by taking specific action tointegration (where beneficial to patie
CCGs will be best placed to promote integration given their knowledge of patient needs, and the commissioning power to design new services around these needs. This is endorsed by early findings from the 16 Integrated Care Pilots (running since 2009) which suggest that GPs in particular are taking on responsibility not only for the individual patient but also for that person’s journey through the system.
6. To better join up health and care, the boundaries of CCGs should not normally cross those of local authorities – unless the CCG is able to clearly y. justify to the contrar
7. Health and wellbeing boards bring everyone together. The Bill gives Health and wellbeing boards a duty to encourage health and care commissioners to work together to advance the health and wellbeing of the people in its area.
8. Boards will bring all of the relevant people together ‐ representatives of the different health and care services will, together, have to draft and agree a Joint Health and Wellbeing Strategy for their local area. How different services work together around patient needs will be a key part of the strategy. The Bill places a duty on Boards to consider the partnership arrangements under the NHS Act (such as pooled budgets) when developing their strategy.
9. Integration working with competition. There have been concerns that integration will be prevented by competition, and in response new safeguards have been introduced. First, Monitor’s core duty is now clear that patient interests always come first. Where an integrated service raises competition concerns, Monitor will focus on what benefits patients their role will be to ensure that the benefits to patients outweigh any negative effects to competition, and that any negatives are kept to a minimum. Secondly, Monitor has new duties to support integration where it is in the b with enefits of patients, working others to enable integrated care.
Factsheet C3 provides details regarding integration within the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebillEmail: [email protected]
CASE STUDY 1 – INTERGRATING CARE FOR OLDER PEOPLE IN TORBAY
Torbay has sought to deliver better care for older people, through the use of five integrated health and social care teams, aligned with GP practices. A single point of contact gives access to intermediate care services ‐ including therapists, social workers and district nurses, with an urgent response service for emergencies.
This approach has almost removed delayed transfers of care from the acute sector to the community, helping greatly reduce the average number of daily occupied beds used in both the district general hospital and community hospitals (750 in 1989/99 to 528 in 2008/09) and ensure below average emergency bed days for that population group in the locale (2,025 emergency bed days per 1,000 population aged 65 and over, compared with an average of 2,778 per 1,000 population in the southwest as a whole).
This case study is drawn from independent research undertaken by the Nuffield Trust (see Chris Ham and Judith Smith, 'Removing the policy barriers to integrated care in England', September Briefing, 2010.)
Torbay is one of the Department’s Integrated Care Pilots.
CASE STUDY 2 – JOINING UP HEALTH AND SOCIAL CARE IN SUTTON
When health and social care partners work together to tackle particular problems in their local area, patients can benefit and resources can be deployed more efficiently. This Bill fosters such partnerships in a consistent manner through the statutory creation of Health and Wellbeing Boards, and by giving organisations the incentive to work together where it is in the best interests of the patients to do so.
For example, integrating health and social care services for patients and carers has resulted in substantial savings in the London borough of Sutton.
Between August 2010 and January 2011, a multi‐disciplinary team GPs and council staff piloted reducing hospital admissions through better integration of health and social care. Led by GP Dr Raza Toosy, the pilot targeted people who had presented at A&E or passed through A&E with heart failure, diabetes or chronic obstructive pulmonary disease.
Joining up support for patients and carers ensured that people could remain at home, in a healthy and sustainable situation, where they were supported by a consistent team of professionals. People receiving the service did not have to provide information about themselves more than once and the multi‐disciplinary team learnt about each other’s services, which aided a more integrated and complementary approach.
The six‐month pilot, based on just these three medical conditions and a trial area of only 25,000 patients, reduced PCT admissions by 29 patients with long‐term, high risk conditions and saved approximately £322,000.
FURTHER INFORMATION
• ort (June 2011)NHS Future Forum Patient Involvement and Public Accountability rep • Department of Health – Integrated Care Pilots: an introductory guide
Context 1. We want the NHS to deliver high quality
services for patients, and value for money for taxpayers. Choice and competition are powerful means to achieve this aim.
2. There is emerging evidence of the benefits of competition in the NHS. Where there is competition and choice of hospital provider
tion for it leads to better outcomes, satisfacpatients and better hospital management.
3. The Bill does not change EU or UK competition and procurement legislation. It also does not introduce or extend the previous Government’s policy of patient choice of any qualified provider.
4. What the Bill does do is create a framework in which choice and competition (on quality, not price) can operate, including appropriate safeguards. Currently, there is not a robust framework tailored to healthcare able to protect patients.
