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2. COMMISSIONING 1
FRAILTY COMES OF AGE
DR PHIL HAMMOND WEIGHS UP THE NHS
COMMISSIONERS’ LETTER TO SANTA
5 YEAR FORWARD VIEW UNDER THE SPOTLIGHT
THE HOMELESS, YELLOW MEN AND A&E
PAT H W AY S / / PA R T N E R S H I P S / / P E R F O R M A N C E
VOLUME 1 // ISSUE 7
Unwrapping
the potential
of nurses
3. 2 COMMISSIONING
for further details go to
www.gmjournal.co.uk
Save the date
The 9th GM Conference
Improving the care of older patients
Thursday 4th June 2015
Royal College of Physicians, Edinburgh
Chair: Dr Nicki Colledge, Director of Education, Royal College of Physicians
of Edinburgh and Consultant Geriatrician, Liberton Hospital, Edinburgh
Tuesday 6th October 2015
Royal Society of Medicine, London
Chair: Professor Peter Passmore, Professor of Ageing
and Geriatric Medicine, Queen’s University Belfast
Suitable for all GPs and hospital specialists with an interest
in the 50+ patient and the conditions that impact on them.
CPD
applied
for
Previous exhibitors and supporters include
5. The NHS England's five year plan is a masterpiece. It
should, perhaps, be called the Simon Stevens Plan – he lends
it considerable personal credibility as someone, who has lived
and talked the principles of this plan for many years. Others
have frequently mouthed the rhetoric of extending primary
care and taking individual and community health seriously, but
this time it is meant. Will it change anything?
Its first strength is in re-establishing the relationship
between NHS England and the Department of Health.
Effectively it says: “Tell us how much money you want to give
us and we will tell you what sort of health service you can
have” – a role that I suggested in a previous editorial for
Commissioning that NHS England had singularly failed to
fulfil. NHS England's challenge to a future government is
“We will do our job and make the NHS as cost effective as
possible, but don't expect a Rolls Royce if you are paying for
a Mini Minor, unless if you are only paying sufficient for a
Reliant Robin”. It's important because in future, the NHS and
its frontline clinicians and managers, can no longer be blamed
for failing to deliver services and standards that have not
been paid for.
The plan is highly supportive of clinical commissioning
too and recognises the crucial role of clinical commissioners
(Clinical Commissioning Groups (CCGs)) in developing
out-of-hospital care at scale. This now becomes the priority of
NHS England and our 211 CCGs with a clear commitment
that CCGs will be given air cover to prevent inappropriate
rules and regulations getting in their way. It is an opportunity
for CCGs, but also a significant challenge given that, as
integrated commissioners, they will be expected to do so with
the tightest overheads imaginable. They will also, apparently,
receive help in this role from national organisations such as
IQ and the Leadership Academy, but it is not clear what such
organisations have done for primary care to date and one
wonders if NHS England might have the courage to melt them
down and create a temporary Development Fund in every
CCG. This would provide the time, headroom, expertise and
resource to rapidly develop out-of-hospital services based on
the GP registered list – especially important in areas where
CCGs are already financially challenged. Good policy requires
good implementation. That will mean offering support to
CCGs and their member GP practices and other primary
care professionals and managers in a form that is helpful.
Not, as has happened historically, the sort of “Does he take
sugar?” approach, which involves a revamping of national
organisations being asked to serve up what the centre thinks
is required.
For many CCGs, one of the first tasks in achieving this will
be to reverse the historical flood of money from primary to
secondary care. That will require a revamping of Payment by
Results, which has been a major factor in this happening.
The continuing squeeze on the tariff through efficiency savings
may help to create a more reasonable dialogue between
commissioners and hospitals, but it is difficult to see much
happening unless local CCGs, hospitals, general practices and
other primary care providers can get round the table and create
their own local version of the NHS England plan.
The plan's important aspirations for individual and
community health and engagement may start with some
useful conversations on Health and Wellbeing Boards. Their
implementation, however, will once again need to be far
more granular and will require local 'centurions' of health
linked to the new organisations that will provide integrated
out-of-hospital care at scale and who can ensure locally the
right links between primary care, hospitals, local authorities,
voluntary agencies, local business, volunteers and local people.
This is a dramatic and overdue re-description of the NHS
frontline as a collective 'social mission', every bit as much as a
consumer service.
Simon Stevens has established his credentials as a supporter
of clinical commissioners and CCGs and his report suggests
a new basis for the relationship between NHS England and
CCGs based upon mutual respect and trust. It also suggests a
new relationship with frontline general practice and primary
A PLAN IS JUST A
PLAN – OR IS IT?
Commissioning's Consulting Editor, Dr Michael Dixon,
praises NHS England's 'Five Year Forward View'
4 COMMISSIONING
6. FIVE YEAR
FORWARD VIEW
Dr James P Kingsland OBE
Senior Partner in
General Practice
President National
Association of Primary Care
Chairman National
Primary Care Network
Seema Buckley
Chief Pharmacist,
NHS Kingston CCG
EDITORIAL DIRECTORS
care, which previously regarded NHS England as bureaucratic
and heavy-handed with an underlying plan to claw back
money from primary care for other parts of the health service
that it thought really mattered.
This change of direction makes the plan more than a plan.
A truce, a renaissance and a process of emancipation re-
establishing a new 'modus operandi' between NHS England,
Government, clinical commissioners and frontline primary
care. It offers hope in an icy financial climate. Hope is not a
bad place to start.
Consulting Editor
Dr Michael Dixon OBE,
Chair of NHS Alliance
”
“The NHS England's
five year plan is
a masterpiece
COMMISSIONING 5
EDITOR’SCOMMENTARY
7. Next year’s diaries already have Thursday May 7th
ringed in red. With six months still to go, the 2015 General
Election may seem a distant prospect, but the political parties
have already mapped out the key battlegrounds and once
the Christmas turkey is finally finished and the New Year
fireworks have faded into the night sky, campaigning will
begin in earnest.
As usual the NHS will be one of those battlegrounds and
once Parliament dissolves at the end of March, the coalition
government that put the Health and Social Care Act on the
statute book and brought clinical commissioning into being,
will dissolve too.
The Conservative party will want to reap the credit for the
Lansley reforms and all the good work CCGs have already
done in system transformation – and is pledging a real-
terms increase in NHS funding. But Labour has vowed to
repeal the Health and Social Care Act – potentially spelling
untold chaos for CCGs’ ongoing commissioning plans. And
the Liberal Democrats want to create a pooled health and
social care budget held by bigger, more powerful Health and
Wellbeing Boards which, while leaving the broad direction of
travel the same, could severely curtail CCGs autonomy and
independence.
Another coalition government could combine any of these
policies, making the future for clinical commissioning very hard
to predict. But, however the electoral mathematics shakes down
and whatever the political complexion of the next government,
clinical commissioners are clear that they want system leaders:
1. to let them finish what they have started
2. to support general practice
3. to resource CCGs better
Wish 1: Let CCGs finish the job they have started
The overwhelming majority of CCGs and commissioning
stakeholders we spoke to want to be allowed to continue the
system transformations they have begun.
Dr Stewart Findlay, Accountable Officer for NHS
Durham Dales, Easington and Sedgefield CCG
wants national leaders of whatever political
stripe to let CCGs make local
decisions unhindered:
“I’d like to see
politicians and NHS England leaders leave us alone to develop
local priorities,” he says.
Dr Anne-Marie Houlder, Chair of NHS Stafford and
Surrounds CCG is more specific: “There must be no more top-
down reorganisations,” she says. “Leave us alone to get on with
the job. It’s taken us two years to get to this stage. We’re still
immature organisations. Staff are exhausted. The last thing
they need is more reorganisation.”
