Liberating Commissioning Impact of the NHS White Paper

1. Liberating Commissioning � Impact of the NHS White Paper Welcome Please Switch of your Mobile Phones

2. 2 17 May 2012 Liberating Commissioning 15th Sept 2010 Doug Forbes � Director

3. Other Speakers Dr James Kingsland -National PBC Clinical Network Lead Senior Partner St Hilary Brow Group Practice President National Association of Primary Care Janice Horrocks Executive Director of Engagement, Partnerships & OD, Blackburn and Darwen PCT, MIoCP 3 17 May 2012

4. Simon Cox, Commissioner NorthTyneside PCT, MIoCP Nick Capon Director of Partnerships, Portsmouth University Dr Tammi Sinha Principal Lecturer, Portsmouth Business School 4 17 May 2012

5. Programme 10.00 NHS White Paper and Consultation Papers 11.00 Commissioners Perspective 11.45 Impact on Councils, Adults and Children�s 12.30 Opportunities for Commissioners 5 17 May 2012

6. Facilitated sessions - Workshops A � Involving patients in GP led commissioning � Kit Roberts, Joint Commissioner, Telford and Wrekin, MIoCP B � What lessons are there from the PCT experience and how can PCTs lend their expertise to GP Commissioning Consortia? Carolyn Boyd, MIoCP C � Forming employee-led GP Commissioning Consortia � Doug Forbes, MIoCP 6 17 May 2012

7. Goals of IoCP Member owned, not for profit To improve commissioning standards Act as the voice of commissioners 7 17 May 2012

8. Progress 60% membership from PCTs National Occupational Standards now agreed for Commissioning and Contracting Two key strategies Introduced a membership exam Examination Committee Exploring voluntary registration of Commissioners with Council for Healthcare Regulatory Excellence 8 17 May 2012

9. Council for Healthcare Regulatory Excellence Regulates General Medical Council General Dental Council Health Professions Council Royal Pharmaceutical Society of GB General Optical Council Nursing and Midwifery Council 9 17 May 2012

10. Timescale Next year - in parallel with CHRE Impact on IoCP Size and recognition Governance and growth Income and resources Improving professional standards 10 17 May 2012

11. Today�s Conference Speakers will Cover; � GP Commissioning Consortia: Creating the new Commissioning arrangements; � NHS Commissioning Board; � The role, centralisation and regulation; � Monitor; � Role of CQC; � Developing GP Consortia; 11 17 May 2012

12. � Use of National Occupational Standards to inform the job design; � Impact on Local Authorities; � The new powers; � Is this the end of S75 Agreements? � What is the future of Learning Disabilities and Mental Health Services in Councils? � Will there be changes in Assessment and Care Management? 12 17 May 2012

13. � What Impact is there for Districts and Community Services? � Public Health Service and HealthWatch; � JSNA and Commissioning for Outcomes Improvement; � Partnership Opportunities for the Third Sector. 13 17 May 2012

14. Dr James Kingsland National PBC Clinical Network Lead Senior Partner St Hilary Brow Group Practice President National Association of Primary Care 14 17 May 2012

15. GP Commissioning Dr James Kingsland General Practitioner Wallasey National PBC Clinical Network Lead, Dept of Health President National Association of Primary Care

16. Linda RA Duplication of service Untimely unclear correspondence from hospital Unnecessary F/U arrangements Inefficient administrative support Duplication of GP work Extra administration in practice Use of NHS resources for research purposes Patient experience...... Not good

17. David 43 yr old solicitor with type II DM w/e emergency admission with lower limb cellulitis Chaotic IP Rx with i.v. a/b EBM? and use of hospital beds 8 day admission with discharge on Sunday Monday postman and Med 3 ? Use of GP time Saving cpw home Rx = �3500 Patient experience��Not good

18. Economies of scale 20,000 x 250 x �50 = �250m 8,230 x 250 x �250 > �0.5 bn 35,000 x 52 x �500 = �1 bn (Linda) 8,230 x 52 x �3500 = �1.5 bn (David) 20,000 = conservative estimate of consulting GPs on daily basis 35,000 = No of GPs in England 8230 = general practices in England 250 = No of normal working weekdays annually 52 = weeks / year 20,000 = conservative estimate of consulting GPs on daily basis 35,000 = No of GPs in England 8230 = general practices in England 250 = No of normal working weekdays annually 52 = weeks / year

19. Challenges Transition period Commissioner �Provider split Contestability and AWP Consortia form and function Management allowance and support Accountable Officer and governance Regulation Managing poor performance and failure Investing in success and use of freed up �15-20 bn