5. Our approach is to focus on protecting patients rights to choice; ensuring good value for taxpayers’ money; and addressing abuses that act against patients interests.
Ke legislative changes 6. The Bill provides for Monitor to become a
sector specific regulator for healthcare, with an overarching duty to protect and promote the interests of people who use healthcare services. This would mean that competition issues are considered and the rules applied by a regulator who knows
y
and understands the NHS –something the NHS Future Forum stressed is crucial.
7. As now, it would be for commissioners to take decisions on when and how to use choice and competition to improve
services, in line with guidance from the e NHS Commissioning Board and the choic
mandate set by the Secretary of State. 8. Monitor’s role in respect of competition
would be to tackle specific abuses and unjustifiable restrictions that demonstrably act against patients’ interests. It is not to promote competition as an end in itself or to promote the interest of private providers – as we made clear following the NHS Future Forum report.
9. Monitor would have powers to tackle abuses by providers through its licensing powers and, where relevant, by applying the Competition Act 1998. For example, Monitor could take action against a provider restricting patient choice.
10. For commissioners, Monitor would enforce regulations made by the Secretary of State to ensure that good procurement practice is followed, that patient’s rights to choice are protected and promoted and that restrictions of competition that are not in the interest of patients and the public are
e prevented. This builds on existing guidancand rules for commissioners.
11. For example, in determining where there may be overriding benefits to patients of limiting competition – such as the concentration of specialist services in regional centres or in providing services through a clinical network.
Factsheet C4 provides details regarding choice and competition and the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: Web: www.dh.gov.uk/healthandsocialcarebillEmail: [email protected]
Choice and competition – The Health and Social Care Bill
“To me, competition in the NHS means British Red Cross volunteers being able to help more people adapt to life back at home after a lengthy spell in hospital, so preventing the need for readmission… Do we want less of this, or more? To me – and I suspect most of us – the answer is obvious. The people who rely most on the NHS are the vulnerable, the very people, indeed, who charities were set up to help precisely because they were let down by the status quo.” Stephen Bubb, Chief Executive of ACEVO, (January 2011).
INNOVATIVE NEW PROVIDERS We want patients to be able to choose the best services for their needs – whether this is from an NHS, third sector or independent sector provider and the Bill strengthens patients ability to do so. We want to se d by Test
e more new high quality, innovative providers such as the wound healing services provide Valley Community Services (TVCS) in Eastbourne:
• TVCS Ltd was established in 1999 by Sylvie Hampton, previously Tissue Viability Nurse at Eastbourne DGH, and Fiona Collins, previously Senior Lecturer in Occupational Therapy at University of Brighton. Sylvie has an international reputation for healing wounds and Fiona for preventing pressure damage, particularly in the seated patient.
• In January 2008, TVCS opened a Wound Healing Clinic in Eastbourne – the first nurse led complex . They aim wound health clinic in the UK specialising in the prevention and management of wounds
to offer patients the right treatment at the right time and in the right place for their wounds. • As the clinic meets the quality standards required by required by the local PCTs and can
CT can offer patients demonstrate that they deliver the results the PCT wants for its patients, the P
• the choice of being treated at the clinic as well as local NHS providers. The Wound Healing Clinic has both a high success rate and is cost‐effective.
• 82 per cent of patients have their wounds healed over a six‐week period ‐ one of the highest in the UK. To put this into context, wounds have had an average duration of 3.3 years when patients arrive at the centre.
G
REATER CHOICE
Measures of NHS use of the Independent Sector
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
Mar
-06
Jun-
06Se
p-06
Dec-0
6M
ar-0
7Ju
n-07
Sep-
07De
c-07
Mar
-08
Jun-
08Se
p-08
Dec-0
8M
ar-0
9Ju
n-09
Sep-
09De
c-09
Mar
-10
Jun-
10Se
p-10
Dec-1
0M
ar-1
1Ju
n-11
No.
cas
es p
er m
onth
First outpatient bookings to all IS providers via Choose and BookProcedures procured under IS ECN / FCN (discontinues Jun-11)
Note: ECN/FCN is lower because it is a subset of all IS providers and not all first outpatient appointments result in surgery.
• Patients tell us they want more choice and control over their health and care; its something they increasingly expect
d from a moderniseNHS.
