StabilisationProposed approach to continuing reform in

NHS without major legislation

2

Agenda for ReformNicholson Challenge (QIPPR)

Patients at the centre (no decision about me .…)Greater patient and public involvement Clinicians in charge Reduce bureaucracy and management

Improving outcomes

5 Year plan?

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Key Reform ThemesClinically led commissioningAcute – primary shift – prevention

But investment required and potential strains on social care

Specialisation (tier one/two/three) as for trauma, stroke etc

Reducing unacceptable variation (costs and outcomes)Reducing inequality of outcomesSocial – health care integration and integration around

patient needs

Elephant – Social Care collapsing - Dilnott04/02/2012 SHA D R A F T 5

The AlternativeWithout Primary Legislation

Using Existing Powers

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Key PrinciplesNo major primary legislation

Use existing SoS powers or Bill without Part 3. Integrated local commissioning – clinically

ledEarned autonomyConvergence with local authoritiesCompetition within managed frameworkSystem planning approach to reconfiguration

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Stabilisation PlanConcentrate on Nicholson Challenge/QualityConsult, then develop and publish proper 5 year planPlanning and system management with genuine involvementKeep CSHAs and CPCTs as proper statutory bodiesIntroduce NCB (operational not policy)Tell SoS and NCB not to micro manage

Actually culture change not organisational change required.Complete provider transitionFacilitate reconfiguration across systems (acquisitions &

mergers?)Build on commissioning strengthsProvide flexibility in commissioning support

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Stabilisation PlanIncrease clinical involvement – devolve through

earned autonomyAllocate commissioning functions to right level

Local wherever possibleBegin serious engagement with local authorities

Provide incentives use existing flexibilitiesContinue developing incrementally tariff, outcomes

framework, PRCC.Park further changes until after NC is achievedConsult on longer term plans.

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Secretary of State RolePromotes the comprehensive NHS - secures

provisionLegally and politically accountableDelegates powers and dutiesIntervenes when necessary in best interests of

NHSBUT not compelled to interfereDefines the foundationsDirects the system (Op. Framework or Mandate)Sponsors key bodies

Nice, CQC, SpHAs04/02/2012 SHA D R A F T 5

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FoundationsNHS ConstitutionPrinciples and Rules for Cooperation and

CompetitionNHS Tariff (could be set by independent

body)Standard contract termsOutcomes FrameworkCommissioning Outcomes FrameworkNational Service FrameworksTerms and Conditions – GPs contractsMandate (Operating Framework)

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CompetitionValuable as one tool – within managed frameworkRetain existing Principles and Rules for

Cooperation and Competition (PRCC) Retain Cooperation and Competition Panel to

advise on disputesSet boundaries for services open to competition

through Mandate (choice mandate as from Future Forum)

Flexibility to extend AQP already usedClarification of EU position

Protection for commissioners acting in good faithNo externally applied imposition of competition

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Provider DevelopmentAccept role for some NHS Trusts (safe haven)Complete TCS transitionEmpower PDA to manage pipeline to FT status

Continue with supervision through TPAsReview pipeline and challenged FTs on whole system basis

(Monitor looking at this)Revise reconfiguration process – mandate use

Needs planning and leadership – much faster route than market/failure

Allow de authorisation by choice to enable reconfigurationRather than under pressure from commissioners or regulator

Licensing can wait – reconsider 201604/02/2012 SHA D R A F T 5

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MonitorMaintains current roleRegulator of providers of service to NHSContinues to authorise FTsContinues to oversee FTs (including PP Cap)

Change to PPI Cap requires legislationCompromise possible if cap set by local

governance

Can advise SoS on prices, contract conditions and competition rules

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Failure RegimeFocus on prevention of failure – whole system

approach Continue deauthorisation of FTsIntroduce pre–failure regimeStrengthen but streamline reconfiguration

processImplement Special Administration powers

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Wellbeing BoardsUse existing local authority “wellbeing” powersContinue to promote pro-active community involvementUse access to funding incentives to join up provision of

careWide membership base including public and patient

representativesInclusion of elected members (Councillors)Support and drive integration across all public servicesJoins up public health, social care and health care Involve and engage with Tier Two authorities if present

