New Standard NHS Community Contracts Part 3 April 2009

1. New Standard NHS Community ContractsPart 3 April 2009 Christian Geisselmann Consultant – Contracts & Commissioning NHS South of Tyne and Wear - Substance Misuse Commissioning Team

2. Quality Assessment Framework (QAF) The Quality Assessment Framework (QAF) will hopefully to be introduced by NHS South of Tyne and Wear Substance Misuse Commissioning Teams in 2009 and sets out the integrated governance and quality standards expected in the delivery of Substance Misuse services funded by NHS South of Tyne and Wear Substance Misuse Commissioning Teams. The QAF also identifies methods of evidencing achievement and will be a successful practical tool for ensuring continuous improvement in services delivering treatment services for substance misusers.

3. Quality Assessment Framework (QAF) The QAF will become an essential part of the NHS SOTW Substance Misuse Commissioning means of ensuring that providers deliver services to an acceptable standard and in accordance with contractual expectations. When first introduced there was some concern from both the sector and authorities on how rigorous the QAF could be implemented. The QAF was first used in the Supporting People programme and the majority of Administering Authorities continue to use the QAF today. There is also evidence that other areas across authorities, such as Adult Social Care and the NHS, are also adopting the QAF as the standard tool to measure the quality of services being delivered.

4. Quality Assessment Framework (QAF) The original purpose of the QAF remains: to continue to drive up quality standards across the sector and to ensure that services evolve to meet the changing needs and aspirations of clients. A refreshed QAF-lite will be available shortly. This can be used for services delivered by small providers that employ no more than four full-time equivalent members of support staff, and/or have a contract value of less than £5,000 per year / grant arrangements.

5. Quality Assessment Framework Core Objectives There are five core objectives: C1.1 Assessment and Support Planning C1.2 Security, Health and Safety C1.3 Safeguarding and Protection from Abuse C1.4 Fair Access, Diversity and Inclusion C1.5 Client Involvement and Empowerment The most significant area within the core objectives themselves are the broadening of the Protection from Abuse objective to include safeguarding principles and obligations to children, and the inclusion of a core objective on Client Involvement and Empowerment, which incorporates the previous Complaints objective.

6. Quality Assessment Framework Standards Performance Levels Levels A and B denote services that are either striving for excellence or are providing excellent services and are therefore innovative in their approaches to delivering services. When assessing compliance with level A and B standards therefore, it is acceptable to cite alternatives to the evidence examples where these genuinely demonstrate that the standards are being met by other means.

7. Quality Assessment Framework Level A Level A means excellence and is associated with providers striving to be leaders in their field. In addition to meeting minimum standards and evidencing good practice, level A requires that the service: is flexible and responsive, and able to adapt the service to best meet clients’ needs is a learning organisation that reflects on its work and uses this information to challenge its own performance effectively engages clients and staff in this shared learning engages in partnership working at a strategic level to better meet the needs of clients, the service/organisation and commissioners demonstrates the achievement of shared outcomes as a result of effective partnership working demonstrates vision, leadership and creativity that influences practice beyond the boundaries of the service

8. Quality Assessment Framework Level B Level B means the service can evidence good practice. In addition to meeting minimum standards, level B requires that the service: has policies and procedures in place that go beyond statutory requirements to embrace good practice, and that these are followed has staff that are confident to take the initiative, and work effectively with other agencies has clients meaningfully engaged at a service level engages in partnership working at a service level to better meet the needs of clients and the service is working towards the achievement of shared outcomes at a service level challenges its own performance with internal auditing and the setting and monitoring of targets demonstrates a commitment to continuous improvement

9. Quality Assessment Framework Level C Level C means that the service meets, and is able to evidence; the required minimum standard but there is scope for improvement. Level C requires that the service: complies with any statutory requirements has policies and procedures in place, and that these are followed has staff that understand and can explain the policies and procedures has clients who understand the nature of the service they are receiving engages in partnership working at a client level to better meet the needs of the individual is working towards the achievement of individual client outcomes demonstrates a commitment to continuous improvement

10. Quality Assessment Framework Level D Level D means that the service is below the minimum statutory requirements and an urgent action plan will be put in place. Providers should bear in mind that individual contracts may require them to meet a higher level of performance than these minimum standards.

11. Quality Assessment Framework Levels Providers / Teams should complete the scoring sheet with their assessment for each standard. The spreadsheet contains formulas which will calculate the performance level for each core objective, and an overall performance level for the QAF as a whole, according to the following rationale: Failure to reach level C on any standard / objectiveFailure to reach minimum standards Level C on a majority of standards / objectives and no failure to reach level CPerformance Level C Level B or above for a majority of standards / objectives Performance Level B Level A for the majority of standards / objectives and no level CsPerformance Level A This would mean three As and two Bs would result in an A overall. The presence of a C would bring you down to a B.

