Editorial Tuesday 24 April 2012: Notes of NHS Clinical Commissioners conference

Notes from the main sessions of the NHS Clinial Commissioners conference

Dr David Bennett, Monitor
Dr David Bennett, executive chair and acting CE, Monitor gave a wide-ranging presentation on the role Monitor will play in the post-Act NHS. Among his key themes was looking at GPs as providers, and whether GP provision may be covered by Competition Act and whether or not extended primary care provision may be exempt from the NHS provider licencing regime.

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Dr Bennett emphasised that Monitor’s focus would be on anti-competitive arrangements, and abuse of market position

Taking questions, Dr Bennett recognised that Monitor haven't done enough with and for commissioners in relation to FTs – he acknowledged a need to engage more and for plans to alert commissioners if an FT gets into difficulties. He observed that tariff is not based on robust cost information, and contains such perverse incentives as the lack of financial incentive to treat patients in the community. Dr Bennett also outlined a potential future of mixing fixed and variable cost tariffs to give providers stability and incentivise the right changes.

Dr Bennett also suggested that Monitor may need to align geographically, in the way that it is clear the NHS Commissioning Board will with its regional and local presences.

Dr Michael Dixon: how much will Monitor be an umpire and a knight in shining armour for inexperienced CCGs?

DB: There are current difficulties between PCTs and FTs. It can be frustrating for providers when think agreed cap and work still turns up, especially in A&E, where it puts pressure on access times. Providers have problems too, which have to be sorted, and I think we have to get engaged with that.

Q: What can you tell us about the future structure of Monitor and clinical input into Monitor?

DB: We’re working out our own structure out right now, and working through all the indications from the Health Bill changes. We’re also working on how to do proper clinical and patient engagement, and also working out how to engage with CCGs. This is about starting a dialogue between us, about what we think are issues with providers in your areas, assumed would be effective handover from SHAs and PCTs (delegates responded with a big laugh), need to enter discussion with

Dr Niti Pal – How will Monitor issue and regulate provider licences for any qualified provider (AQP)? Also, what about community services as extant providers in primary care – will we have to apply for provider licences to take on community services>

DB: There are three elements to the AQP licence: must be registered by CQC, have to be licensed by Monitor, and I would be surprised if any AQP provider were covered by the licensing exemptions. AQP also requires some sort of accreditation by commissioners, which I thought would be done nationally, but it seems the NHSCB is still working this out. Will you need provider licence if you take on community services? Possibly, so that’s where the exemption regime kicks in. Big FTs obviously should need a licence; very small providers, I think, shouldn’t – it’s not just on size, but DH working this out right now. The real question is how use provider licence to get better patient care, and then go from there.

Professor Malcolm Grant, chair, NHS Commissioning Board
I see CCGs as absolutely engine room of new NHS and see these reforms as utterly transformative. The healthcare model of the future has to be completely different form the past top-down model, which is not fit for purpose to meet the challenges facing the health system of this country.

And not just this country – all nations are struggling to see how to afford healthcare. We spend 9% of GDP; the USA 18%; and all developed nations spend somewhere between us. We all know health spending as a proportion of GDP will not increase: speinding faces stagnation and austerity.

I cannot contemplate that we would start charging for services, co-payments or reduction in quality, so we have to reconfigure all services. That’s hard enough, even if there were no demographic issue. We face an increase in population: the ONS sees 4.4 million extra people in 2020, and much of this extra is expansion in those with most healthcare needs: the very young and very old. Our success in new clinical techniques, diet and smoking has led to an older population, who become much more healthcare-dependent. For older people, care is not about resolve issues of episodic illness / injury, but dealing with growing chronic conditions and Alzheimers, especially in those over 84.

Huge challenges arise from that issue, and we face a budget which will grow marginally if at all after the significant real-terms growth of the last decade.

The growing impact of non-communicable diseases of longevity and lifestyle; the role of obesity … we have no comprehensive response yet.

The Commisisoning Board remains a special health authority until October, when we formally become the new board, an executive arms-length body with independence. In October, we will start authorising CCGs, and from 1 April 2013, we become the NHS Commissioning Board, full-stop!

What I find really important is in the title of the 2010 white paper – liberating the NHS. The NHS can function better outwith the day-to-day operational control of politicians; and also not under day-to-day operational control of the NHSCB – the NHS will be in a variety of hands; of which yours, as CCG leaders, are the most important.