• A wide choice of provider of elective care has been on offer since 2007. Over 200,000 patients a year choose to use an independent sector provider under existinchoice policy and morechoosing between NHSproviders.
g
FURTHER INFORMATION
• Choice and Competition Delivering Real Choice – A report from the NHS Future Forum. (June 2011)
• The Department’s response to 38 Degrees’ legal advice on the application of procurement and competition law. (Sept 2011) more information on the emerging evidence around choice and competition in health care s
• For ee:
Death by Market Power: Reform, Competition and Patient Outcomes in the National Health Service. NBER Working Paper No. 16164. (July 2010)
• Does Hospital Competition Save Lives? Evidence from the NHS Patient Choice Reforms. (Cooper, Gibbons, Jones and McGuire). Working Paper 16/2010. LSE Health. (Jan 2010)
The overarching role (NHS) of the Secretary of State – The Health and Social Care Bill
“The NHS should be freed from day‐to‐day political interference but the Secretary of State must remainultimately accountable for the National Health Service.” NHS Future Forum Report (June 2011).
Context1. The intention of the coalition government
is to reduce political micromanagement of the NHS so that frontline professionals are free to focus on improving outcomes for patients. The Bill rebalances the relationship between government and the NHS. Whilst the Secretary of State will remain ultimately accountable for the NHS, Ministers will not be able to interfere with the day to day running of the NHS.
Ke2. We are committed to the founding
principles of the NHS ‐ that it should be a comprehensive service free at the point of use, regardless of ability to pay, and funded from general taxation. The wording of section 1(1) of the 2006 NHS Act, which contains the Secretary of State’s duty to promote the comprehensive health service, will remain unchanged in legislation, as it has since the founding NHS Act 1946. Section 1 also ensures that services remain free of charge, except where charges are set out in legislation.
y legislative changes
3. The Secretary of State will retain ultimate accountability for securing the provision of services through his relationship with the NHS bodies to be established by the Bill, for example the NHS Commissioning Board by way of the “mandate”. Subsection (2) of clause 1 requires the Secretary of State to exercise his functions so as to secure that services are provided in accordance with the Act.
4. To ensure clear and transparent expectations of the Health Service, the Secretary of State will set priorities for the health service through a mandate for the NHS Commissioning Board. The mandate will be a multi‐year document that is refreshed annually. The mandate may only be changed in year where there are exceptional circumstances or a general election and changes must be reported to Parliament. This will protect the NHS from
continuous micromanagement and frequent ’moving of the goalposts’, by
r ing.
ensuring that Ministers must justify theireasons for changes of direction or fund
5. Alongside the mandate the Secretary of State can make regulations ‐ “standing rules” – which would, for example, include requirements to ensure that there is legal underpinning for certain rights set out in the NHS Constitution which are currently achieved by way of directions to PCTs, such as in relation to choice of secondary provider.
6. To give further teeth to the commitment to reduce political micromanagement, the Secretary of State will be required to promote the autonomy of Arm’s Length Bodies, commissioners and providers to
n the exercise their functions, where it is ibest interests of the health service.
7. However, the Secretary of State still remains ultimately accountable for the health service. Where an organisation is significantly failing the Secretary of State will have extensive powers to intervene. He will also have a duty to oversee national bodies and to report annually on the performance of the health service.
8. In addition, the Bill places a number of duties on the Secretary of State with equivalent duties on the Board and clinical commissioning groups. These are duties to; promote service improvement (clause 2); to have regard to the need to reduce health inequalities, (clause 3); and to promote research on areas relevant to the health service and the use of evidence within the health service (clause 5).
Factsheet C5 provides details regarding the changes to the role of the Secretary of State within the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: web: www.dh.gov.uk/healthandsocialcarebille‐mail: [email protected]
FREQUENTLY ASKED QUESTIONS ice Clause 1 ‐ the Secretary of State’s duty to promote a comprehensive health serv
Why have you removed the Secretary of State’s duty to provide services? The Government believes it should not be the responsibility of Ministers to provide or commission NHS services directly. That should be the job of frontline organisations, free from political micromanagement. Indeed, subject to a few exceptions, the duty to provide or secure the provision of services has for many years not been fulfilled by the Secretary of State actually providing or commissioning services directly. He has until now delegated these functions to SHAs and PCTs. The role of Ministers should be to set direction, oversee the NHS, and hold national organisations to account.
This is why the Bill removes the current duty to “provide or secure the provision of services” and replaces it with a duty that reflects what Ministers should be responsible for: setting the strategic direction and regulatory framework for the NHS and, if necessary, using their extensive powers of oversight and intervention to ensure that services are provided in accordance with the NHS Act. his change updates the duty to align the legislative framework with the reality of how the Tmodern system operates. Changing the duty will strengthen accountability, by making clearer who is responsible for what, and will help enable local NHS services to be more responsive to the needs of patients.