12. Quality Assessment Framework Passporting There is a number of externally validated quality monitoring frameworks that could potentially be used to passport services through the Quality Assessment Framework. Currently, none of these has been mapped to the QAF and cannot be used for passporting. Agencies responsible for these various frameworks are encouraged to send them to the team and they can discuss this further.

13. Quality Assessment Framework Validation Visits The purpose of QAF validation visits is to verify the quality of the service and the provider’s QAF self-assessment by talking to the people who receive and deliver it. While much of the QAF, particularly at performance level C, is concerned with policies and procedures, it must be remembered that documents are only one source of evidence for the assessment of quality. Desktop validation can therefore have only limited value. Visiting the service will also allow for observations of accommodation and day-to-day practice, including interactions between clients and staff, clients and managers, between clients, etc. which also constitute sources of evidence.

14. Quality Assessment Framework Validation Visits A QAF validation visit is not a statutory inspection but is instead a ‘check’ on whether providers achieve particular standards. The PCT can carry out the visits themselves or, where appropriate, they can commission a specialist organisation to carry out visits on their behalf. The team may wish to review policies and procedures and other documentation for the previous three years. Providers should ensure that documentary evidence is available. NHS SOTW Substance Misuse Commissioning Teams are responsible for checking service quality as part of their ongoing contract monitoring obligations. The team will develop a programme of visits that prioritises services based on an assessment of risk. In addition the team will carry out random or spot checks.

15. Quality Assessment Framework Core Objective 1.1 C1.1 Assessment and Support Planning The overall intended outcome of core objective 1.1 is that: All clients receive an assessment of their support needs and any associated risks. All clients have an up-to-date support and risk management plan. Assessment and support planning procedures place clients’ views at the centre are managed by skilled staff and involve other professional and/or carers as appropriate. It consists of the following five standards. The needs of applicants / clients and any inherent risks are assessed on a consistent and comprehensive basis prior to a service being offered, or very shortly afterwards as appropriate to the needs of the client group. All clients have individual outcomes-focussed support and risk management plans that address the needs and risks identified by the assessment process. Needs / risk assessments and support / risk management plans are reviewed regularly on a consistent and systematic basis. Needs and risk assessment, support planning and reviews involve clients and take full account of their views, preferences and aspirations. Staff carrying out needs and risk assessments and negotiating support and risk management plans is competent to do so.

16. Quality Assessment Framework Core Objective 1.2 C1.2 Security, Health and Safety The overall intended outcome of core objective 1.2 is that: The security, health and safety of all individual clients, staff and the wider community are protected. It consists of the following 3 standards: There is a health and safety policy which is less than three years old and is in accordance with current legislation. The service has a co-ordinated approach to assessing and managing security and health and safety risks that potentially affect all clients, staff and the wider community. There are appropriate arrangements to enable clients to access help in crisis or emergency.

17. Quality Assessment Framework Core Objective 1.3 C1.3 Safeguarding and Protection from Abuse The overall intended outcome of core objective 1.3 is that: There is a commitment to safeguarding the welfare of adults and children using or visiting the service and to working in partnership to protect vulnerable groups from abuse. It consists of the following five standards: There are robust policies and procedures for safeguarding and protecting adults and children that are less than three years old and in accordance with current legislation. Staff are aware of policies and procedures and their practice both safeguards clients and children and promotes understanding of abuse. Staff are made aware of and understands their professional boundaries and their practice reflects this. Clients understand what abuse is and know how to report concerns. The service is committed to participating in a multi-agency approach to safeguarding vulnerable adults and children.

18. Quality Assessment Framework Core Objective 1.4 C1.4 Fair Access, Diversity and Inclusion The overall intended outcome of core objective 1.4 is that: There is a demonstrable commitment to fair access, fair exit, diversity and inclusion. The service acts within the law and ensures clients are well-informed about their rights and responsibilities. It consists of the following three standards: Fair access, fair exit, diversity and inclusion are embedded within the culture of the service and there is demonstrable promotion and implementation of the policies. The assessment and allocations processes have been reviewed in the last three years and ensure fair access to the service. There is a commitment to ensuring fair exit from the service.

19. Quality Assessment Framework Core Objective 1.5 C1.5 Client Involvement and Empowerment The overall intended outcome of core objective 1.5 is that: There is a commitment to empowering clients and supporting their independence. Clients are well informed so that they can communicate their needs and views and make informed choices. Clients are consulted about the services provided and are offered opportunities to be involved in their running. Clients are empowered in their engagement in the wider community and the development of social networks. This core objective consists of the following five standards: People wanting to access a service can make an informed decision before accepting an offer and know about the range of services and support available to meet their needs. Clients are consulted on all significant proposals which may affect their service and their views taken into account. The service encourages clients to do things for themselves rather than rely on staff. Clients are encouraged to consider ways in which they can participate in the wider community. There is a written complaints policy and procedure that has been reviewed in the last three years and is used as a tool for service development.