Dr Graham Jackson, Clinical Chair of NHS Aylesbury
Vale CCG also wants to see greater freedoms for CCGs in 2015:
“We can do without our decisions based on evidence and need
being challenged. The same applies to NHS England leadership.
Allow local variation to flourish and let’s continue on the path
we’re already on.”
“CCGs have proved themselves, although clearly limited
by resources. But if we’re going to try and focus on a proper
approach to long-term conditions that straddles available
services, then we need to be allowed to continue on the
same path.”
Amanda Bloor, Chief Officer of NHS Harrogate and
Rural District CCG is another CCG leader adding her voice
to the chorus: “We need the space and time to bring our
local strategy and vision to fruition and would urge no top
down reorganisation – which would only serve to dilute the
momentum and halt the positive local service transformation.”
Amanda Philpott, Chief Officer of NHS Eastbourne,
Hailsham and Seaford CCG and NHS Hastings and Rother
CCG agrees: “There shouldn’t be any imposed structural
change. Our three local CGGs and local authorities are working
well together. If the hierarchies were changed we’d end up with
massive distraction and status issues. I’d like to see more of a
‘coalition of the willing’.”
For Dr Bill Tamkin, Chair of NHS South Manchester
CCG, time and space to get on with the job heads a list of asks
for the next government: “What we want from politicians is
freedom to innovate. They must stop undermining CCGs, stop
the rhetoric on prevention and make it a priority, materially
encourage new models of general practice, train more GPs, stop
the political short-termism and make the default locus of care
the community not the hospital.”
“We’d like to see stability of structures and support for
delivery of fantastic local plans at local level with minimum
interference from politicians and NHS England leaders,”
says Debbie Fielding, Accountable Officer for NHS
Wiltshire CCG.
Rick Stern, Chief Executive of the NHS Alliance,
which represents clinicians, managers
and patients, warns the 2015
political floorshow could
interfere with
All I want for Christmas…As an action-packed 2014 draws to close, Clinical Commissioning Group (CCG) leaders
and commissioning stakeholders set out their key wishes and predict the agenda for clinical
commissioning in 2015
6 COMMISSIONING
UPFRONT
8. commissioning on the ground: “CCGs mustn’t get too distracted
by the election. There are so many political permutations and
variations in the way the parties see things. The NHS will be
a key battleground, but the broad shape of where we’re going
won’t be that different.”
“I’d say to politicians, have confidence in the central concept
of clinical commissioning. Let go and give permission for CCGs
to do the work.”
And Julie Wood, Director of NHS Clinical
Commissioners, which now represents upwards of 85% of
CCGs adds: “All the politicians say there won’t be another
major reorganisation. We want them to mean it.”
“Sort the money – the NHS is in a crisis situation – and
trust what you set up.”
Wish 2: Support general practice
CCG leaders and GP representatives are united in their
wish to see the new government and NHS England leaders give
general practice top priority in 2015.
Dr Nina Pearson, Chair of NHS Luton CCG calls for
urgent action: “I hope that NHS England will promote a
rejuvenation of primary care. This needs to involve increased
funding for primary care, incentives to attract qualified GPs to
become partners or salaried GPs rather than the alternative of
freelance locums and promotion of self-care to the public.”
Ms Philpott feels next year is a crucial period for primary
care: “The move that’s signalled by co-commissioning of
primary care next year is very important. Commissioning can’t
progress without improving primary care. The possibility of
place-based budgets offered by the NHS 'Five Year Forward
View' could help us hugely.”
“I would like to see a very strong signal that the proportion
of the NHS budget spent on primary care is going to increase.”
This plea is echoed by GP leaders. Dr Nigel Watson,
Chair of General Practitioners Committee’s (GPC’s)
commissioning sub-committee is clear that getting general
practice right is a priority for next year: “CCGs should be
focusing on out-of-hospital care and supporting and developing
general practice in the next 12 months. From politicians,
I’d like to see greater investment in general practice and a
reduction in bureaucracy.”
Dr Maureen Baker, Chair of Council at the Royal College
of General Practitioners argues that the Better Care Fund
should have a role to play: “NHS England’s 'Five Year Forward
View' explicitly calls on CCGs to facilitate a shift in resources
from the acute sector as part of its ‘new deal for primary care’.”
“We urgently need resources to be ploughed back into GP
services in the community, so we now need to look at how to
deliver this. One readily accessible means of shifting resources
into general practice is the Better Care Fund.”
“It’s encouraging that many CCGs are exceeding the
minimum amount that they are required to put aside for the
Fund. Now it’s a case of seeing how much of this goes directly
into allowing GPs to provide more – and better – services for
our patients, away from hospitals.”
GPC negotiator Dr Beth McCarron Nash
says that if CCGs are to play their part
in supporting general practice
they themselves must
be properly resourced: “The key
issues facing CCGs are the
same as that facing wider
general practice and the
NHS: if they are to deliver
improved services for
patient’s, practices need
properly resourcing and
realistic goals. Co-commissioning
offers an opportunity to give
that support to practices – a vehicle for CCGs to
commission truly joined-up community services wrapped
around general practice, pushing much needed funding into
practices and improving patient care.”
And she believes CCGs co-commissioning primary care need
to offer practices a better deal: “CCGs must ensure practices
become as resilient as possible by protecting and significantly
beefing up the core contract offer. Too much local contract
flexibility risks practice security, increasing variable
standards of patient care and workloads for practices. Core
performance indicators will continue to be monitored even
if funding streams are diverted to local incentives. Be careful
what you wish for.”
“CCGs must deliver practice security, as then and only
then will they have the capacity to evolve, add on services and
be part of much needed system wide re-design. The central
push for CCGs still in their infancy, to take on fully delegated
authority with no increased management support or funding is
madness as it risks destabilising things further.”
Wish 3: Give us more resources
Dr McCarron Nash’s plea for CCGs to be properly funded
is reinforced by CCG leaders. Dr Houlder again: “We need
more resources. The fear is we’ll just be expected to take on
more work – such as primary care co-commissioning – without
the funding. And for that reason we’re reluctant to take on
specialist commissioning.”
One mechanism for ensuring better resourcing for CCGs is
the funding formula, which must reflect local need according to
Dr Findlay: “Politicians need to make sure that the formula for
setting budgets for CCGs, reflects the deprivation that exists in
the population.”
Dr Nina Pearson also wants to see changes to the quality
premium: “I hope that NHS England will rapidly correct the
underfunding on the fair share formula and disaggregate
achievement of the quality premium from achieving statutory
financial responsibilities.”
“CCGs in financial strain will be working extremely
hard next year to stabilise their position, as
well as implementing integration
and their Better Care Fund
plans,” she says.
COMMISSIONING 7
9. SPEND A DAY IN PRACTICE
By Dr Crystal Oldman,
Chief Executive, The Queen’s
Nursing Institute, Registered
Nurse on the Governing Body
of NHS Aylesbury Vale CCG
I wrote an article recently for the Nursing Times
about the power of community nurses to work with their
local communities to deliver the current health agenda.
I described those who work in the community as a hidden
army of nurses who are much less visible than our hospital
based colleagues – and they know their communities
so well.
They understand the impact of housing and living
conditions in the area, the web of extended family
members in the locality, the carers, the children, the
services available and the teams of practitioners working
in the area. It might be argued that nurses working in
a locality or a GP surgery become a critical part of the
community they serve.
When speaking about community and primary care
nurses, I think it is helpful to clarify the practitioners to
whom I am referring, as these are commonly used terms
with several definitions.
PRIMARY CARE NURSES
Nurses working in primary care are normally referred
to as General Practice Nurses (GPNs) and some GPNs
may also have undertaken additional development and
training to become Nurse Practitioners (NPs), which will
normally include the ability to assess, diagnose and treat
– and also to prescribe medications and treatments for
patients. Those who have undertaken their training at an
advanced academic level (masters level) may be employed
as Advanced Nurse Practitioners (ANP), but those who
have undertaken their NP education and training at an
undergraduate level may also be named ANPs. However,
that principle is not uniformly applied.
