Implementing the proposals in the final report of the NHS Next Stage Review, “High Quality Care for All”, is core business for the national health service. The NHS budget for England for 2008-09 is £96 billion and will rise to £110 billion by 2010-11. The proposals will be funded from within that settlement.
To support decisions on how to spend their allocated resource, primary care trusts have developed operational plans on the specific national requirements for all primary care trusts to deliver, alongside locally determined stretch targets which focus on local ambitions. To support this new approach the Vital Signs indicator set was published with the “Operational Plans 2008/09-2010/11”.
Lord Darzi’s review, “High Quality Care For All” foresees that in an NHS with a stronger focus on preventative healthcare, there will be large scale investment in wellbeing services, according to local needs. All of the areas highlighted by “High Quality Care For All” (obesity, alcohol, drug addiction, smoking, sexual health and mental health) appear in Vital Signs and the National Indicator Set, either as national priorities for local delivery (Tier 2 indicators), or local priorities which can be prioritised by primary care trusts in conjunction with local partners (Tier 3 indicators).
Improving preventative and wellbeing services was a priority in every strategic health authority vision document published as part of Lord Darzi’s Next Stage Review of the NHS. Each vision document is based on an assessment of the evidence by over 2000 clinicians across England, and each one highlighted some or all of these areas (obesity, alcohol, drug addiction, smoking, sexual health and mental health) as requiring action, hence their inclusion in “High Quality Care For All”.
The World Class Commissioning programme was launched in July 2007 by the Department in order to provide support and improve commissioning across the NHS. This programme will bring about a step-change in commissioning, with one aspect of this change being a stronger focus on long-term health issues.
Through stronger engagement of stakeholders, and strategic planning with a greater focus on the longer-term, we expect to see increased investment in wellbeing services throughout the NHS as a result of the World Class Commissioning programme and “High Quality Care For All”.
Primary care trusts commission services from appropriate providers to deliver the services and care required. Services could be commissioned from a range of possible providers who are able to meet the service specifications identified by that primary care trust, in line with NICE guidance, where appropriate. It is up to primary care trusts to decide the appropriate settings for services as part of the commissioning process and the decisions are likely to take account of preferences of the target groups for that service.
Third sector groups are part of the ongoing stakeholder engagement work that has been undertaken since vascular checks were announced in Putting Prevention First at the beginning of April this year. Regular meetings are held with the Cardio Vascular Coalition third sector group, as well as with individual third sector organisations. They provide vital information about their own work in reaching those less able to access services and we will continue to work closely with them through the development of the programme.
The draft NHS Constitution proposes that the new right be underpinned by new statutory directions from the Secretary of State to primary care trusts (PCTs). This is subject to consultation. This could be done through directions under section 8 of the National Health Service Act 2006 by requiring PCTs to ensure choice. These could specify which services are covered and any exceptions. They will also require PCTs to provide information to enable choice, and to make arrangements to enable a patient to exercise choice if not offered by their general practitioner.
In addition, we propose to use the forthcoming National Health Service Reform Bill to place a legal duty on all NHS organisations to take account of the Constitution when performing their functions.
The draft NHS Constitution and the Government’s proposals are open for public consultation until 17 October 2008. The details, including how to feed in views, may be found at:
www.dh.gov.uk/consultations
The Government will build a Coalition for Better Health to work in partnership with the many other organisations outside Government that seek to promote healthier lifestyles. The Coalition for Better Health will first focus on tackling obesity and we expect partner organisations to include health, non-Government organisations, the food industry, the fitness industry, employers and others.
The Department has not made any assessment of the level of rurality of primary care trusts. However, the Department for Environment, Food and Rural Affairs did publish such a classification of the then 303 primary care and care trusts in England in 2005, based on research led by Birkbeck college at the university of London.
The Patients’ Prospectus aims to empower and support people with long term conditions to understand and exercise their choice around support for self care so that they can better control their condition and ultimately improve their quality of life. The Prospectus will be a national product, generic and will cover the four pillars of our existing policy on support for self care (information, tools, skills and support networks) together with healthy lifestyle choices. A wide range of stakeholders, including patients, clinicians, third sector representatives and staff from national health service organisations and local government are involved in developing the content, which will be launched first on NHS Choices in the autumn.