The Act embodies crucial principles to make this happen. Autonomy from government for the NHSCB and autonomy from the NHSCB for CCGs. CCGs will not be the only relationships the NHSCB will have – though the bulk of the annual £90 billion revenue spending will go through you, but importantly, the NHSCB will use a significant sum to commissioning primary care – which is very important – and to specialised services. The Board has, through all this, powerful financial means to secure the outcomes we all wish for; beyond that, it’s over to you.

The relationship between NHSCB and CCGs has three dimensions. 1: shared responsibility for a leadership able to deliver a new vision for the NHS for the future. 2: a relationship of support and development. The NHSCB’s head office will not be called ‘HQ‘; the Board will have national, regional and local support components. The word ‘support’ implies different behaviours to those to which we’ve become accustomed in the system; the shared responsibility with CCGs means that the Board’s role is about support and co-development. 3: hierarchical responsibility to deliver outcomes for the country as a whole, and to ensure that CCGs deliver that. There are other responsibilities to Monitor, etc, and ultimately performance failure can lead to intervention, but our job is mainly to work as a new partnership in the NHS.

Political independence and the Board matters – legislation is very clear that the Secretary Of State has no power to issue day-to-day directions to the Board. This is a move to trust and autonomy. Legally, NHSCB gets the annual mandate, with Year 1 in sight but also Years 2 and 3 in perception, which is annually refreshed and rolled on. This gives us real ideas of stability. The mandate is only amendable if: 1. the Board agrees; 2. there has been a general election; or 3. the SOS sees “exceptional circumstances”. This is crucial as the mandate will be couched in terms of outcomes, though inevitably a few parts will be process measures, against the five domains: preventing premature death, dealing with LTCs; dealing with episodic illness and injury; enhancing patient experience; and safety. I anticipate material with the mandate to cost performance against requirements, and resources will be matched against performance.

I worry that the mandate may tend to accumulation through Whitehall. I hope we can work with you to ensure that we do not see a ‘more in the mandate, more obscure message’ effect. We must resist pressure to have every clinical condition described in the mandate, which would lead to obfuscation and confusion. The mandate will also become longer thru consultation. And it’s not just our mandate: it’s your mandate, and delivery to it is out co-responsibility with you. I hope for a mandate so clearly expressed that you could publish it in The Sun – intelligible. I’m struck by the NHS world’s jargon and unintelligibility: simplify, clarify and produce simplicity.

It’s the early stages of the NHSCB, but we’re establishing a style of working that I hope will continue, being as open as we can, papers to board meetings for publication, holding meetings in public (with the necessary part in private), webcast our meetings, a written record of our SOS meetings will be published, as will the mandate. I hope philosophy will be reflected across our practices, to ensure public trust in NHS – and I hate the word ‘transparent’, which means ‘I can see through you’. ‘Openness’ is much better, but it has  to be fought for and it’s often difficult. Difficult arguments can be had in public if you respect each other and there's good behaviour.

The best test of all is clearly of autonomy. For CCGs, autonomy can give rise to different behaviours across country; this is implicit in the model of CCGs. It’s for CCGs to define the need of local variation. Local variations will see much special pleading, but having made it through authorisation and got their allocation, CCGs will have assumed liberty and autonomy to deliver. I don’t want to inhibit your ability of deliver on outcomes. And we will have to be quality- and outcome-obsessed.

I hope authorisation leads to about 220 CCGs, and in some parts of the country I think this will be entirely straightforward. In other parts of the country, there will be more caution, and it will be varying. Authorisation is not a regulatory but a development function. I want CCGs to work with each other to ensure best practice is shared across the community.

How in an era of devolution and autonomy can we maintain concept of a national health system and service across the board? This is a huge responsibility for the NHS Commissioning Board, government and arms’ length bodies to develop a powerful strategic vision for the NHS for the next 10 years, which will not be a top-down plan published and administered by direction. The NHS Constitution details various rights and process issues already. And this process will be most led by changes already in the system, such as with specialised services i.e. hyper-acute stroke reconfiguration in London leading to a dramatic improvement in safety. That specialisation model is inexorable: better clinical safety produced in real concentration of expertise constantly doing procedures. It will have real impact.

Then we must address the design of pathways for LTC treatments, especially around referrals to acute care, and particularly reducing confused elderly patients’ referrals to acute care.

The system now is data-rich but intelligence-poor. We need to use data and intelligence collectively for the benefit of patients and advancement of treatment, and also for service quality improvement, which is critical. I think the best CCGs have best data systems, sharing and highlighting variation. And a major co-responsibility is driving up change in primary care. CCGs can do this uniquely among peers, which has not happened before. Let the primary care approach drive change. And we need to acknowledge that there are some concerns about primary care's use of data.