The reason for this is that whilst the education for
prescribing as a nurse is regulated by the Nursing and
Midwifery Council (NMC), the training for the professional
roles of the NP and ANP are not regulated by our
professional body. This can lead to potential differences in
the skills and knowledge of NPs and ANPs who may hold
similar titles, but work very differently in practice.
In 2008 the Royal College of Nursing (RCN) developed
and published a guide to the ANP role, competencies and
programme accreditation. These have proved to be very
supportive for nurses and their employers in a range of
practice environments (including hospital-based ANPs)
The unique role and contribution of nurses working in district
and primary care teams should be a significant consideration in
developing and shaping out-of-hospital, community-based models
of care. Considering their extensive training and diverse activity, the
Queen's Nursing Institute proposes commissioners might spend a day
in practice to more fully understand the breadth and potential of their
roles. NHS Clinical Commissioners' Nurses Forum calls for priority to the
development and leadership of General Practice Nurses, while Marie Curie
details new evidence highlighting how community-based nursing can
improve end of life care
Unwrapping the
potential of community
primary care nurses
8 COMMISSIONING
10. and many university programmes for ANPs now map their
ANP programmes to these.1
Interestingly, the NMC has education standards for
the recordable qualification of specialist practitioner for
GPNs and such programmes of preparation for the role
are regulated by the NMC. It has parity with the specialist
practitioner recordable qualification of District Nursing
and where both programmes are offered at universities,
there is much shared learning. However, only a small
number of universities offer the GPN programme because
the demand has been low over the years, with few GPNs
being released to undertake the qualification. I anticipate
that with the higher profile of the GPN in practice and
revision of a career pathway for the GPNs in primary
care, that this will change in future years.
Nurses working in primary care as GPNs, NPs and
ANPs will be undertaking a variety of roles supporting
the health of the whole GP registered population, from
babies to the frail elderly. Whilst GPNs are generalists by
definition, many nurses working in these roles will develop
a specialist area of work so that they become experts in, for
example, immunisations, cervical screening, diabetes,
asthma, heart failure, frail older people or sexual health.
The specialist areas will, to an extent, be determined by the
local population profile and needs, to ‘fit’ within the
portfolio of the GP service and the interests of the
individual nurse.
The nurses working for the GPs will link closely with the
District Nurse (DN) teams, wherever appropriate, to
provide the most suitable, seamless care and to avoid
duplication. They may see members of the same family;
for example, an elderly carer may see a GPN for their
care, while the housebound patient they care for may be
known to the DN.
COMMUNITY NURSES
Arguably, we now more than ever before, know what
people want at the end of their lives
DN teams comprise health care assistants, staff nurses
and the team leaders who are normally DNs holding
the NMC specialist practitioner qualification referred to
previously. The programme of preparation to become a
qualified DN takes one year of full time study at a university,
with 50% of this time spent learning in practice with a DN
Community Practice Teacher.2
The programmes of preparation for DN’s ensure a team
leader that is able to assess patients and carers with complex
needs, coordinate and provide care for all patients with
long-term conditions and disabilities, palliative and end of
life care needs and the frail elderly population. The course
will also provide preparation for prescribing (the NMC
regulated V100 or V300 programme); for leading and
managing a team of staff nurses and health care assistants
and for implementing evidence-based nursing interventions
in the home.
DN teams work mostly with those who are housebound,
COMMISSIONING 9
UPFRONT
11. but not exclusively so, with many DN services extending
to tissue viability clinics in GP surgeries for example.
The way in which they work will of course depend on the
service that has been commissioned. In January 2013,
the Department of Health and NHS England published a
guide for commissioners on the District Nursing service
– Care in local communities: A new vision and model
for District Nursing.3
The guide explains the potential of the DN service
to meet the current agenda as they are experts in the
coordination of care in the community, the care of older
people, tissue viability, long-term conditions (for adults
of all ages), disabilities, the frail elderly, caring for carers
and people with palliative or end of life care needs.
The DN is frequently the lynch pin that holds the
services in the home together, like a conductor of the
orchestra, so that any boundaries between services appear
seamless to the patients. It is surprising, therefore, that
as a critical community service, the DN service has been
particularly underfunded in terms of their development
to meet the growing needs of the populations they serve.4
However, that situation is now changing and The
Queen’s Nursing Institute (QNI) has documented an
increase in commissions of DN training programmes
over the last year, with a 38% increase in DN qualifying in
England in the summer of 2014 and several universities
re-opening their DN programmes after a period in abeyance.
This is good news, but the picture remains varied in
places and where there has been low investment in the
DN specialist qualification programmes in recent years,
there is now a recognition that this needs to be addressed
if the potential of the DN service to innovatively meet
the growing health needs in a coherent and skilled way is
to be realised.5
CONCLUSION
I would urge those seeking to commission an
innovative community nursing service to meet the needs
of the local population, to spend a day shadowing a DN
or a Practice Nurse, to see the creativity of the service to
meet the needs of the individual patients and their carers;
their engagement with technology (wherever available)
to drive up efficiency and effectiveness; their focus on
health and wellbeing; their passion to increase supported
self-care – and the lasting impact they have on the health
of the communities they serve, every day.
Alternatively, or perhaps in addition to a shadowing
visit, on 7th
November 2014, the QNI released a film
which provides an insight into the work of nursing
services in the community and primary care.6
The film
also provides recognition by the most senior nurses in
England, Wales and Northern Ireland of the power of
community nurses to meet the current and future needs
of the population.
For more information contact the Queen’s Nursing
Institute: www.qni.org.uk.
The DN is frequently the lynch
pin that holds the services in the
home together, like the conductor
of the orchestra
“
”
UPFRONT
10 COMMISSIONING
12. They are integral to the development,
delivery and co-ordination of an
integrated approach to quality person-
centred care out-of-hospital
“
”
Dr Crystal Oldman is a member of:
1. The Commissioning Nurse Leaders Network: http://www.6cs.
england.nhs.uk/pg/groups/97047/ 2. NHS Clinical Commissioners
Nurses' Forum: http://www.nhscc.org/networks/nurses-forum/
References:
1.http://www.rcn.org.uk/__data/assets/pdf_file/0003/146478/003
207.pdf;2.http://www.nmc-uk.org/Documents/Standards/
nmcStandardsForSpecialistEducationandPractice.pdf;3.https://
www.gov.uk/government/uploads/system/uploads/attachment_
data/file/213363/vision-district-nursing-04012013.pdf;4.http://www.
qni.org.uk/campaigns/report_on_district_nurse_education;5.http://
www.qni.org.uk/docs/2020_Vision_Five_Years_On_Web1.1.pdf;
6.http://www.qni.org.uk/news_events/community_nursing_film
VALUING AND DEVELOPING
GENERAL PRACTICE NURSES
By Judi Thorley, Governing
Body Nurse NHS South
Cheshire CCG and NHS Vale
Royal CCG, Chair of NHSCC's
Nurses Network
The National Nursing and Care Strategy ‘Compassion in
Practice’ states that leadership is necessary at every level of
health and social care, every person involved in the delivery
of care needs to contribute to creating the right environment
and providing clear leadership to patients, carers, staff and
colleagues. NHS Clinical Commissioners' (NHSCC's)
Nurses Forum is a unique network specific to nurse leads
on Clinical Commissioning Groups (CCGs), representing
experts across the country. Responding to feedback from our
members, we identified supporting leadership development
of General Practice Nurses (GPNs) and their essential role in
implementing and shaping out-of-hospital care as one of our
top priorities.
