NHS reforms and their relevance to tissue viability22nd March 2013
By Mike Sobanja, Director of Policy, NHS Alliance
The overarching drive of the Health and Social Care Act 2012 is to put the patient and public first. This is to be achieved through changing the way that information is accessed, collected and analysed, with greater choice and control. The mantra from the Department of Health (DH) that resonates through the document is 'no decision about me, without me'. Focusing on patient choice, the DH has urged that patients should be able to select their treatment from any qualified provider (AQP), consultant-led team or GP practice.
A key point here is that the Government will enable patients not only to choose where and how they are treated, but also to rate hospital and clinical departments according to the quality of care that they receive. There will be a strengthening and increased utilisation of quality standards that will be developed by the National Institute of Health and Clinical Excellence (NICE) to inform commissioning of all NHS care and payment standards. In essence, money will follow patient choice.
Monitor, as a body, has refocused to become the economic and value regulator in the NHS. It assesses the overall health economy and ensures that the pathways of funding align to the appropriate pathways of care. Its focus areas will be to promote completion of care, regulate prices and safeguard the continuity of services.
Another group to identify is HealthWatch England. The Care Quality Commission (CQC) is leading the work to set up this group, which will 'strengthen the voice of patients'. The formal relationship between HealthWatch England and CQC is currently under discussion.
An independent and accountable NHS Commissioning Board has been developed. Technically, this is a non-departmental public body accountable through the NHS, which will lead on:
- Achievement of health outcomes
- Allocation and accounting for NHS resource
- Quality improvement
- Promoting patient improvement and choice
- Directly commissioning both specialist and primary care services.
The NHS Commissioning Board will be responsible for allocating some £95 billion of public expenditure to the various GP-led CCGs across the country.
CCGs are based within primary care but will commission services for their local population from providers, some of which may be in secondary and tertiary care. Specialist services will be commissioned by 10 of the 27 local area teams (LATs), which are the local offices of the Commissioning Board.
Understanding Clinical Commissioning Groups (CCGs)
The introduction of CCGs is perhaps the single biggest NHS change suggested by the current Government, and is part of their desire for a clinically-driven commissioning service that is sensitive to patients' needs. CCGs are membership groups of general practices and other members of primary care that wish to work together. In order to deliver better patient experience, higher quality care, and more efficient use of NHS resources, they will need to:
- Work with colleagues in the wider NHS and social care
- Form partnerships with local authorities
- Engage with patients and local communities.
Effectively, from April 2013, they will be responsible for designing local health services in England. Their governing body will include GPs, at least one registered nurse, and a doctor who is a secondary care specialist. All GP practices will have to belong to a CCG.
Emerging CCGs are being authorised by the Commissioning Board in four waves and, at the time of writing, the first two waves have been authorised. There will be 211 in total. They must be able to demonstrate:
- A strong clinical and multi-professional focus which brings real added value
- Meaningful engagement with patients, carers and their communities
- Clear and credible plans which continue to deliver the QIPP (quality, innovation, productivity and prevention) challenge within budget, in line with national requirements and local joint health and wellbeing strategies
- Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities, including financial control, as well as effectively commission all the services for which they are responsible
- Collaborative arrangements for commissioning with other CCGs, local authorities and the NHS Commissioning Board, as well as the appropriate external commissioning support
- Great leaders who individually and collectively can make a real difference.
Click here for further resources for CCGs.
One of the biggest changes facing the NHS is that it will employ fewer staff by May 2015. The aim is to initiate a rebalance toward clinical staffing ensuring good frontline support and less 'excessive administration'. In real-terms, this means that NHS management will be reduced by 45% by 2014. Much of this has already been achieved by the formal abolition of primary care trusts (PCTs) and strategic health authorities (SHAs).
Health and Social Care Act 2012
The Act became law in 2012 after a prolonged and difficult progress through Parliament. During this process, the Government was keen to emphasise that they had made changes, which will lead to:
- Competition only for the benefit of the patient
- Membership of new commissioning bodies
- Integration of care
- Safeguards against 'cherry picking' (i.e. private providers taking routine, less complex healthcare services that are cheaper to provide and more profitable, thereby leaving the NHS to deal with the higher-cost, more complex and long-term conditions without adequate remuneration, which would result in destabilisation of local hospitals).