20. Thank Youjameskingsland.dh@gmail.com Questions?

21. Janice Horrocks MIoCP Executive Director of Engagement, Partnerships & OD, Blackburn and Darwen PCT, 21 17 May 2012

22. Commissioners Perspective IoCP 15th September 2010 Janice Horrocks MIoCP Director of Engagement, Partnerships & OD

23. Background Strong established partnership between Blackburn with Darwen Borough Council and NHS Blackburn with Darwen through a Care Trust �Plus� Section 75 Partnership Agreement Single integrated health and social care commissioning Single integrated management team Joint working between the council NHS Blackburn with Darwen has been developed into a strong and vibrant partnership over the past ten years. The council boundaries are co-terminous with those of NHS Blackburn with Darwen which provides excellent opportunities for joint planning and service delivery. The Joint Strategic Needs Assessment (JSNA) and Public Heath Annual Report highlight the major health inequalities in the Borough that remains a challenge for improving life expectancy. The need to combat major illnesses and stimulate healthy lifestyles is such that only strong partnership working has a hope of achieving. NHS Blackburn with Darwen and the council already work closely on economic and regeneration initiatives to improving community safety, educational attainment and community cohesion. These are the factors that will continue to have a long term impact on the health and wellbeing of local people and are major factors influencing the health inequalities. World Class Commissioning (WCC) is a new approach to gaining better health outcomes across the country. At its heart is the requirement to ensure systems are competent to deliver world class services to people. Effective partnerships and joint commissioning between the NHS and local authorities is strongly encouraged. The joint partnership board in Blackburn with Darwen and history of joint working places the borough in a good position to deliver better services through enhanced joint working arrangements.Joint working between the council NHS Blackburn with Darwen has been developed into a strong and vibrant partnership over the past ten years. The council boundaries are co-terminous with those of NHS Blackburn with Darwen which provides excellent opportunities for joint planning and service delivery. The Joint Strategic Needs Assessment (JSNA) and Public Heath Annual Report highlight the major health inequalities in the Borough that remains a challenge for improving life expectancy. The need to combat major illnesses and stimulate healthy lifestyles is such that only strong partnership working has a hope of achieving. NHS Blackburn with Darwen and the council already work closely on economic and regeneration initiatives to improving community safety, educational attainment and community cohesion. These are the factors that will continue to have a long term impact on the health and wellbeing of local people and are major factors influencing the health inequalities. World Class Commissioning (WCC) is a new approach to gaining better health outcomes across the country. At its heart is the requirement to ensure systems are competent to deliver world class services to people. Effective partnerships and joint commissioning between the NHS and local authorities is strongly encouraged. The joint partnership board in Blackburn with Darwen and history of joint working places the borough in a good position to deliver better services through enhanced joint working arrangements.

24. The White Paper Sets out a vision where clinicians are empowered to deliver results To achieve this it proposes the setting up of: GP Commissioning Consortia Responsible for commission local services An autonomous NHS Commissioning Board Responsible for commissioning other services such as primary medical services, dentistry and community pharmacy. A new role for local authorities To support local strategies for NHS commissioning and integration of NHS, social care, and public health services All NHS Trusts will become foundation trusts (FT), or be part of an FT with staff having a greater say in how their organisations are run

25. GP commissioning consortia These will be statutory bodies and required to comply with procurement laws and duties to involve service users and consult. Issues: Other disciplines Sufficient clinical engagement Capacity limited management costs establishing an appropriate blend of risks carried by and incentives available to GPCs Lead commissioning arrangements

26. GP commissioning consortia Capability need to develop skills infrastructure and IT support role of specialist clinicians (GPs are generalists) A different relationship with patients Governance - framework for commissioning decisions and conflict of interest Fostering competition and choice � preferred providers Monitor will be given new powers to investigate and remedy complaints about procurement/ant-competitive conduct.

27. NHS Commissioning Board Autonomous national leadership role and will set the framework for commissioning by GP consortia (GPC). Some aspects of the direct commissioning obligations need to be clarified: Extent to which GPC will assist in managing the primary care contracts Specialist services to be delegated to GPCs How GPCs will work together with the criminal justice system

28. Contracting and payment framework NCB sets structure for payments NCB working with Monitor to determine which services will be subject to tariff Monitor will set prices in consultation with NCB and providers Providers will have a right to challenge prices set to Competition Commission

29. A new role for Local Authorities Within this new system, local authorities would have an enhanced role in health: leading joint strategic needs assessments (JSNA) to ensure coherent and co-ordinated commissioning strategies supporting local voice, and the exercise of patient choice promoting joined up commissioning of local NHS services, social care and health improvement leading on local health improvement and prevention activity