GPNs work in a unique situation to nurses in other sectors
and can find themselves working in isolation without the
support larger organisations are able to offer. They are integral
to the development, delivery and co-ordination of an integrated
approach to quality person-centred care out-of-hospital. The
general practice nursing workforce delivers a wide range of
services and interventions to support people to manage their
health conditions and maximise their quality of life. With the
transformation agenda and recognition of the need to provide
increased integrated support within the community for
patients, the role of the practice nurse is critical. Practice Nurses
have well-established relationships with their patients, they have
a big role in supporting patients to manage their own health
needs, have valuable knowledge and skills relating to impact
for and approaches with patients and will be invaluable in both
driving up quality and informing and developing integrated
approaches within the community for patients. In short, their
role is pivotal to the success of the new vision for primary care –
a vision which requires leadership.
There is now a national focus on supporting development of
GPNs including leadership; specifically work is underway led
by NHS England and Health Education England to consider the
case for change, leadership, career structures and competencies.
NHS Alliance recently published a report Think big, Act now:
COMMISSIONING 11
UPFRONT
13. Creating a community of care (October 2014), which clearly
states the leadership role that GPNs need to be empowered
to take on, working together with other key stakeholders and
patients to deliver a responsive and responsible community
based system.
Our NHSCC's Nurses Forum is prioritising development
and leadership of general practice nursing: We recognise
the crucial need for joined-up working and innovation;
bringing together general practice nursing, community
nursing, district nursing and Allied Health Professionals
(AHP’s), to influence and challenge commissioning practice.
Reducing the separation of out-of-hospital nurses and
AHP’s delivering care to the same population is essential to
achieving more flexibility in what each nurse or AHP can
offer and delivery of ‘whole system’ change. There is already
lots of good practice in developing GPN and achieving more
joined-up working and our NHSCC's Nurses Forum will
be capitalising on our networks to share and build on these
approaches. Planning and developing the general practice
nursing workforce is a priority to realise the out-of-hospital
community-based model of care. To achieve this there is
a need for CCG Nurses to understand the local general
practice nursing workforce situation and increase the number
of student nurses going into General Practice for placement.
General practice nursing needs to be seen as a possible career
option along with other out-of-hospital services and CCG
Nurses have a key role in driving local approaches. CCG
Nurses working together with GPN can start to address local
workforce issues and influence developments within Higher
Education Institutes and Health Education England to
develop new and creative models for education.
Our NHSCC's Nurses Forum also identified quality within
General Practice and the role of GPNs within that as a priority;
recognising that CCG’s can support consistency to reduce
the variation of standards which exist in general practice
nursing, driving up quality and compliance with Care Quality
Commission standards within the five domains of quality. The
National Nursing and Care Strategy six Cs general practice
nursing framework provides a comprehensive values-based
tool to support the delivery of patient centred, high quality
care. Engaging with GPNs, CCG Nurses can develop their
confidence and draw on their experience and expertise
to embrace the 6 Cs making a difference to quality within
individual practices, and contribute to the development and
shape of out-of-hospital care at a commissioning level.
Investing in and supporting GPN leadership and
development will create the opportunity for creative
and innovative, integrated models of working, enabling
multidisciplinary teams to come together around the person,
focused on well-being and quality of life.
“
”
NHSCC Nurses Forum is prioritising
development and leadership of
general practice nursing
“
”
UPFRONT
12 COMMISSIONING
14. By Dr Phil McCarvill,
Head of Policy and Public
Affairs at Marie Curie
Those responsible for developing, commissioning and
configuring future health and social care services are currently
faced with an unprecedented set of challenges, most notably
from on-going financial pressures and a rapidly ageing
population. The bottom line is that over the coming decade,
we will have to meet the challenge of delivering more, to more
people, with less money.
Changing the way we configure, commission and deliver
end of life care services could enable the health and social care
system in England to address these challenges by shifting more
resources from hospitals into the community.
CHOICE IN END OF LIFE
Arguably, we now more than ever before, know what
people want at the end of their lives. Historically when we
have talked about giving people choice at the end of life,
we have almost exclusively focused on place.
Choice in end of life is clearly about more than where
someone wants to die; it is also about pain management,
care and treatment preferences and being close to family
and friends. Place, however, remains a key measure of
choice.1
Analysis of a range of studies show that preferences
for ‘home death’ range from 31% to 87%.2
Whilst it is
important to underline that hospital will always be the ‘right
place’ for some people to be, few people say that they would
chose to die there.2
The National Survey of Bereaved People (VOICES),
2013 tells us that 80% of respondents said that their relative
had wanted to die at home.3
However, the latest Office for
National Statistics data shows that only half of people (50%)
who express a preference to die at home actually do so.3
Gomes et al established that there has been a long-term
trend over the last decade of fewer people dying in hospital
and a greater proportion of people dying in their usual place
of residence.4
We know that the percentage of people dying in
their usual place of residence in England has increased from
37.9% in 2008 to 43.7% in 20122
and rose again in 2013-14
to 45% of deaths.5
However, the reality is that the majority of
people continue to die in hospital.2
EXPERIENCE AT END OF LIFE
So we know that many people express the desire to die
somewhere other than in hospital, but the majority continue
to do so. We also know that the quality of care they receive in
hospitals in England is rated lower than care experienced in
other residential settings such as hospices and care homes. This
is illustrated most starkly by the results of the first three years of
the National Survey of Bereaved People (VOICES), which found
significant variation in the quality of care in different settings,
from different professionals and across different geographical
areas of England. Hospital doctors and nurses score significantly
lower than professionals working in hospices, generalpractice,
communityservicesandcarehomes.3
This picture is replicated when bereaved relatives were
asked how often their loved one was treated with dignity and
respect by professionals in different settings, hospital doctors
and nurses again lag behind other colleagues.
The latest National Care of the Dying Audit of Hospitals
led by the Royal College of Physicians (RCP) and supported
by Marie Curie casts further light on people's experiences
of end of life care in hospitals in England.6
This draws on
individual patient records, an assessment of organisational
readiness to deliver palliative and end of life care and the
views of bereaved relatives. It underlines concerns about
access to high-quality, consistent and equitable end of life
care in hospitals across England.
The organisational findings reveal that only 21% of NHS
hospital trusts provide seven-day access to palliative care
and just 2% of trusts offer a 24/7 face-to-face service. Raising
further questions about whether end of life care is being
adequately prioritised in hospitals, only 47% of trusts had
a formal process in place to capture the views of bereaved
relatives or friends.6
END OF LIFE CARE:
SHIFTING PRIORITIES
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COMMISSIONING 13
15. These organisational issues are similarly reflected in the
recorded communications between hospital professionals
and terminally ill people and their families. The review of
patient notes (which formed part of the same review) shows
that in 87% of cases professionals had recognised that an
individual was in the last days of life. However, conversations
had only been initiated with 46% of those capable of having
them and almost a quarter (24%) of bereaved relatives did not
feel they had been involved in decision making.6
Much has been written about the suitability of hospitals
for people who are in the last days and weeks of life. As
Murray et al report: “Hospitals are frequently criticised
for being too costly, unresponsive to public priorities, and
generally the wrong place for terminal care. Problems
here include the increasing pressure on time and beds
and, at times, negative perceptions of palliative care. The
preoccupation with curative treatment has a cost in terms
of delayed consideration of end of life issues.” 7
Again, it is important to underline that for a significant
number of people who are approaching death, hospital will,
for clinical reasons, be the right place. However, there are
clearly questions about whether hospitals are places in which
we can ensure that everyone gets the highest possible quality
of care at the end of life.
Concerns about the ability of hospitals across all parts of
England to consistently deliver equitable, high-quality end of
life care are most acutely underlined by the Neuberger review
of the implementation of the Liverpool Care Pathway.8
The
review found that whilst there were clearly many examples of
excellent care in hospitals across the country, there were too
many examples of poor, insensitive and inappropriate care
being provided for people who found themselves in hospital in
the last weeks of life.