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Wellbeing BoardsProduce strategic needs analysis (as now)*Produce wellbeing strategy (generally as now)*Produce integrated commissioning plan*

*Working with CPCTs and CCGs as appropriateSign off commissioning plans from CPCTs and CCGsOversee implementation of plans

and can refer to SoS if any dispute or disagreement

Could be integrated with CPCTs to become Commissioning Authorities - as recommended by Health Committee

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Commissioning ArchitectureSimplifying Structures

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Under HSC BillNational Commissioning Board Part A

Commissioning of servicesNational Commissioning Board Part B

Oversight of commissioningRegional Outposts (4)Local Outposts (50)Clinical Commissioning Groups (250)Commissioning Support Organisations (40)Health and Wellbeing Boards (160)Clinical Senates (30?)

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Under Stabilisation PlanBoard – no need for separation of fucntions

Regional directorates (4) CPCTs – sub regional – coterminus with LAs

(50)CCGs (250 reducing over time)Wellbeing Boards – to be merged into CPCTs

over time

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Clustered PCTs Public bodies – NOLAN compliantHave publicly appointed non executives

Must include health professionalsSupport development of strategic needs assessmentsAgree commissioning plans - within local wellbeing

commissioning strategy and integrated planCoterminous with Tier One Local Authorities (one or more) Integration of commissioning to drive integration of provision

Commission specialist services Commission and manage PMS contracts

Conduct periodic service reviews to demonstrate VfMDelegate hard budgets to CCGs – monitor deliveryAccountable (through CSHAs) to NCB to SoS

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CCGsPublic governance and accountability – but as sub committees of

CPCT (as now)Formal constitutions and Boards (local within a national template)

Must include lay representatives as well as professionalsLocal commissioning (but not PMS or specialist)Delegated Hard BudgetsEarned autonomy

Use authorisation framework already developed nationally – apply locally

Same relationship of CCG – PCT as already developed for CCG – NCB

No bonuses!04/02/2012 SHA D R A F T 5

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Functions from CPCTs to CCGs?CGGs can draw on support as required – not as mandated

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Functions from CPCTs to CCGs?

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Do not create market ready CSOsKeep functionality within CSHA/CPCT/CCG as

appropriateWill vary across localities

Very large CCGs could have (mostly) own capacityExpertise kept within NHS (reduces redundancies)Supplement where required (?data analysis) from

external sourcesSome services may be national (economies of

scale)Some services might be shared with local authority

23

National Commissioning BoardNHS Management Board? DH?Management of Commissioners and NHS TrustsHost for specialist commissioningEnsures continuity of CommissioningRegional outposts with locally appointed Boards/NEDs

Split Operational/Policy

Policy development - mandateTariffNational Service FrameworksOutcomes etc frameworksNational programmesResource allocations – capital programme

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Other Issuesto be resolved without primary legislationHealthwatch (replacing Links)H&SC Information CentreNICEALBsWorkforce Regulation

TrainingResearch

Widespread support for changes can be built upon and existing powers used where necessary.

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Solution HeadlinesNCB as SpHA – system performance management

Commissioning development and oversight Reconfiguration Hosts national specialist commissioning Hosting networks, senates, national services

Keep SHA and PCT Clusters CPCTs and CSHAs have strong governance structures

in placeAppoint clinicians to Boards – keep proper NEDsSenate for each CPCT (not PECs - more multi

professional)where CCG not appropriate or not competent04/02/2012 SHA D R A F T 5

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Solution HeadlinesMerge the CSOs into CPCTs – support to CCGs

(no market)Migrate capacity into CCGs as appropriate Will vary depending on size and capacity of CCGs

Converge CPCTS and HWBBs over timeColocation, shared posts, pooled budgets, shared

systems and informationContinue CCG authorisation process as CPCT

sub committees – but genuine delegationCPCTs have role in commissioning04/02/2012 SHA D R A F T 5