30. What does it mean locally?

35. The voice of patients also needs to be strengthened To help achieve this: existing Local Involvement Networks (LINks) would be transformed into local HealthWatch organisations. a national HealthWatch organisation would be a new independent consumer champion within the Care Quality Commission HealthWatch would represent the views of patients and carers HealthWatch would be able to suggest which poor performing services should be investigated

36. What do the public think ? Most prioritise the protection of services for those who need them most when asked, �Which of these comes closest to your opinion about how the government goes about reducing the deficit?� 75% - The government�s priority should be to protect services for people who most need help, even if that means that other people are harder hit by tax rises and cuts to the services they use 20% - The only way for the government to reduce the deficit is to cut spending on all services, even if that includes services that are mainly used by people who most need help

37. What do the public think ? How quickly do the public think public spending should be cut? And which of these comes closest to your opinion about how the government goes about reducing the deficit? 69% - It is better to cut spending more slowly, to reduce the impact on public services and the economy 25% - It is important to cut spending quickly even if this means immediate job losses, because it will be better for the economy in the long term

38. What do the public think ? When given a list of public spending areas and asked �Which TWO or THREE, if any, of the following main areas of public spending do you think should be protected from any cuts?� 82% - NHS/care 58% - Schools 46% - Care for the Elderly 35% - Police 15% - Social Services 13% - Defence 8% - Benefit payments 6% - Local Authorities 5% - Foreign aid

39. What do the public think ? Two in five want to either have more of a say or get actively involved in how decisions about spending cuts are made. 11% - I would like to become actively involved in how decisions about cuts to public services are made 29% - I would like to have more of a say in how decisions about cuts to public services are made 36% - I would like to know how decisions about cuts to public services are made, but I don�t want to be involved beyond that 22% - I'm not interested in knowing how decisions about cuts to public services are made, as long as the government consults relevant experts

40. What do the public think ? How people say they would prefer to participate: 77% - Taking part in a survey 66% - Receiving regular updates and information 63% - Giving your views online on a government website 56% - Through a suggestion box in your local area

41. What do the public think ? How people say they would prefer to participate: 49% - Attending a public meeting, sometimes called a Town Hall meeting 45% - Attending a small group discussion or focus group in my local area 37% - Joining a community group or organisation and letting them represent my views 28% - Through social networking sites such as Facebook or Twitter

42. Where is the system leadership? NHS Commissioning Board Health and Wellbeing Board Public Health

43. What needs to be done? Understanding �commissioning� � a wide range of responsibilities. One size solution will not fit all GPC - what is the appropriate size population and how will a fair budget be set? They will need to be of sufficient scale to access capital. Who will hold GPCs to account and assess GPCs performance as commissioners? Who sets and monitors standards � NCB/GPCs/CQC? Supporting GP leadership Managing the transition! Incremental transfer of responsibilities, but need parallel transfer of accountability and regulation

44. Opportunities? Pioneers �seize the day!� Giving clinicians more commissioning �clout� may shift hospital sector � pathway redesign BUT What effect will culture have ? Maslow's hierarchy

45. Simon Cox MIoCP Commissioning Officer NorthTyneside PCT, 45 17 May 2012

46. Impact on Councils Children�s and Adult Services Simon Cox North Tyneside PCT DAAT

48. Local Government Secretary of State �We've already made sure that councils will have a central role in new health reforms. Who would have believed Councils would be so central to the running of the NHS?� Rt Hon Eric Pickles, Communities Secretary

56. Additional functions

57. Challenges Budgets Culture Systems Training and development S75 Agreements � Partnerships on LD/MH Personalisation Assessment and Care Management

58. Nick Capon/ Dr Tammi Sinha Director of Partnerships, Portsmouth University Principal Lecturer, Portsmouth Business School 58 17 May 2012

63. Opportunity 1 Grab early retirement package Fed up with constant change and reorganisation in NHS, and re-visiting old ground as if it had never happened in the past. Then seek job in private sector

64. Opportunity 2 Transfer to new jobs with GP Federations Not yet being advertised Commissioning roles not clarified yet Need to be proactive and seek out

65. Opportunity 3 Will GP federations outsource commissioning? So new jobs with outsourced providers like Tribal? Suggest toooo risky to hand over all those billions to the private sector to buy healthcare Not yet clear, but unlikely �It is certainly not about replicating current structures with some new players involved.� Sir David Nicholson, 10th Sept