Many of those who are in hospital at the end of their lives
have no clinical need to be there and arguably find themselves
in hospital because of the inability of other parts of the system
to prevent their admission, or facilitate their discharge to other
alternative places of care. Once people are admitted to hospital,
many remain there because they cannot access the support
they need to enable them to be cared for, and ultimately to die,
in their own home or their care home.
So the evidence suggests that most people do not want
to die in hospital, often have no clinical need to be there
and experience poorer quality care when they end up there.
But the reality is that commissioners and decision makers
have been reluctant to shift funding from hospital beds into
the community, because of the concern that social care and
community services cannot fill the gap or alternatively that
they are expensive alternatives, particularly in a specialist area
such as end of life care.
THE VALUE OF COMMUNITY-BASED SERVICES
AseriesofreportsfromtheNuffieldTrusthashelpedto
challengetheseperceptionsandemphasisetheimportantrole
thatsocialcareandcommunityservices,suchastheMarieCurie
NursingServiceplayindeliveringhigh-qualityendoflifecarein
thecommunity.Theseindicatethatensuringanindividualhas
therightsocialcarepackageornursingsupportinthecommunity
canmakeahugedifference,notonlyforthemandtheirfamily,
butnowalsoforthewiderhealthandsocialcaresystem.
In 2012, the Nuffield Trust published Social care and
hospital use at the end of life, 9
a study of 73,000 people in
England who were in the last year of life.10
The study looked at
those who received local authority‐funded social care in the last
months of life and in particular their hospital admissions and
in-patient use during that period.
Whilst 'social care costs rose modestly' over the course of
the last 12 months, the rise in hospital costs is more marked.
According to The Nuffield Trust, over half of all hospital costs
were due to activity in the last three months of life and over 30%
due to activity in the last month itself. Emergency admissions
accounts for 71% of all hospitals costs in the final 12 months and
85% in the final month. The Nuffield Trust concludes: “As in
earlier studies we did observe a broadly inverse relationship
between hospital costs and social care costs that existed at
all age groups. This meant that the people incurring higher
social care costs (which in most cases means those in a care
home) tended to use less hospital care.” 10
Having explored the relationship between access to social
care and hospital use in the last year of life, the Nuffield Trust
then turned its focus to the impact of community-based nursing
for those at the end of life, with its evaluation of the Marie Curie
Nursing Service.11
The study compared the experiences of 31,107 people who
hadreceivedMarieCurieNursingServicecarewithmatched
controlswhowerealikeineveryrespectthatcouldbemeasured,
otherthantheyhadnotreceivedcarefromtheMarieCurieNursing
Service.Thestudyfoundthataccesstothisnursinghadaprofound
impactonoutcomesforthoseattheendoflife,intermsof:
This clearly has implications for the relative cost of end
of life care: “We found significant differences in the costs
of both planned and unplanned hospital care between
Marie Curie Nursing Service patients and controls. Total
hospital costs for Marie Curie Nursing Service patients
were £1,140 per person less than for controls from the first
1st - Where they died:
“76.7% of those who received Marie Curie Nursing
care died at home, while only 7.7% died in hospital.
In contrast, 35% of the controls died at home, while
41.6% died in hospital.”11
2nd - Their use of hospital care at end of life:
“People who received Marie Curie Nursing care
were less likely to use all forms of hospital care than
controls. 11.7% of Marie Curie Nursing Service
patients had an emergency admission at the end
of life, compared to 35% of controls; while 7.9% of
Marie Curie Nursing Service patients had an AE
attendance, compared to 28.7% of controls. Across
most types of care, Marie Curie Nursing Service
patients used between a third and half of the level of
hospital care of controls.” 11
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14 COMMISSIONING
16. contact with the Marie Curie Nursing Service until death.
However, this figure should be considered alongside
other costs, including the cost of the Marie Curie Nursing
Service itself and possible impacts on other services.” 11
Allthatremainednowwastodeterminewhetherreduced
hospitalcostswerelikelytobeoffsetbyincreasedcostsinother
caresettingsaspeoplespendmoretimeathomeattheendoflife.
Theconcernwasthatwhilstcommunitynursingandsocialcare
interventionsweresignificantlylessexpensive,thismight“merely
displace care activity (and costs) to other care sectors.” 11
WithitslatestpublicationExploring the cost of care at the
end of life,12
theNuffieldTrusthassoughttoanswerthisquestion
bycalculatingandestimatingthecostsofallrelevantaspectsof
community-basedendoflifecare,includingGP,districtnursing,
socialcare,hospiceandhospitalcosts.TheNuffieldTrustthen
useddatalinkagetoestablishcostsforindividualswhohad
receivedcarefromtheMarieCurieNursingServicecomparedto
thecontrolgroup.12
TheNuffieldTrustestablishedimportantdifferencesin
patternsofserviceuse,outcomesandcostsforarangeofgroups
attheendoflife.Theyincludeprofoundlydifferentpatternsof
servicesandrelativecostsforpeopleofdifferentagegroupsand
withdifferentconditions.
Importantly,theNuffieldTrusthascalculatedthecumulative
costsofcaresothatwecanfinallyanswerthequestionofwhether
community-basedendoflifecareisreallycheaperthanhospital-
basedcare.
The Nuffield Trust established that those who received a
Marie Curie Nursing Service spent two and a half fewer days of
their final 90 days in hospital, Nuffield then sought to ‘determine
the scale of costs that would be accrued in non-hospital care
services if two and a half extra days were spent at home at the
end of life, rather than in hospital’.12
CONCLUSION
Most people who are terminally ill wish to die somewhere
other than in hospital; a significant proportion have no
clinical need to be there and they experience poorer care
when they do. The cumulative impact of the three Nuffield
Trust studies is that we now have the evidence-base needed to
transform care. We now know that not only are people who
have good social care packages or receive community-based
nursing care from an organisation such as Marie Curie, more
likely to die out-of-hospital and less likely to spend time in
hospital in the last weeks of life, but that these scenarios can
also cost less than hospital-based care.
The Nuffield Trust’s analysis means that commissioners
now have strong evidence regarding the potential savings
which could be accrued, by shifting care from acute hospitals
out into the community. However, as the Nuffield Trust
cautions, the bottom line for commissioners is: “Cashable
savings to the hospital would only be achieved if they
were able to release staff or capital costs in some form”.
It is clear that this requires big decisions and a will on
the part of both commissioners (and ultimately politicians
and the public) to make this shift. This may mean a phased
shifting, perhaps starting with a greater number of staff
currently working in hospitals being jointly located in the
community and staff from organisations such as Marie
Curie and local hospices being based in hospitals in AE
departments and on wards to help triage, signpost and speed
up the discharge of people to the most appropriate settings
for their care. Charities like Marie Curie have a fundamental
role to play in making this happen.14
It is essential that we use this evidence base to ensure that
your chances of experiencing excellent end of life care is not
determined by where you live, the conditions you have or the
services you use. As a minimum, we must prevent
unnecessary admissions and ensure that we get those people
who have no clinical need to be there and do not want to be
there, out of hospital. To do this, we must shift resources from
acute hospitals out into the community. The challenge is for
commissioners across England to make this a reality.