The Department is currently developing a range of options to measure and incentivise the delivery and impact of care planning including the use of patient surveys to monitor patient experience at a local level. Planned trajectories for the uptake of care plans will be decided locally. Information included in care plans will also be decided locally using recommended minimum standards.
High Quality Care For All outlined the commitment to make payments to hospitals reflect the quality of care given to patients through a Commissioning for Quality and Innovation (CQUIN) scheme. Over the next few months, we will be working with stakeholders and national health service colleagues to develop a national enabling framework for the scheme. These discussions will include the scope of the framework, both in terms of services and specialties covered, and how the incentives will work. We will then clarify the framework later this year. The CQUIN scheme will commence from 2009 and evaluation will be subject to a competitive tender process.
The National Patient Safety Agency (NPSA) will work with interested Primary Care Trusts (PCTs) and wider stakeholders (including patients and members of the public) to draw up a list of Never Events. This list will be published later in the year and will be available for PCTs to use in their operating plans from April 2009. The incidence of each of these events will vary between PCTs and therefore it will be important that PCTs have the flexibility to prioritise and select the events which will have the most impact on their own health population. The Department also anticipates that, over time, PCTs will expand their list of Never Events and the NPSA will keep under review the national list to incorporate more events that PCTs are able to use as we continue to learn from safety incidents and develop evidence-based interventions to prevent them happening again.
The first release of the NHS Evidence Service is scheduled for April 2009.
(2) what assessment he has made of the effects on competition in referrals to secondary care resulting from the creation of integrated care organisations, as referred to on page 65 of High Quality Care for All, Cm 7432.
The Next Stage Review and the Primary and Community Care Strategy announced that the Department would pilot models of integrated care. A prospectus inviting pilots to submit applications against pre-agreed selection criteria will be published over the summer. This will also set out funding available for the pilots to support set up costs and project management.
The pilots will be evaluated and the criteria will include the delivery of better health outcomes, patient satisfaction, and the effects of competition and choice.
Practice-based commissioning (PBC) has the potential to transform healthcare services, allowing clinicians to develop better services for patients in local communities. However as noted by the Audit Commission’s report on PBC, “Putting Commissioning into Practice” (November 2007), while there are examples of PBC thriving in a growing number of areas, the scale of service redesigns undertaken have been limited in comparison with the potential impact of PBC. “High Quality Care for All” signals the Department’s intention to intensify its implementation programme and as PBC matures locally, we expect to see more ambitious redesign of local services undertaken.
The standard contract for community services is being tested in all strategic health authority areas for implementation from April 2009. From this date all primary care trusts (PCTs) taking the lead role in awarding new contracts for community services will use the standard contract. The contract will apply to all relevant providers, including the third and independent sectors, and it will also be used as a service level agreement for PCT provider organisations. Where there is a legally binding contract in place which commenced prior to 1 April 2009, and is not due to expire until after this date, this agreement will remain in force until the expiry date unless otherwise agreed by both parties.
As part of the national health service next stage review process, Sir Ian Carruthers examined the drivers of change for delivery models with a particular emphasis on rural settings. This work will be published in due course.
We are developing a legal and governance framework for new organizational models, which we expect to issue later this year.
The Department does not collect comprehensive information on arms length provider organisations or on primary care trusts exploring social enterprises as an organisational model for community services.
We are working with six community foundation trust pilots, covering Ashton, Leigh and Wigan, Middlesbrough, Redcar and Cleveland, Liverpool, Oldham, South Birmingham and Cambridgeshire
We are also supporting four social enterprise pathfinders that are primary care trust provider arms exploring the potential for separation and the development of a social enterprise model. These are Hull, Milton Keynes, Surrey and the Forest of Dean.
It is anticipated that projections for multi-year tariff uplift and efficiency gains will be announced later in the year, at the same time as the publication of the NHS Operating Framework for 2009-10.
Clinical effectiveness is one of the principal elements of the quality of health services. Therefore, information on clinical effectiveness will form part of the full set of quality measures for acute patient care that are being identified by the Department. Officials have begun identifying measures from existing sources in the national health service, other health-related organisations and internationally. The first set of national quality measures will be assessed for robustness, accuracy and relevance and improvement will be supported by a National Quality Board and strategic health authority-based quality observatories.