Doesn’t this reduce Ministers’ responsibility? This alters the way in which Ministers are responsible, but it does not remove their overall responsibility for the NHS. The Bill does not change the Secretary of State's overarching duty to promote a comprehensive health service, which has underpinned the NHS since it was founded. The Secretary of State will retain ultimate accountability for securing the provision of services. inisters will have an extensive range of powers to set objectives for and oversee the NHS and M
ensure that services are being provided effectively. Clause 4 (new section 1C) ‐ the Secretary of State’s duty to promote autonomy What is the rationale behind the autonomy duty? The purpose of the autonomy duty is to free frontline professionals to focus on improving outcomes for patients rather than looking up to Whitehall. It means that, when considering whether to place requirements on the NHS, the Secretary of State should always consider the mpact of his actions on health service organisations and ensure that he is acting proportionately. similar duty applies to the NHS Commissioning Board. iA Doesn’t it tie Ministers’ hands behind their backs when it comes to intervening on behalf ofpatients? No. The duty of promoting autonomy only applies “so far as is consistent with the interests of the health service”. The interests of the health service always take priority. The autonomy duty aims to ensure that Ministers only intervene where it is appropriate; they will always be able to
intervene where they think it is necessary.
The duty must be viewed in the overall context of the Bill. In particular it must be considered alongside the Secretary of State’s other general duties such as that in section 1(1) (duty to promote the comprehensive health service) and in new section 1A (under clause 2) (duty as to the improvement in the quality of services). The effective discharge of these core duties is in the interest of the health service. The autonomy duty could never prevent the Secretary of State from intervening where he had reasonable grounds for considering that this was in the interests of the health service.
FURTHER INFORMATION
• Department of Health response to the legal opinion of Stephen Cragg, on behalf of 38 degrees
• Further information for legal professionals on clause 1 of the Health and Social Care Bill • The NHS Constitution – Access the latest version of the NHS Constitution, as well as the
handbook to the NHS Constitution.
Co1.
2.
3.
4.
5.
K6.
Reconfiguring services – The Health and Social Care Bill
• The Government is clear that, in a patient‐led NHS, service change must begin and end with what patients and local communities need.
• Our reforms will enable change to be driven from the bottom‐up, by the clinicians who know the health needs of their patients best, and underpinned by proper local engagement, partnership working and effective local authority scrutiny.
ntext The NHS has always had to respond to patients’ changing expectations and advances in medical technology. As
o lifestyles, society and medicine continue tchange, the NHS needs to change too.
Evolving clinical practice and technology means that some services that previously could only be provided in an acute hospital can now be safely provided in a local health centre, GP surgery or even the patient’s own home. At the same time, other services requiring highly specialist care are being centralised at larger, regional centres of
ence excellence, where there is clear evidthis improves health outcomes.
Reconfiguration is therefore about modernising treatment and improving facilities to improve patient outcomes, develop accessible services closer to home and most importantly ‐ saving lives.
The reconfiguration of services is a matter for the local NHS. There is no national blueprint about how healthcare services should be organised locally, as services
eds of the need to be tailored to meet the nelocal population.
This is why the Secretary of State introduced four tests last year that current and future reconfigurations should meet. These tests set out that local plans should demonstrate: support from GP commissioners; strengthened public and patient engagement; clarity on the clinical evidence base; and consistency with current and prospective patient choice.
e legislative changes There is no one section of the Bill relating to service reconfiguration. Rather the way the NHS develops and implements proposals for change will be influenced by
an interlocking series of clauses covering matters such as commissioning, provider
nd local
y
regulation, public involvement, agovernment.
7. The Bill will help to ensure that reconfigurations are locally led by underpinning commissioning decisions with clinical insight through the establishment of clinical commissioning groups; and by strengthening local partnership arrangements.
8. Health and wellbeing boards will provide a forum where commissioners, local authorities, local HealthWatch and other local leaders across health and social care can discuss the future shape of services, building on their assessments of local
all health health and care needs and overand wellbeing strategy.
9. To ensure proper scrutiny and accountability, the Bill will enable the retention of an independent health scrutiny function within local authorities and the strengthening of this scrutiny function so it can be applied to all NHS‐funded services rather than just services provided by NHS bodies as in the current system.
10. Where local authorities don’t agree with a proposed reconfiguration (on which there was a requirement to consult them), they will be enabled by regulations to refer the matter firstly to the NHS Commissioning Board, and ultimately to the Secretary of State for Health.
Factsheet C6 provides details regarding the reconfiguration of services and the Health and Social Care Bill. It is part of a wide range of factsheets on the Bill, all available at: web: www.dh.gov.uk/healthandsocialcarebille‐mail: [email protected]
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