The Act contains provisions covering five main themes:
- Strengthening commissioning of NHS services
- Increasing democratic accountability and public voice
- Liberating provision of NHS services
- Strengthening public health services
- Reforming health and care's arm's length bodies (ALBs).
Visit the Government Website for a series of factsheets concerning the Act and its practical implementation.
Quantifying tissue viability
As a result of ongoing changes to the NHS, it is important that tissue viability services are able to quantify the quality of their wound care provision. The key domains are:
- Patient safety
- Effectiveness and cost-effectiveness of care
- Patient experience.
Healthcare providers and commissioners will be expected to meet the quality agenda and achieve cost-savings, while not being detrimental to patient care. The launch of the high impact actions (HIAs) for nursing and midwifery in 2009 is an example of how awareness of tissue viability services has been raised, with the inclusion of 'your skin matters' which aims to result in no avoidable pressure ulcers occurring in NHS provided care and 'protection from infection' as two of the key HIAs (http://www.institute.nhs.uk).
Each HIA sets out the scale of the challenge and the potential opportunity in terms of improvements to quality and patient experience, and reduction in cost to the NHS.
Many healthcare trusts and organisations are currently using the HIAs as measures of quality to form part of their Commissioning for Quality and Innovation (CQUIN) targets. The key aim of the CQUIN payment framework (DH, 2009) is to help produce a system that actively encourages trusts and organisations to focus on quality improvements and innovation in commissioning decisions.
It is the responsibility of healthcare providers to supply evidence of the achievement of quality and innovation within their practices to assure commissioners of the value of service offered. With the emergence of integrated services across primary and secondary care and with the DH drive of offering care 'closer to home', it is important for those offering wound care management that there is tangible proof of continuity of care across the healthcare sector boundaries.
Many of the recently published documents regarding NHS policy address quality from a strategic perspective. Despite this, it is necessary to put these theoretical models into practice and make them work.
How these theoretical, national ambitions and ideals from the DH are transferred into everyday practice and, indeed, who is accountable for delivering on the metrics of quality care, are of equal importance.
Any Qualified Provider (AQP)
The DH has committed to working alongside the NHS to support the phased roll-out of extended patient choice through the AQP platform. Operational guidance to the NHS, setting out plans to deliver the Government's commitment to extending patient choice of provider has been published on the NHS AQP Resource Centre website.
When a service is opened up to choice of 'Any Qualified Provider', patients can choose from a range of providers, all of whom meet NHS standards and price. Prices paid to providers will be determined in advance by the NHS. This could be a national tariff where it applies, or a locally agreed price. Patients will choose based on quality and individual preferences. Money will follow patients' choices and competition will be on quality not price.
Setting outcomes-based service specifications encourages providers to innovate. Providers must pass a standard qualification process to ensure that they meet the appropriate quality requirements.
Providers only need to be registered with the Care Quality Commission (CQC) where they are carrying out a service which is already regulated. If a provider does not need CQC registration, they will need to meet other, equivalent assurance requirements. Further details about the specific qualification requirements will be set out when AQP offers are posted on the NHS Supply2Health web site.
Commissioners will own the service specification and will confirm if the provider can deliver that specification. The commissioner holds the contract held with a qualified provider - this means that the commissioner has a key role to play in the qualification of providers. Because providers are qualified, commissioners know that a range of safe, good quality and affordable providers are available to which they can refer their patients without the cost and effort of competitive tendering.
A national directory of qualified providers and contracts will allow information sharing across the NHS when the regulator or a commissioner terminates or suspends a contract. This could potentially make care safer for patients.
In developing this guidance, the DH has engaged with clinicians, providers, commissioners, patient groups and voluntary organisations on how best to extend patient choice of provider. The perceived goal is to enable patients to choose any qualified provider where this will result in better care. Choice of provider is expected to 'drive up quality, empower patients and enable innovation'. Importantly, extending choice of AQP provides a vehicle to improve access, address gaps and inequalities and improve quality of services where patients have identified variable quality in the past.