Its conclusion was clear:
“Any increase in activity that might occur in primary care,
community care and in social care activity as a result of
reduced hospital bed days, is likely to be very modest when
considered against the entirety of care activity during
the last months of life. The increases in costs we have
calculated are only in the order of 1% to 3% of the observed
reduction in hospital costs of £1,140 that we found in our
evaluation of the Marie Curie Nursing Service.” 12
This is good news for commissioners:
“We found that the scale of probable changes in
non-hospital costs was relatively small and concluded
that local care costs were likely to be lower even when
considering the costs to a commissioner of home based
nursing support at the end of life.” 15
In financial terms this means significant
potential savings:
“Even when costs in other sectors (social care, primary
care and community care) were considered, the Marie
Curie patients’ costs were of the order of £500 less.” 16
This is good news for commissioners:
“We found that the scale of probable changes in
non-hospital costs was relatively small and concluded
that local care costs were likely to be lower even when
considering the costs to a commissioner of home
based nursing support at the end of life.” 12
In financial terms this means significant
potential savings:
“Even when costs in other sectors (social care, primary
care and community care) were considered, the Marie
Curie patients’ costs were of the order of £500 less.” 13
UPFRONT
COMMISSIONING 15
17. References:
1. Leadbetter, C. and Garber, J. 2013, Dying for change,
Demos; 2. What we know now, 2013, National End of
Life Care Intelligence Network, http://www.
endoflifecare-intelligence.org.uk/resources/publications/
what_we_know_now_2013; 3. ONS (2014), National
Survey of Bereaved People (VOICES), 2013, Office for
National Statistics http://www.ons.gov.uk/ons/
dcp171778_370472.pdf ; 4. Gomes B. et al, (2012)
Reversal of the British trends in place of death: Time
series analysis 2004–2010, Palliative Medicine, March
2012 vol. 26 no. 2 102-107 http://pmj.sagepub.com/
content/26/2/102; 5. Proportion of deaths in usual place
of residence (2014), National End of Life Care
Intelligence Network http://www.endoflifecare-
intelligence.org.uk/data_sources/place_of_death; 6.
Royal College of Physicians National Care of the Dying
Hospitals Audit (2014) https://www.rcplondon.ac.uk/
resources/national-care-dying-audit-hospitals; 7.
Murray, S.A. et al, (2008) End of life care in the UK: a
wider picture of service provision and initiatives,
European Journal of Palliative Care, 2008, 15(6) http://
www.cphs.mvm.ed.ac.uk/groups/ppcrg/images/pdf/
Murray%20et%20al%202008%20EJPC%2015(6)272-275.
pdf; 8. More care, less pathway: A review of the
Liverpool care pathway. https://www.gov.uk/
government/uploads/system/uploads/attachment_data/
file/212450/Liverpool_Care_Pathway.pdf; 9. Nuffield
Trust, 2010. Social care and hospital use at the end of
life. http://www.nuffieldtrust.org.uk/sites/files/nuffield/
social_care_and_hospital_use-full_report_081210.pdf;
10. Nuffield Trust, 2012. Understanding patterns of
health and social care at the end of life http://www.
nuffieldtrust.org.uk/sites/files/nuffield/121016_
understanding_patterns_of_health_and_social_care_
full_report_final.pdf; 11. Nuffield Trust, 2012. The
Impact of the Marie Curie Nursing Service on Place of
Death and Hospital Use at the End of Life, Nuffield Trust
http://www.nuffieldtrust.org.uk/publications/marie-
curie-nursing; 12. Nuffield Trust, 2014. Exploring the
cost of care at the end of life, Nuffield Trust http://
www.nuffieldtrust.org.uk/sites/files/nuffield/
publication/end_of_life_care.pdf; 13. http://www.
mariecurie.org.uk/Commissioners-and-referrers/
Commissioning-our-services/Why-work-with-
Marie-Curie/?Tab=2; 14. http://www.mariecurie.
org.uk/en-GB/Commissioners-and-referrers/
16 COMMISSIONING
UPFRONT
18. By Rob Webster,
Chief Executive at
NHS Confederation
Six months away from the
General Election, we find ourselves
experiencing the toughest time
health and care services have known
for a generation. The very essence
of universal healthcare free at the point of need faces
its greatest threat. That threat comes from tightened
budgets, the changing needs and expectations of the
population, and our failure to have an effective, open and
honest discussion with the nation about what needs to
change. It seems as though the perfect storm is upon us.
Although the dark clouds are rumbling overhead, I
have many reasons to be optimistic they will pass and a
sustainable future for health and social care will emerge.
Now more than ever, it feels as though there is a real
commitment from all parts of the health and care system
to delivering long-term change. We now need political
support and the resources to make it happen.
This is reinforced in the recently-published Five
Year Forward View (5YFV) and the NHS Confederation
coordinated 2015 Challenge. Both lay down the gauntlet
to politicians to take decisions in the best interests of the
service and the people they serve.
I believe the 5YFV is the first credible commissioning
strategy of the new NHS. Crucially, it represents the
views of all of the ‘arms-length’ national bodies. It
spells out to current and future governments where
our healthcare system needs to be and how we achieve
this change. It is a large and an important step in
making clear the consequences of the 2012 Act on
accountability, authority and responsibility. For the first
time, national NHS bodies are setting out their needs for
the consideration of government. In turn those national
bodies will require much of us.
The 5YFV was preceded by The 2015 Challenge
Manifesto. This also sets out an achievable vision of a
sustainable health and care service. It brings together
an unprecedented coalition of 21 major bodies that
represent NHS managers, local government leaders,
public health, royal colleges, patient groups and well-
known charities. It is the frontline equivalent of the
5YFV and sets out 15 asks of politicians and national
bodies that will enable us to build a sustainable future,
together with the public, during the next parliament. It
calls for courageous political leadership, and a collective
ambition that extends beyond headline grabbing
initiatives which, although popular, do not address the
fundamental issues we face.
Takentogether,wenowhaveabroadandunprecedented
consensusfromthefrontlineandthenationalhealthand
caresystem.Thatconsensusincludestheneedforinvestment
andfinancialstability.Weneedpoliticianstohelpgenerate
stabilitybyprovidingclearplansabouthowtheywillfundthe
healthserviceduringthenextparliament.Wehaveseenthe
headlines,butneedfurtherdetailtobeconfidentthattheir
visionwilladdressourreality.
In this environment it is time for commissioning to
fulfil its potential. Commissioners must help overcome
the barriers in reshaping care and supporting providers
through transition. New approaches are needed to
unlock the potential of more community-based, locally-
integrated models of care, alongside larger specialist
centres that consolidate expertise and deliver world-
class innovation and outcomes. Wise commissioners
will work with providers and the local community to
drive these changes, including through local place-based
mechanisms like Health and Wellbeing Boards. As co-
commissioning of specialised services increases, there
will also be the opportunity to do this on a larger scale.
The importance of this becomes greater as
organisations across health and social care increasingly
work together. Many providers I work with need this
support in the short-term and as they develop their
medium-term futures – many of which begin to look
very different. Commissioners have a role to play here
too. Recent polling shows that the public are not content
with just preserving the current motions of the NHS.
They recognise that change is necessary but want
reassurances that it will be done in the right way.
A recent NHS Confederation survey of the general
public found that 76% would support changes to their
local NHS if there was evidence that it would improve
care. But 74% did not feel they had sufficient knowledge
to contribute to a debate on the NHS and wanted more
information on how it is funded and what the money
buys. Significantly, 81% of respondents disagreed that
politicians are honest about the future of the NHS.
This information suggests that local people feel
strongly about wanting clinical leadership, a better
future they can understand, engagements with local,
trusted organisations and political barriers to be
removed – a strong case for Clinical Commissioning
Groups. We need strong commissioners doing great work
on the needs of our populations, the redesign of care,
leadership, culture, workforce, technology and finances.
We need local leaders across commissioners and
providers – with clinical, managerial and patient/public
buy-in – to be empowered to be bold. These ‘placed-
based’ local approaches need to be backed by a reformed
performance and regulatory culture to help foster the
ability to change. Getting there is no mean feat! The
prize is a future NHS, free at the point of need.
The NHS has put the challenge to the politicians.
When they answer the call, we need to be ready to act.
Commissioners, are you ready?
