Commissioning and System Management NHS Contract for Community Services Third Sector Learning Event Welcome & Introduction Melinda Letts OBE Commissioning and System Management Strategic context for the Standard NHS Contracts Anthony Kealy – Contract Development Lead Why do we need new contracts? Commissioning and System Management • To strengthen commissioning • To improve NHS business processes • To strengthen accountability and improve performance 3 ‘Failure of Commissioning’ Commissioning and System Management NHS has ‘commissioned’ for over a decade, but … • ‘Command & control’ model has consistently reinforced the ‘provider line’ • Commissioners have lacked robust levers • Not all available levers have been used • Inadequate regulatory regime • Low investment in developing commissioners • Highly variable & fragmented practice • Lack of legitimacy (linked to ‘voice’ & patient /public engagement) • Very limited range of providers 4 Commissioning and System Management Re-launching commissioning – Commissioning Framework (July 06) – Third Sector Commissioning Task Force – (July 06) – Practice-Based Commissioning Guidance (November 06) – Interim New NHS Contract (December 06) – Commissioning Framework for Health & Well-being (March 07) – A Vision for World Class Commissioning (December 07) – New standard acute contract (December 07) – New standard community, mental health & ambulance contracts (December 08) 5 A new approach to contracting • The need for new NHS contracts was introduced with in the Commissioning and System Management Commissioning Framework, July 2006 • This was reinforced by the Third Sector ‘No excuses…’ report • Contracts becomes the main tool for achieving accountability and improving performance in a system with more autonomous providers • The final version of the acute contract was published with the 08/09 Operating Framework • New contracts are now being developed for – Ambulance – Community – Mental Health 6 Structure of the Contract Commissioning and System Management Nationally Applicable Standard Terms 1. 2. 3. ‘Must have’ elements for local negotiation 1. 2. 3. 4. 5. 6. Elements for local agreement 1. 2. 3. Are set centrally Can be changed generically only through the NHS Operating Framework Could be considered as “Standard NHS Terms and Conditions” Are contractual or legal requirements Are defined centrally Require local detail so local agreement is necessary Provide flexibility within a framework Co-ordinating Commissioner defines consortium rules (by agreement) Must be completed to make contract executable Are locally defined, with no national or legal requirement Must be internally consistent and not ‘trump’ required elements Could cover any issues, but typically might cover care pathways, treatment protocols, quality standards 7 Commissioning and System Management Main features • A standard – not a model contract • A new model of co-ordinated contracting • Activity planning and review • Demand management requirements • National and locally-agreed quality standards • Requirements on information flows and provision • Dispute resolution arrangements • Contractual Control mechanisms. • Sanctions and / or incentives for performance on a small number of priority issues • Locally-defined service specifications 8 Stakeholder Principles Commissioning and System Management The contract should: • Reflect vision, long term planning and change • Recognise the community interest • Provide clarity on commitments that need to made to stakeholders • Clarify and define respective roles and responsibilities • Recognise that open information is required from both parties to manage the contract • Underpin a relationship between equals • Understand mutual dependency and benefit of the parties in aiming for a partnership approach • Support co-operation and collaborative behaviours that benefit both parties and cement the positive relationship between them. • Be based on terms that are deliverable in practice 9 Commissioning and System Management Expected behaviours • Find and support win-win solutions • Achieve appropriate risk sharing, and sharing of any benefits that are realised by mutual effort • Maintain mature, regular dialogue within a professional code of conduct • Ensure flexibility where there are genuine problems in delivery • Provide incentives as well as penalties • Recognise investment required to achieve requirements over a reasonable time period • Support providers to change their service offer over time in relation to changes brought about through patient choices • Maintain honesty and transparency – across both parties and with patients and the public 10 Project management Commissioning and System Management Mark Britnell Stakeholder Reference Group Contract National Steering Group DH Contract Project Support Group Mental Health Project Group Ambulance Project Group Community Services Project Group Task Sub-Groups Task Sub-Groups Task Sub-Groups 11 Commissioning and System Management Developing a new Standard NHS Contract for Community Services - Overview of scope and structure Tracy Cannell System Management and New Enterprise Directorate Aims, Strategic Links and Potential Barriers of Community Services Contract Commissioning and System Management Strategic Links Next Stage Review including Primary & Community Services Strategy Aims Flexibly support innovative commissioning approaches Improve care outcomes, System Management 3rd sector & SE Programme Wider programme re. community services development Links to CQC re standard setting, monitoring and response to failure. Catalyst to maximise quality and productivity Potential Barriers Wide scope of coverage Cross-departmental approach for Section 75 agreements Joint approach to be agreed with DCSF re. childrens’ services, Legal agreements already in place with non-NHS bodies may delay implementation Support both joint commissioning & pathway based care Develop benchmarking. Current lack of standards/ targets in relation to quality and activity Community MDS not in place, metrics not yet available for majority of services 13 Scope of community services contract Commissioning and System Management 1 In-Patient Care Includes Rehabilitative and palliative care in community hospitals, hospices, nursing or residential homes 2 Out-Patient care Includes therapy services such as physiotherapy and podiatry as well as district nurse clinics. 