A phased approach to providing these services is being adopted and commissioners are being asked to engage locally to determine where choice of AQP best meets the demands of their patients and is expected to deliver quality improvements. Commissioners will continue to control both contracts and prices, and to challenge providers to deliver services of the highest quality. Industry should therefore align their products to service cost reductions.
By offering people choice in health and care, such as wound healing services, the Government expect to see more services being offered by a far wider range of NHS, private and voluntary providers in the years ahead.
An example of this, run by TVCS in Eastbourne, is described in the case study below.
Wound Healing Clinic, Eastbourne
- TVCS Ltd was established in 1999 by Sylvie Hampton, previously Tissue Viability Nurse at Eastbourne DGH, and Fiona Collins, previously Senior Lecturer in Occupational Therapy at University of Brighton. Sylvie has an international reputation for healing wounds and Fiona for preventing pressure damage, particularly in the seated patient.
- In January 2008, TVCS opened a wound healing clinic in Eastbourne. This was the first nurse-led complex wound health clinic in the UK specialising in the prevention and management of wounds. They aim to offer patients the right treatment, at the right time, and in the right place for their wounds.
- As the clinic meets the quality standards required by East Sussex Downs & Weald PCT and Hastings & Rother PCT, and can demonstrate that they deliver the results the PCT wants for its patients, the PCT can offer patients the choice of being treated at the clinic as well as local NHS providers.
- The Wound Healing Clinic has both a high success rate and is cost-effective, 82–83% of patients have their wounds healed over a six-week period - one of the highest in the UK.
- To put this into context, wounds have had an average duration of 3.3 years when patients arrive at the centre.
The new health and care system - an overview
The health and care system helps people lead healthier lives, recover well from illness and live better for longer into old age. The way the system works is changing, but there will be no change to the core values of the NHS, namely: health care will remain free at the point of use, funded from taxation, and based on need and not the ability to pay. People using care and support services will have more control over the services they use. All professionals working in health and care share a commitment to working together to provide fair and equal access to high quality services, in response to patients' individual needs and choices.
The need for change
The health and care system is facing the biggest set of challenges in its history. Scientific and technological advances mean that we can treat illness more effectively than ever before, but new drugs and treatments are expensive. With better health care, people are living longer than their parents and grandparents. This is an achievement to celebrate, but this trend also means greater pressure on health and care services to maintain people's wellbeing and quality of life for longer. Despite these advances, good health is not shared by all, with inequalities persisting between communities and regions, with preventable ill health creating significant challenges. We need to get better value from public spending, to invest more in preventing ill health, to enable people to stay in their own homes, and to continue to drive improvements in care.
Empowering patients and local communities
The new system is designed to deliver better health, better care and better value for money. Changes will be led by doctors, nurses and other health and care professionals, working with local authorities and local service providers, in response to the needs of patients, people using care services, carers and communities. The new system will focus more on preventing ill health and empower local communities to plan services according to their local priorities. People will have more say in the care they receive and doctors and nurses will have more freedom to shape services to meet people's needs. A wider range of healthcare providers will offer more choice for patients and greater value.
Good health begins in our communities. Local health and care services that people use on a daily basis, such as GP surgeries, home care, hospitals and care homes are at the heart of the new system. Family doctors, nurses, pharmacists and online/telephone services will continue to be the first port of call for most people needing health care. As well as providing patient care, in the new system, doctors, nurses and other professionals will use their knowledge of local health needs to commission the best available services to meet them. They will do this by joining together to form CCGs. CCGs will have the freedom to commission services for their local community from any service provider which meets NHS standards and costs - these could be NHS hospitals, social enterprises, voluntary organisations or private sector providers. This means better care for patients, designed with knowledge of local services and commissioned in response to their needs.
Health and Wellbeing Boards in every area will ensure that services work together and are responsive to communities' needs and priorities. Local Healthwatch will give patients and communities a voice in decisions which affect them, reporting into Healthwatch England, a new national body to represent the views of the public at the highest level.