Navigating the way through stormy
seas will require political support
and courage
COMMISSIONING 17
19. CLINICALCOMMISSIONING:
ANUNNECESSARYENGLISH
OBSESSIONORNECESSARY
FORITSSUSTENANCE?
It is worthy of comment that the rightly lauded 'Five
Year Forward View' does not major on the separation of
commissioning and provision. That separation was first
introduced to the NHS in the 1991 reforms much influenced
by the work of the U.S.A. economist Alain Enthoven. Of
progressive health systems only England focuses so strongly
on commissioning, nevertheless, I have always supported
the concept. I believe a separation is of benefit to the public
to protect them from the potential excesses of ‘provider
capture’. I also over the succeeding years have recognised
as have so many, that our approach to commissioning is
too bureaucratic, transactional, of poor value and often too
adversarial. Commissioning is often wrongly interpreted
as synonymous with contracting as in the often repeated
phrase ‘Clinical Commissioning Groups' cannot commission
primary care’ – of course they always could.
In my involvement as a GP of 36 years and working
at a strategic level in the NHS for 16 years – much of it
overlapping I hasten to add – I have observed, learnt and
indeed forgotten much. In now, my misspent old age, I have
also written various pieces from which, for this article, I will
call on to make some points relevant I feel to the current
NHS – post the Lansley necessary reforms of commissioning
leadership and post the 'Five Year Forward View'. I will quote
(in italics) from the latter, as in contrast to past Department
of Health/NHS publications, this is a most enabling view.
Not least as it is labelled a view not a plan. Maybe semantics,
but to me a distancing from a previous neo Soviet model of
centralised management.
ByProfessorDavidColin-ThoméOBE,
IndependentHealthCareConsultant,former
GPandNationalClinicalDirectorforPrimary
CareandMedicalAdvisertoCommissioning
Directorate,DepartmentofHealth
In A New Commissioning 2011, 1
I described
commissioners;
Becoming the ‘people’s organisation’ – a partnership
with the public, a transparent accountability, enabling
community leadership and adopting a facilitative approach
to developing patient-determined outcomes. Is of the
people, by the people and for the people
Building new relationships and partnerships, across the
wider health ecosystem
Being the healthcare system leader, ensuring
integration across all NHS funded providers. Utilising
methodologies such as alliance contracting or
identifying a prime provider
Creating a completely new relationship with care
providers – relationships underpinned by a contract, not
relationships defined by the contract
Pursuing value – defined by Porter of Harvard Business
School value = outcomes/cost
18 COMMISSIONING
20. Share your views on articles within Up Front by emailing your comments to
upfront@commissioningmonthly.com. All emails will appear within the Up Front blog on our website.
Visit the blog, see what fellow commissioners are saying and provide your own comments.
In reality, commissioning is all about provision-identifying,
enabling and supporting value-based providers. So why
have we made it so complicated and costly? Why did NHS
England, in responding to the aims of the Health and Social
Care Act of 2012, deem it necessary to bestow on us four
statutory commissioners? Not what the then political
leadership called for and surely too many in number
and size. I hope co-commissioning is but a step to ‘right
sizing’ commissioning. And not before time-witness the
scathing assessment of NHS England commissioning in
the recent National Audit Office report of GP out-of-hour
services and the burgeoning size and financial overspend
of specialised commissioning. There is of course a corollary
to commissioning. Where is the provider responsibility and
leadership in ensuring high value care? Maybe that frequent
lack of secondary care local health system involvement and
leadership is the product of England having one of the more
centralised hospital models amongst advanced health systems.
Local commissioning can usurp centralisation.
A key focus for future commissioners must be to
commission for individual patients, surely an essential
component of personalised care. On this in particular, the
NHS has much to learn from local government. In trialling
this approach, I would suggest focusing initially on those
identified patients with complex problems, as they are of
high priority, yet their numbers being relatively small make a
piloting manageable. Devolving budgets to patients has and is
encouraged – ‘year of care’ budgets that will be managed by the
people themselves or on their behalf. But many may not wish
a budget and for those patients who have an agreed care plan,
for them or their carer to overtly hold all providers to account
for the delivery of their plan. The concept could be expanded
to include other patient groups as locally appropriate and
has strong echoes in the ‘Integrated Personal Commissioning’
described in the ‘Forward View’.
And if we are to have a radical upgrade in prevention and
public health, Health and Wellbeing Boards have enormous,
if often unfulfilled, potential. They are the most intriguing
and challenging of organisations, as having no statutory
population budget requires a skill set much lacking in public
management. How do they achieve leverage for change by the
use of the ‘softer’ skills of relationship building, influencing
and transparent accountability.2
Now that’s a paradigm shift
for commissioners, which de facto is what these Boards are.
SO IT IS ALL ABOUT PROVISION
Four models are offered to us in the 'Five Year Forward
View'. I will focus on the one that potentially is the most
transformative, but first reinforce an underlying provider
principle. The foundation of NHS care will remain list based
general practice. In all my years, including those I spent at
the Department of Health, never can I recall such a clear
confirmatory statement in any previous official document.
Therearemanyovertheyearswhohavebeenkeentoridthe‘list’,
sothemessagetoGPsstillremains‘useitorloseit’.I remain a
passionate believer of the merits of general practice being
about care for both the registered patient in front of, and
the patients not in front of, the clinician. As the redoubtable
Donald Berwick described general practice; ‘the soul of
a proper, community orientated, health-preserving care
system’. One of the key reasons general practice has been a
central plank of all the NHS reforms of the last 23 years, is
that with list responsibility a population health focus can be
achieved and budgets can be devolved. The clinical benefits
of the quality and outcomes framework, which has led to
a narrowing of health inequalities, is only possible with a
list-based responsibility. So I welcome the proactivity of the
government ordained Care Quality Commission focus on
population groups in their assessment of general practice.
General Practice, to remain the foundation, needs to be both
‘small and big’. An achievable paradox as we retain both local
practice as an essential part of social capital and develop the GP
led ‘meso’ organisations – networks/localities/federations. The
latter preferably, but not essentially developed ‘bottom up’ and
who essentially relate to individual practices as equal partners.
The Primary Care Home 2011,3
is a proffered idea to further
develop the ‘meso’ organisation. An integrated population-
based budgeted provider organisation that can be formally
commissioned to undertake some commissioning responsibility
on the ‘make or buy’ principle. A home not only for general
medical practitioners and their teams, but for all primary
care independent contractors, community health service and
social care professionals. And potentially a home for many
currently working in hospitals, in particular those who have a
responsibility for long-term conditions care, for rehabilitation
and re-ablement and for the surgeons who in particular
specialise in ‘office-based’ procedures. With modern technology,
such procedures are on the increase. The model is an extension/
forerunner of the Multispecialty Community Provider.
SUMMARY
For many of us who have spent much of our working lives
trying to develop a community-based integrated provider
as an alternative to the prevailing hospital centricity, let’s
seize the day. But unless we also adopt a new approach to
commissioning, a community led and based focus may not be
sustainable, even though essential for a sustainable NHS.
References:
1. A New Commissioning 2011, www.dctconsultingltd.co.uk
2. Health and Wellbeing Boards 2011, www.dctconsultingltd.co.uk
3. The Primary Care Home 2011, www.dctconsultingltd.co.uk
“The rightly lauded 'Five Year Forward
View' does not major on the separation
of commissioning and provision
”
UPFRONT
COMMISSIONING 19
21. ENGLAND´S MOST NORTHERLY AND MOST
SOUTHERLY CCGS TALK COMMISSIONING
HEADTOHEAD
330,000 534,000
POPULATION
£410 million £682.071 million
COMMISSIONING
BUDGET FOR 2013/14
46 69
NUMBER OF PRACTICES
£7.96 million £13.520 million
RUNNING COST ALLOWANCE
Dr Alistair Blair,
Chief Clinical Officer,
NHS Northumberland CCG
Joy Youart,
Managing Director,
NHS Kernow CCG
JYAB
20 COMMISSIONING
UPFRONT
22. GEOGRAPHY
AB “We're the most rural county in England. That's not so
much about latitude as about our large geographical area and
very dispersed population. You can drive down the A1 for 90
minutes and spend the whole journey in Northumberland
and that's without a rush hour! Rurality can certainly affect
performance and costs. Solutions that work well in compact
city environments might not work as well in rural areas when a
GP might have to travel for an hour to see one patient.”