3 Community dropin Includes specialist services such as family planning & health visiting 4 Domiciliary Care Includes home visits by district nursing, occupational therapy, community midwifery and health visiting. Community Services 14 Potential Contract Routes for Community Services (1 of 2) Commissioning and System Management Option 1 Commissioner Benefit: Reflects most common current practice with commissioner contracting on an organisational basis with each provider therefore easy to implement Option 2 Commissioner Lead provider for geographical area Benefit: Could reflect PBC or local approach with Local Authority with one provider accountable to commissioner 15 Potential Contract Routes for Community Services (2 of 2) Option 3 Commissioner Commissioning and System Management Strong Commissioning Benefit: Commissioner / provider split is maintained, and commissioner retains full control of commissioning care SINGLE CARE PATHWAY Option 4 Commissioner Lead provider Benefit: One provider retains clinical and financial responsibility for the patient, as well as accountability to the commissioner SINGLE CARE PATHWAY 16 Structure of community services contract Commissioning and System Management 1 Heads of Terms Standard section containing nationally mandated approach with no local variation Contains standard legal requirements National core standards applicable to all community services, e.g. this could include HCAI targets, minimum data collection requirements 2 Core Requirements Nationally identified issues but local targets, e.g. Could include stretch targets for performance information and quality standards. 3 Local Issues For local determination 4 Supporting Guidance To include guidance re. liabilities Service specification template to support locally determined commissioning Community Services Contract 17 Commissioning and System Management Performance and quality issues being considered for inclusion • Patient held records • Patient based use of NHS number • Use of national MDS (to be developed) • Assessment & care plan • Diagnosis & Treatment codes • Outcomes • Communication between professional/services • Infection control • Choice/convenience - appointment times, transport and location • Waiting times – 18 weeks, 1st & follow up, referrals • Patient satisfaction • Patient information re service 18 Commissioning and System Management Key Policy Issues to address • The role of sanctions and incentives • Minimum information requirements and flows • Mandatory performance and quality requirements • Anticipating outcome of community metrics work and development of tariffs • Compact Compliance e.g. Flexible payment arrangements • Transition and adoption requirements for very small providers • Relationship with primary care contracts 19 Commissioning and System Management Key timescales & milestones March - Collation of current best practice completed April - Outline heads of terms available - Stakeholder workshops - Initial testing with stakeholders commences June - Identification of test sites & initial workshops - 3rd Sector Learning Event September - Test sites complete Final Report October - Impact assessment processes Nov - Contract published & Transitional guidance issued, Dec - Implementation support programme Feb 2009 - Contracts agreed and signed 20 Further Information Commissioning and System Management • Tracy.Cannell@dh.gsi.gov.uk Monthly Bulletin available via ‘The Week’ (www.dh.gov.uk/en/managingyourorganis ation/commissioning/DH_085048) Commissioning and System Management Performance and quality issues being considered for inclusion • Patient held records • Patient based use of NHS number • Use of national MDS (to be developed) • Assessment & care plan • Diagnosis & Treatment codes • Outcomes • Communication between professional/services • Infection control • Choice/convenience - appointment times, transport and location • Waiting times – 18 weeks, 1st & follow up, referrals • Patient satisfaction • Patient information re service 22 Commissioning and System Management Workshop Discussions • Each group to consider how the contract can provide a sound approach and clarity for both commissioners and providers re. responsibility and accountability, performance management, risk management • Identify any barriers/enablers/vital links • Consider what support will be required to implement the contract • And also specifically: – Performance Management – Contract Terms – Service Specification – Quality Standards – Flexibility 23 Commissioning and System Management Workshop Topics Group 1- Performance Management • What are the key performance measures that should be incorporated into the contract as a baseline platform? • Are/should these be duplicated by regulation? • What measures should have incentives or penalties attached? Group 4 – Quality Standards • What are the key generic standards that should be incorporated into the contract as a baseline platform? • Are/should these be duplicated by regulation? • What standards should have incentives or penalties attached? Group 2 – Contract Terms • Are the generic heads of terms appropriate in both its scope and detail? • Can/should we scale the documentation according to contract value? • Should block contracts be permitted? Is there sufficient understanding in the use of contracts vs grants? • What if any variation or flexibility be given to the contract duration and notice periods? Group 5 – Flexibility of Contract Is the contract appropriately structured to support both commissioners and providers of:• Differing Organisations • Care pathways • Umbrella or lead provider arrangements • Section 75 arrangements • Co-ordinated commissioner arrangements Group 3 - Service Specification • Will the proposed specification guidance be sufficient to support local commissioning? • Is it structured appropriately? • What supplementary guidance would be helpful? If not how should this be changed and/or what’s missing?