66. Opportunity 4 Will commissioning cease to exist as a profession? Time to find a different job role. Suggest commissioning will continue Government has changed all the BODIES but not the PROCESS It�s a case of �Who moved my cheese�? Will contracts and pay-by-results cease to exist � back to fixed, capped financial grants to in-house NHS providers, with service level agreements and just-in-time provision within capacity available. Suggest contracts will continue Because need for partial privatisation unavoidable in given financial constraints

67. Conclusion Commissioning skills will still be needed, just chair shuffling of where role will be done So best opportunity for Commissioners is to strengthen their marketability ready for new job interviews Three ways to achieve this: Networking � conference, institute attendance Experience � embrace new project opportunities Qualifications � either general MBA or sector specific professional qualifications

68. Appendix (for thought later): Importance of building trust � a further opportunity for commissioners?

69. Commissioning not adequate without trust Opportunity to build trust between commissioners and: Providers? Public? Government? Need for trust to supplement commissioning: Bounded rationality Opportunism Uncertainty Frequency of transactions Specific assets

70. Bounded rationality Commissioners cannot know everything People�s ability to make rational decisions limited. There are limits to everyone�s capacity to receive, process, store and retrieve information. Commissioners are unable to foresee all contingencies that may affect a transaction. No contract can capture all contingencies.

71. Opportunism Commissioners will not always find out Economists generally see people as mainly concerned with their own interests. Transaction economists go further and maintain that market actors will take every opportunity to deceive and be dishonest if they believe that they will not be found out.

72. Uncertainty Commissioners cannot predict Uncertainty about the future development of the demand and market makes decision-making difficult. With bounded rationality it is not only difficult to plan for the future but even to elaborate all the known possibilities of the moment. Future outcomes of business transactions cannot be predicted with any certainty.

73. Frequency of transactions Commissioning complex for one-off transactions Commissioning control cheaper for high repetition The specific investment needed to monitor and control a one-off business deal with a specific partner is costly. When transactions are one-off, higher level of trust required.

74. Specific assets Costly to mechanise The resources used to make a product or service can either be very unique (tailor-made) or very general, non-specific. Specific resources such as specialised machinery or management skills cannot easily be employed elsewhere. Any firm investing in specified assets makes itself highly dependent on one or very few client firms. Trust essential to encourage providers to bid

75. Critique of Transaction Economics Being too exclusively focussed on efficiency and ignoring other aspects that may influence decision-makers such as fairness, and concerns for relationships Having a static rather than a dynamic perspective. It cannot explain how relationships evolve

76. Critique of Transaction Economics It ignores the influence of power. Sociologists writing on organisations often argue that hierarchies are about the exercise of power rather than about efficiency. Key scholar/further reading: Williamson, O (1979), Transaction-cost economics: the governance of contractual relations, Journal of law and Economics, Vol.22, October 1979, pp. 233-161

77. Lewicki and Bunker model

78. Conclusion Way forward for commissioners? Similar actions to those in early part of this presentation are suggested by trust theory: Reputation building by the Institute Qualifications � either general MBA or sector specific professional qualifications Networking � conference, institute attendance

79. Kit Roberts MIoCP Joint Commissioner Adults with Learning Disabilities Telford�& Wrekin Council and Telford�& Wrekin PCT 79 17 May 2012

80. Involving patients in GP led commissioning Group discussion Kit Roberts 15th September 2010

81. Liberating the NHS and patient involvement? The White paper gives importance to the involvement of patients. Some patients more straightforward to involve than others and how is this managed? The White paper focuses on a more clinically commissioned service so will the patients really �have a voice�? How do GP consortia provide evidence of quality outcomes for all patients?

82. Involving patients in GP led commissioning What needs to develop locally to support GPs/consortia involving all patients? What are the barriers to involving all patients, and how can these be overcome? How do GP consortia ensure equitable representation of patients across all clinical areas?

83. Carolyn Boyd MIoCP What lessons are there from the PCT experience and how can PCTs lend their expertise to GP Commissioning Consortia? 83 17 May 2012

84. Doug Forbes D � Forming employee-led GP Commissioning Consortia GP Commissioning Consortia DH has indicated that they will be classed as a Statutory Body regulated by the NHS Commissioning Board Governance and Leadership? 84 17 May 2012

85. Right to request the formation of a Community Enterprise How is this working in practice? Leadership � employee survey Business Case Business Plan Patients/ service users Information systems 85 17 May 2012

86. Employee buy in Extent Risk Reward Resources Communications Scale and strategy 86 17 May 2012

87. Local Authority and Big Society (Third) Sector What warranties and guarantees will be required? Insurance Cash Flow Overspending by GPs What will be different about the relationship between all partners, GPs, LA , Provider and Third Sector? 87 17 May 2012