Many of the major hospitals in London will receive well over 30, if not over 50, per cent of their revenues from the commissioning of specialist services through the board. So the board has some very powerful financial means in order to secure the outcomes we all wish for in the system. But beyond that it’s over to you.

In our commissioning of primary care, we'll be sure to use data. We don’t want to reduce the quality or quantity of NHS healthcare, so we have to transform care delivery.

You’re not alone, we’re here to work with you but you are taking on a huge role. The more we trust to autonomy, the more rests with you to deliver outcomes

Questions and answers
MG: Authorisation is development, and on occasions conditions will be used. I envisage the NHSCB’s relationship with CCGs as a partnership. And you should be free to decide where you get your commissioning support.

How risk averse should you be? Risk-aversion is ingrained in public service, especially in the highly-politicised NHS. We need to be clear, and you need to be free from other lines of accountability.

The best way to manage risk is clarity, openness and accountability. Things fail when too many people are responsible and so there’s no clarity. You can never completely reduce risk or media interest in NHS – so we must be clear who’s responsible to put right when things go wrong. We all share responsibility with SOS for comprehensive service, so risk-aversion’s pretty  difficult.

Q: Will the NHSCB support a CCG whose decommissioning decisions threaten a provider’s stability?

MG: Destabilisation of providers is a real issue, and the more successful a CCG is in reducing referral and specialising, it will take away services from the provider, which means providers need to do things differently. There are big issues in London and across the country about what is the future of our provision landscape. Much reconfiguration happens relative to provider relationship – understanding how centralisation enhances safety and quality

Q: How will the NHSCB ensure CCGs become the best we can be at providing care for our population? Which will take primacy: central direction vs. localism? How can the NHSCB have individual relationship with CCGs?

MG: It’s for you to do this. It’s up to you this where responsibility lies in new regime. There isn’t any central direction – you’re on your own, until it all goes wrong (said with tongue firmly in check, got a big laugh).

Monitor, NICE, CCG and NHS Commissioning Board have a responsibility to work together and we’re taking that very seriously. We’ll try to see a commonality of standard of delivery across the country, but we don’t want CCGs held back from being better than others: that would be utterly perverse. There will be variation, which you can never safeguard 100% against, but we also have an obligation to address health inequalities.

Q: How will you go about managing relationship with multiple players?

MG: There’s a range of fronts for partnership delivery – local government, HWBs, social care - and between CCGs themselves. In many areas, CCGs need to combine to commission more specialist services. There will be disputes, ( I know this will come as surprise) when things don't flow smoothly. We won’t solve them, but we will work closely with you to overcome them. We are supporter and regulator.

Secretary of State Andrew Lansley
As I was planning the reforms that led to the Health Act, you were telling us “we can do this thing; we believe clinical leadership is essential to leadership of services. NHS telling us we can improve services make more responsive closer to home, know we need to do this and can do it”.

That’s why I see clinical leadership as being at the heart of legislation. You tell me that you've watched the Westminster debate with alarm, frustration and expletives. There was a lot of politics - and a lot of politics inside the health service, which are very specific - but part of the objective was to get beyond all that for good. Our 2007 policy document, ‘Autonomy and Accountability’ laid out the principles behind what we were setting out to do.

Our central proposition was that the NHS does not benefit from political interference. David Cameron and I said that we wanted to be clear what we were asking the NHS to achieve, but not constantly telling you how to do it. A&A was about setting out clearly the outcomes we’re trying to achieve and the resources within which you’ll be working, and then holding you to account; not trying to proscribe how you do it. That creates a sense of ownership and autonomy in the NHS. I hope the day will come, soon, when the media do not think that monthly variation in NHS performance is (for good or ill) the result of political interference. The NHS can be continuously improving, and that is credit to you and your colleagues. You should take the credit, as you will be doing it.

Where now? The legislation is there now; the transition will be hard. The mechanics of change will be harder over the next six months: these will be the hardest, amid 6 months where people will be trying to live in two worlds at the same moment, doing the day job while shaping the future. We need to be as clear as we can, and have spent recent weeks and months getting out to you as CCG leaders frameworks for authorisation, human resources, guidance on transfer of staff, how to access support. Tell me if there’s more that you need to know, but I think we’re approaching point where the information about basic structures is there.

Now it’s about turning this into a reality. Because without that, there would be no point us legislating for a clinically-owned locally-led patient-centred system. The NHSCB is clear that it’s not trying to be HQ, and commissioning support is to be just that: support, not control. Autonomy is real, not just devolved by the NHSCB’s discretion. Parliament has passed a Bill which says that you, as CCGs, will be statutory bodies with your own processes.