Local authorities will commission care and support services and have a new responsibility to protect and improve health and wellbeing and will use their knowledge of their communities to tackle challenges such as smoking, alcohol and drug misuse and obesity. Working together with health and care providers, community groups and other agencies, they will prevent ill health by encouraging people to live healthier lives. A new organisation, Public Health England, will provide national leadership and expert services, to support public health and work with local government and the NHS to respond to emergencies.
Most people will need care and support at some point in their lives, because they are getting older, have developed an illness or have lived with a disability since birth. Alongside their health care, people need the right combination of care and support - financial, practical and emotional - to manage day-to-day living. Care and health services will be organised to work together to provide seamless services that respond to people's individual needs and choices, including personal budgets to choose the care that is best for them.
Supporting providers of care
NHS services nationally will be supported by the new NHS Commissioning Board (NHS CB). It will fund local CCGs to commission services for their communities and ensure that they do this effectively. Some specialist services will continue to be commissioned by the NHS CB centrally where this is most efficient. Working with leading health specialists, the NHS CB will bring together expertise to ensure national standards are consistently in place across the country, maintaining the 'N' in the NHS. Throughout its work, it will promote the NHS Constitution.
Health trusts will continue to manage hospital care and community and mental health services, with all trusts becoming foundation trusts to benefit from greater independence to manage their own services. They will be able to innovate, introducing new approaches to provide the services local CCGs want to commission and they will be able to generate private income to bolster their budgets to the benefit of NHS patients. A new NHS Trust Development Authority will support NHS trusts to improve in order that they can take advantage of the benefits of foundation trust status when they are ready.
High quality patient care demands first class education and training of healthcare professionals. A new organisation, Health Education England will ensure that the healthcare workforce has the right skills and training to improve the care patients receive. It will support a network of local education and training boards (LETBs) that will plan education and training of the workforce to meet local and national needs.
The National Institute for Health and Care Excellence (NICE) will provide guidance to help health and social care professionals deliver the best possible care based on the best available evidence.
The National Institute for Health Research (NIHR) and its clinical research networks form a health research system in which the NHS supports outstanding individuals, working in world-class facilities, conducting leading-edge research focused on the needs of patients and the public. The Health and Social Care Information Centre will collect, analyse and publish national data and statistical information and will deliver national IT systems and services to support health and care providers.
NHS Blood and Transplant will continue to manage the supply of blood to hospitals as well as organ donation and transplants across the UK. The NHS Litigation Authority will resolve fairly all claims made against NHS trusts and will help the NHS to learn from them to improve patient safety. The NHS Business Services Authority will continue to carry out a range of support services, including payments for community pharmacists filling prescriptions and dentists carrying out NHS treatment.
Safeguarding the interests of people using health and care services
As the new system brings more freedom for those who plan, commission and provide services, new and existing health and care regulators will safeguard the interests of patients and the wider public. The Care Quality Commission (CQC) will assess the quality and safety of services against government standards through its registration, regulation and monitoring of services, ensuring that people are treated with dignity and respect. Healthwatch will give patients and communities a voice in decisions which affect them, reporting their views, experiences and concerns to Healthwatch England. Healthwatch England will work as part of the CQC.
As the sector regulator, Monitor's main duty will be to protect and promote patients' interests by creating incentives, providing information and enforcing rules where necessary. Licensing providers of health care will be one of the main tools Monitor will use to do this.
The Health Research Authority (HRA) will work to protect and promote the interests of patients and the public in health research. The Medicines and Healthcare Products Regulatory Agency (MHRA) will continue to make sure that medicines and medical devices work and are safe to use. The Human Tissue Authority (HTA) regulates human tissue, such as donated organs, to ensure it is used safely and ethically, and with proper consent. The Human Fertilisation and Embryology Authority (HFEA) regulates fertility treatment and the use of embryos in research.
Health and care professionals are registered with the relevant health and social care regulator, which ensures that professional standards are met.
The Secretary of State for Health has ultimate responsibility for ensuring the whole system works together to respond to the priorities of communities and meet the needs of patients. The Department of Health will empower health and social care bodies to deliver according to national priorities and will work with other parts of government to achieve this. It will set objectives and budgets and hold the system to account on behalf of the Secretary of State.
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