Discussion with clinical staff and expert bodies on the initial set of measures identified by the Department will take place in the autumn. This will ensure that measures are drawn up in partnership with clinical and expert stakeholders prior to the announcement of the national set of measures alongside the next NHS operating framework.
In partnership with Royal Colleges and specialist associations, work will shortly commence to develop further generations of more sensitive and specific measures of care quality and outcomes. These will exploit new sources of data and research evidence, and will deliver better indicators for clinicians to use locally over coming years.
Our Vision for Primary and Community Care published on 3 July as part of NHS Next Stage Review proposes a new strategy for developing the Quality and Outcomes Framework, including an independent and transparent process for developing and reviewing indicators. The report states our intention to:
discuss with the National Institute for Health and Clinical Excellence and with stakeholders including patient groups and professional bodies how this new process should work;
discuss how to reduce the number of organisational or process indicators, and refocus resources on new indicators for prevention and clinical effectiveness; and
explore the scope to give greater flexibility to primary care trusts to work with primary healthcare teams to select quality indicators (from a national menu) that reflect local health improvement priorities.
Some of these matters are subject to the outcome of negotiations with general practitioner representatives and therefore it is not appropriate to set out details in advance of those negotiations. We will discuss with professional and patient groups and other stakeholders how the new process should work.
We have reviewed the potential impact on choice and competition of arrangements where NHS foundation trusts hold contracts for list-based primary medical care and we issued guidance in “The NHS in England: The operating framework for 2008/9 Annex D— Principles and rules for co-operation and competition” copies of which have already been placed in the Library. The guidance sets out the safeguards that primary care trusts, as commissioners of services, should apply both in considering whether to award primary care contracts to secondary care providers and through the contracts for such services. These principles and safeguards apply to any service that involves referrals from community providers to secondary care.
Our Vision for Primary and Community Care published on 3 July as part of NHS Next Stage Review states "we will work to ensure that QOF rewards better reflect the prevalence of illness amongst the populations served by different GP practices".
We are currently discussing with the British Medical Association changes to the prevalence formula which weights Quality and Outcome Framework payments according to prevalence of disease as measured through Quality Management System, which receives data extracted from general practitioner clinical systems.
We will be exploring with the profession the feasibility of developing indicators based on Patient Reported Outcome Measures (PROMs) for the Quality and Outcomes Framework. These may include PROMs for specific disease areas depending on the evidence base for such indicators.
Greater freedoms in managing resources will become available to practice-based commissioners who can demonstrate an ability to undertake increased responsibility. The precise nature of these freedoms, including their application, will be developed this autumn in consultation with primary care trusts and practice-based commissioners.
The draft NHS Constitution (copies have already been placed in the Library) was published on 30 June 2008 and the Government's proposals are open for public consultation until 17 October 2008. The Government will consider these issues, including the principles to support NHS decision-making, following the consultation.
As part of the innovation package agreed through the Pharmaceutical Price Regulation Scheme negotiations, and in support of the objectives set out in “High Quality Care for All”, the Government have committed to developing new metrics for the uptake of clinically and cost-effective medicines, starting with a number of drugs positively appraised by the National Institute for Health and Clinical Excellence (NICE) and to publishing comparative international data. Detailed arrangements for the publication of these metrics have yet to be finalised.
The National Cancer Director’s latest report on the uptake of cancer treatments recommended by NICE will be published later in 2008.
NICE currently publishes information on the uptake of a number of treatments it has appraised on its website at:
www.nice.org.uk/usingguidance/evaluationandreviewofniceimplementationevidenceernie/niceimplementationuptakecommissionedreports/nice_implementation_uptake__commissioned_reports.jsp
We have made no such assessment. The Department recognises that a range of professionals have a role to play in the provision of safe, high quality pre-hospital care but that it is for the local national health service to plan and provide such services and that the particular mix of clinical staff in such services is a local matter. Consultants, doctors and paramedics undergo professional regulation to ensure that standards are maintained.