20. Value for Money National approach to tariffs and currencies Payment in the contract

21. What is Payment by Results? What is PbR? - It is a new method of funding NHS activity introduced from 2003/2004 What is the aim of PbR? - A LONG TERM SUSTAINABLE price to an EFFICIENT provider of APPROPRIATE, HIGH QUALITY ACCESSIBLE services PbR - Creates transparent link between outputs and costs - Helps in identifying and dealing with inefficiency - Funding follows the service user and supports their choices

22. Key links – aims of Currency and Pricing initiatives

23. VFM Tariffs, Currencies & PaymentsPbR for Substance Misuse Background: Introduction of acute PbR in 2003/04 Total money in system remains the same Clear and transparent funding Mental health more complex 13% of NHS budget

24. VFM Tariffs, Currencies & PaymentsPbR for Substance Misuse High Quality Care For All Based on Care Pathways and Packages approach

25. VFM Tariffs, Currencies & PaymentsPbR for Substance Misuse Currency and Prices Often confuse currency and tariffs Currency is the unit for which payment made Price is a set price for a given currency unit Focus is on developing a currency across England

26. VFM Tariffs, Currencies & PaymentsPbR for Substance Misuse Are a way of grouping similar needs and interventions The currency should support the objectives of providing better care and should avoid creating perverse incentives These groups must be similarly resourced & professionally related, and must be workable

27. VFM Tariffs, Currencies & PaymentsPbR for Substance Misuse Benefits Improved allocation of resources Incentivising evidence based care Improved information flows and quality of information Avoidance of community/ inpatient splits in funding streams

28. VFM Tariffs, Currencies & PaymentsPbR for Substance Misuse Activity based contracts Marginal rate of 20% for under/over performance Level of risk capped at £340,000 Associates excluded Rebasing agreement between PCTs Reference costs used as basis for prices

29. VFM Tariffs, Currencies & PaymentsPbR for Substance Misuse Contract allows for: 1/12th of annual contract value Payment of invoices presented, and Recognises “Small Providers” A small provider is one with 50 or fewer FTE and has an annual contract value of less than £130k Here the small provider (if they have a contract) is entitled to receive payments in advance for the services If the small provider is working on an ad hoc basis then PCTs will need to pay against invoices presented

30. VFM Tariffs, Currencies & PaymentsPbR for Substance Misuse Local prices for 2009/2010 Expecting to have an indication of the way forward for 2010/2011 during this year Some PCTs are already unbundling their block contracts and have implemented Activity Based Contracts for services Some are using the reference cost approach as a basis of costs allocation to service lines. This has taken time and a lot of trust between the providers and commissioner – but it has worked What is the approach in this here?.....

31. CQUIN (Quality Performance Incentive Schemes) NHS SOTW is developing a set of Enhanced Performance Indicators to recognise excellent performance by Providers within the contract and will be referred to as CQUIN.

32. CQUIN This approach has been formulated because DH believes that there are areas where providers face particular challenges in achieving and maintaining standards. In NHS SOTW these are likely to include: Workforce Development and Staff Retention Effective support planning and risk assessment Meaningful Service User Involvement Effective provision and ease of access for people at risk of social exclusion.

33. CQUIN In creating incentives to prioritise these areas the local market will be strengthened in the long term and individual providers will be more able to retain business and compete for new business. For that reason the team has decided that: - CQUIN Indicators will be one of the factors considered at Options Appraisal meetings in deciding whether to extend existing contracts CQUIN Indicators will also be evaluated as an indicator of quality in the procurement of new and existing services in line with NHS SOTW Procurement strategy

34. CQUIN Any provider who successfully achieves CQUIN Performance Indicators in all areas will be deemed to have achieved CQUIN Status. Providers will have an option on whether they wish to undertake assessment for CQUIN however this is unlikely to come into force until 2010.

35. CQUIN Progress in achieving CQUIN will be assessed as part of Contract Management meetings. NHS SOTW Substance Misuse Commissioning Teams will aim to provide extra resources to support the development of third and voluntary sector providers in order to help them meet the CQUIN standard. These are outlined in Section 10. A Provider can choose to start assessment for CQUIN at any point during the period of the Contract providing that there is a minimum of six months left before the expiry of the contract. This is to allow sufficient time for assessment to take place.

36. CQUIN A Provider may forfeit CQUIN if there is evidence of a major single breach in acceptable levels of performance or a recurring history of failure to meet minimum standards. Any issues relating to the loss of CQUIN will be discussed as part of a specially convened Contract Management meeting.

37. Thankyou & Any Questions? Christian Geisselmann Consultant – Commissioning & Contracts South Tyneside PCT Substance Misuse Commissioning Team NHS South of Tyne and Wear 17 Beach Road South Shields Tyne & Wear NE33 2QA Telephone: 0191 4967963 xxxxxxxxxx@xxxxxxxxxxxxxxxx.xxx