Functions and mechanisms of Functions and mechanisms of priority setting: the national and local picture priority setting: the national and local pictureSian Davies, Nuffield Trust & Suzanne Robinson HMSC
Outline Describe the proposed structure for the NHS Describe who will be commissioners and what they will commission Analyse some emerging policy themes, post Future’s ForumOver to you: What will priority setting look like in five years time What can be done now to increase our chances of success?
The NHS is obsessed with structure…http://www.guardian.co.uk/politics/2011/aug/05/labour-ridicules-cameron-nhs-structure#zoomed-picture
Commissioners – National levelNICE National Commissioning•TAs, quality standards Board •GP servicesClinical senates •Community pharmacy•Expertise, leadership, •Dental servicesadvise •Prison & military •Specialised servicesClinical networks •Public Health: Child health, immunisations, screeningMonitorHealthwatch
Commissioners – local levelLA Public Health Depts Clinical Commissioning Groups•Advice to CCGs •Hospital services, community services Local authorities HWBs •Social careHealth Watch •JSNA •Sexual health services, alcohol &•Info to support pt choice substance misuse, community•?complaints advocacy •JHWS behaviour change programmes, NHS health checks NHSCB outposts/clusters NHSCB Outposts •Some CCG responsibilities if •Commissioning partially authorised support •CCGs responsibilities where not authorised
Localism v’s centralism• “It is a National Health Service – but it must be a locally delivered service. And that is where the power should lie. That is what the evidence tells us, that is how we’ll improve outcomes, and that is how we’ll achieve real transparency and accountability.” Andrew Lansley Speech to the NHS confederation. 24th June 2010• But the bill retains extensive reserve powers of intervention for the secretary of state, and it is likely that the political dynamics nationally and locally will be so strong that the Department ofHealth will be drawn in to intervene—for example, at times of financial or clinical crisis. Walshe K. Can the governments proposals for NHS reform be made to work? BMJ 2011;342:d2038• The moment he [Andrew Lansley], as a national politician, started to reopen services that clinicians had agreed needed to close, he undermined the whole strategic argument for his reforms. Given his actions how could he claim that he wanted to limit political interference in day-to-day NHS activities? Corrigan P. Securing the Secretary of State’s responsibility for ensuring the provision of health services for all NHS patients without political interference in every aspect of patient care. Blog post 06/09/2011
Localism v’s centralism The Nicholson challenge Quality innovation productivity and innovation CB has wide ranging duties Oversee the commissioning budget Oversee system of CCGs Develop commissioning guidance Develop a medium term strategy for the NHS Authorisation and CCG functions Explicit duty to deliver the QIPP challenge Risk assessment led by SHA clustersDepartment of Health. Developing the NHS Commissioning Board. July 2011Department of Health. Developing clinical commissioning groups. Towards authorisation. August 2011
Competition, collaboration & choice Monitor: Objectives revised to include the promotion of integrated care as well as prevent anti-competitive behaviour Monitor and CB have discretion to include variations in rules for the tariff (e.g. bundling). Move towards commissioning based on outcomes Expansion of patient choice central to H&SC Bill. Choice Mandate – recommended by the Future’s Forum – may offer choice where is has not been offered beforeThanks to Frank Sodeen of the Nuffield Trust for summarising the key changesto the H&SC Bill
Conflicts of interest Providing care for a population v’s individual patient Ethical duty to advocate for the individual patient Legal duty under GMS regulations to ‘order drugs & medicines which are needed for treatment’ Provider and commissioner At worst, the negative impact for GPs could be patients lobbying outside their front door, saying, Youve got a nice BMW car but you will not allow me to have this cytotoxic drug that will give me three more months of life,"Claire Gerada. Doctors warned to expect unrest over NHS reforms. The Guardian. 19th November 2010
Governance and accountabilityInvolvement of outside stakeholders in CCG decision making CCGs will have a duty to act with a view to enabling patients to make choices on the health services that are provided to them CCGs must describe their PPI arrangements in their constitution and have credible plans for public engagement CCGs must have specific arrangements in their constitutions for ensuring transparency in the decisions of the group and the manner in which made Inclusion of other clinicians on CCG boardsExplicit duties with regard to accountability to Health & Wellbeing Boards CCGs will have to share their plans with the HWB boards to check their compatibility with the strategy and explain how those views have been taken into account CCGs must involve HWBs when they are preparing or significantly revising their commissioning plans for the year
What does successful priority setting look like? Process concepts Outcome concepts •Stakeholder engagement •Improved stakeholder •Use of explicit process understanding •Information management •Shifted resources and/or reallocated resources •Considerations of values and context •Improved decision making quality •Revision or appeal mechanism •Stakeholder acceptance and satisfaction •Positive externalitiesSibbald SL, Singer PA, Upshur R, Martin DK (2009) Priority setting: what constitutes success? A conceptual framework forsuccessful priority setting. BMC Health Services Research 9 (43)
Use of explicit process & information management In five years time CCGs will: 1. Recognise the importance of priority setting internally rather than responding to external drivers 2. Will have sufficient resources (time, money, technical expertise) to successfully implement priority setting 3. Will have sufficient access to public health expertise to successfully implement priority setting 4. Have strong clinical leadership in priority setting 5. Have transparent robust processes in place for exceptional treatment requests and broader health system decision making Please score on a scale of 1 to 5: 1=very unlikely, 5= very likely
Stakeholder engagementIn five years time CCGs will:1. Have stakeholders (e.g. hospitals) involved in their decision making processes2. Are seen as legitimate decision makers by their constituent clinicians3. Have patient and public involvement integral to their priority setting processes4. Have been able to lead the implementation of disinvestment decisions5. Have to listen to Health and Wellbeing Boards; they have considerable influencePlease score on a scale of 1 to 5: 1=very unlikely, 5= very likely
Shifted priorities / reallocated resources In five years time CCGs will: 1. Base their priority setting activities more on internal recognition of the value of an explicit process, than on external drivers 2. Have experienced less political interference when trying to implement difficult decisions 3. Have made significant disinvestment decisions and implemented them 4. Have more local autonomy in deciding what treatments and services to provide 5. Have been able to make changes in the whole health economy (especially acute trusts) as a result of priority setting decisions 6. Be less likely to make short-term end of year rationing decisions that their PCT predecessors
3 scenarios…You are a consultant brought in to advise clinical commissioning groups ondeveloping priority setting around major disease care pathways. What 5things do they need to do now to maximise their chances of success?You are a consultant brought in to advise the Department of Health ondeveloping priority setting in the NHS. What 5 key national policies willassist the development of priority setting in CCGs?You are a consultant brought in to advise David Nicholson on how theNHSCB can support local commissioners in priority setting. What 5 keyactions can he do now?