It’s clear in my letter to the NHSCB chairman Malcolm Grant that authorisation is about looking at CCGs being authorised with some conditions in some places, but that we’re looking to authorise CCGs across England so we have a coherent, robust system. Some will inevitably be authorised with conditions, but not enduring conditions. All CCGs will get budgetary powers and the ability to make own decisions. I think many CCGs understand that and have been developing with input from the inheritance of PBC, and they’re already beginning to see the benefits. And we can see the difference being made: conventional performance measures have been maintained, and PCT clusters are delivering a financial surplus, but also things that didn’t happen before have begun to: rising GP referrals to acute care have reduced; and the rising non-elective trend has slightly reduced (although elective is still rising). I think the evidence is already there of a comparable NHS delivering improving results with modest increase in real-terms in spending.

That’s really important, as it’s consistent with improved management of services and better care closer to home. Facts rarely speak for themselves; they have to be interpreted - but it seems engagement of general practice and clinical leads is working.

All this critically depends on redesign of central services: I know the last thing you want is to be politically and centrally led. This change is about your work with clinical colleagues in acute sector. I heard a story recently where a CCG lead and an acute consultant were discussing a change of care pathway, and the consultant said ‘why have we not had this conversation before?’ And too often , the clinicians hadn’t – it was PCT managers and hospital managers arguing about activity ratios and tariffs, not clinical issues.

I don’t want to turn GPs into managers, or get you having those same old conversations. The essence of decisions on behalf of patients matter the most. Patients put their lives in your hands. I want you to make good decisions about patient care and using the resources to support that. Don’t turn yourselves into managers; find good managers to work alongside you to help you do your job - and look for commissioning support that can minimise the amount of your time you spend on administration, and maximise your clinical population health perspective.

There’s still an old-school NHS risk of thinking about structures in terms of NHS structures itself, but now you have huge opportunity in local authorities and population health. The best people to work with you to take the public with you are you yourselves and your local councillors. GPs and councillors have long relationship of working with local councillors.

If a HWB and CCG working together reach a strategy based on the needs of areas, who is to tell them not to? You have the power and responsibility. Getting that relationship right is key.

Another vital point is integrated care. Yes, we need to break down primary-secondary care barriers, we also must locking health and social care together more. As in Cumbria. From my point of view, if those relationships are right, the results will come. I aim to step back and not interfere; to not tell you what to do. It’s about living within your means and delivering improved results to patients.

Let’s focus on results, not staff numbers. I ask you to be accountable for the results you achieve and do that within available resources. Constantly improving results over the coming 5-10 years will be hard when no 6% annual real-terms cash increase is coming. The status quo meant a burning platform and no-one was getting off. Now you are on that platform. It’s going to be hard, but it’s possible.

Extracts from the questions and comments
Michael Dixon: It’s so refreshing to hear a Secretary Of State use the work "autonomy" 10 times in a speech. It’s clear that we’re hoping for 100% of CCGs to get authorised, but with conditions.

Howard Stoate: We’ve had bitter disagreements in the past, but we agree that the status quo is not option and primary care must lead. How will we manage the necessary transformation without large-scale destabilisation of providers?

AL: Localism is terrifically important. Clinical redesign can lead to reconfiguration. Who is likely to take the public with them? If the local authority and clinical community have a shared view of what is the right direction to go even if you are changing services I think the chance of successes are far higher.

Q about funding formula for CCG allocations

AL: what should happen – the advisory committee will do, this I won’t – the number-crunching should get progressively to a greater focus on what are the actual determinants of health need. Wherever you are in the country you should broadly have resources equivalent with access to NHS services”, Mr Lansley added that those deciding allocations “should be looking at what it is in your population data that is likely to give rise to a demand for NHS services - the respective burden of disease.

What is likely to make the biggest difference, therefore? Actually it’s elderly populations who were not in substantial deprivation ... age is the principal determinant of health need”.

Q about tariff-setting

AL: “Tariff is made for man, not man for the tariff". If the tariff serves your purposes use it. If it doesn’t, create a different community tariff or an unbundled tariff … make up your own currencies if national tariffs are not appropriate. Co-operation and competition are tools for the delivery of this. Legislation doesn’t change the rules on competition in the NHS, just that Monitor administers it in future, where previously it was the CCP. From your point of view, if you go out to competition, you have to do so in a way that’s fair, but before that, you can decide what shape services you require, and you can say, ‘it must be end-to-end’.