JY “We're also a very rural community with water on three
sides. We cover the Isles of Scilly – one of the remotest places
to be. I think that makes us mindful that when it comes to
commissioning, one size doesn't fit all.”
AB “Our location affects what we do in several ways. For
example, it's sometimes easier for patients to go to Scotland for
treatment – particularly those in Berwick. It's a unique feature
of living on the border. Many are equidistant from Edinburgh
and Newcastle when it comes to tertiary providers. We have to
take into account that the Scottish health system has different
ways of working and reporting. Location also affects our
ambulance service, as at any time, some of our ambulances
may be north of the border. It's also a necessary expense for
us to maintain several community hospitals – particularly for
local clinics and re-enablement because of the distances people
would otherwise have to travel.”
POPULATION
JY “Our population is quite elderly with pockets of real
deprivation.”
AB “We're about national average for socio-economics,
but there's a big range within that, with pockets of significant
affluence and also significant deprivation. We too have an above
average elderly population – which can create a bit of an issue
when combined with rurality and potential isolation.”
STRUCTURE
JY “NHS Kernow CCG is co-terminus with Cornwall
County Council. In Kernow we have a lot of one-on-one
relationships like this which really helps. We have one main
acute provider, Royal Cornwall Hospital in Truro – and
depending on the services up to 20% of the population in the
east of the county go to Derriford Hospital across the county
border in Plymouth.”
AB “We're also co-terminus with the local authority. We're
actually based in County Hall in Morpeth with social services
just down the corridor. I agree, it really helps having just that
one conversation with key organisations. We're organised on a
locality basis and the four localities are geographically distinct.
Two of the localities cover the rural populations and the others
cover the semi-urban former mining and market towns. This
helps with GP engagement, which I think would drop if we were
too centralised. And it helps people look at commissioning from
a local point of view.”
JY “Our area is divided into 10 localities based on
communities. Each one has a lead GP who connects with the
practices. It's important to have that two-way conversation with
the managerial team of the CCG. It gives us the ability to look
at local needs and what local clinicians – and other groups such
as the police and the clergy – tell us. Within one locality you
can have elderly, the more affluent as well as the deprived. The
challenge is to meet the needs of all those. Early on we began
asking our populations what they needed. This involves having
guided conversations with people about what they want to
achieve. A lot of what we learned was about the need to connect
and integrate services, so we've focused a lot on that work.”
DISTANCE
JY “London is four to five hours from Truro by train. The
question we often ask when invited to meetings is: Can it be
done by teleconferencing? But when we do go to London we
tend to plan lots of activities around that to minimise travel
time and costs. The Isles of Scilly are another travel factor for us.
Over the winter, if you can't take off at Lands End or Newquay,
you can't get there. We're now expanding telemedicine for our
population there and lab tests are now done locally, which
saves a lot of time.”
AB “For us, travel time to London is similar. If we have a half
day meeting in London, it's four hours travel each way, which
can make for a very long day – so we have to be selective. But
there's also a question of how can we make sure the northerly
population is represented in the national debate. You have to
think carefully about what you do and don't do because we
mustn't become isolationist.”
JY “We believe creating a learning organisation is beneficial
when you're so far away. We've looked at what they're doing
elsewhere in the world, in the US – particularly in Alaska – and
we've had people over from New Zealand. The Canterbury
earthquake in 2010 moved their integration agenda forward
massively and we're learning from that.”
WEATHER
AB “I think another geographical factor for us is weather
and winter. Four years ago we had snow on the ground for three
months so the impact of winter can be significant. It's certainly
something we have to plan for.”
JY “We might not get snow but we do tend to get storms
and flooding hitting us – like last winter. Another uniqueness
to Cornwall is the influx of tourists every summer. We can have
a million visitors over a summer, which also needs to be taken
into account.”
AB “Like Cornwall, when a lot of people think about
Northumberland, they remember a holiday place with beautiful
beaches. But as in Cornwall there are deprived former mining
villages. That's another thing we find we have to challenge.
When you're talking to policy makers there's a need to make
sure rurality is factored into the commissioning formula.”
COMMISSIONING 21
UPFRONT
23. There has been a significant growth in the size of the NAPC
annual conference over the last few years. The number of
delegates – 2,354 – that were there this year and the calibre of
the speakers – the Secretary of State, and Shadow Secretary of
State for Health, the Chief Executive of NHS England and very
senior clinicians from primary care – shows the stature of the
organisation we’ve become.
If you look back 10 years, the NAPC was probably
marginalised as the NHS was more managerially-focused.
But now with clinical leadership recognised as being vital
to the current reforms, this was a very practical conference
demonstrating improvements in care delivery. We focused
on things that are actually happening for which the reforms
have been a catalyst, with streams on transforming primary
care and clinical updates, as well as best practice workshops.
As President, this overview is very gratifying: our annual
conference has become the centrepiece of celebrating an
improving NHS.
From the Secretary of State's speech, it was clear that the
Five Year Forward View for the NHS, launched on day two
of the conference, has been strongly influenced by our input
and Jeremy Hunt is clear that he wants to work with us in
implementing it. It's pleasing to hear a politician acknowledge
on stage that a membership organisation such as ours has
such impact.
Our ‘Wish Tree’ was aimed at collecting delegates’ one wish
for the NHS. The wishes we collected were wide-ranging, but
we distilled certain themes. The number one wish was for
a general recognition that primary care is a lot bigger than
general practice. That has been granted already by the NAPC.
As an organisation, as well as our GP members, we have strong
membership in pharmacy and optometry with more from
dentistry joining. So now we have an organisation that's a
voice for the best practice across the whole of primary care.
We are also forging stronger links across community services
and welcomed the input at the conference from the Chartered
Society of Physiotherapy, with a presentation from their CEO,
Karen Middleton CBE.
Demonstrating the variety of best practice across primary
care, in our awards this year, Sarah Emery of the Oakfield
Surgery Ystrad Mynach in Wales won Practice Manager of
The Year. The Community Pharmacy Future Project Team
– a collaboration between Boots UK, Lloyds Pharmacy, the
Co-operative Pharmacy and Rowlands
– won Joint Working Initiative of The
Year. Health and Wellbeing Initiative
of The Year was won by Wellbeing
Enterprises – an award winning social
enterprise supporting individuals and
communities to achieve better health and
wellbeing in Runcorn, Cheshire. The NAPC
specialrecognitionawardwaswonbyRayGuy
whohasservedasamemberofNAPCExecutive
for many years and is a dedicated Practice
Manager at Ellergreen Medical Centre, in Liverpool.
This year, as an organisation, we'll be following
up another wish on the tree: ‘Give me a real budget’. This is
consistent with the aspirations of (former Health Secretary)
Andrew Lansley’s White Paper of July 2010. Under the original
plans for the reforms, devolving a budget to the clinical teams
that do the work and holding them to account for the spend,
was core to the reforms, whether you’re a district nursing team,
a consultant team or in general practice. By now we should
have seen some ownership of the NHS budget delegated to
those deploying this public purse resource. Some budgetary
control – and crucially, accountability for that budget – really
puts primary care provider teams in the driving seat and
responsible for their make or buy decisions.
I have often said that a GP with a budget is worth 10 on a
committee. We've got plenty of GPs on Clinical Commissioning
Group boards, but somehow this hasn't fully been translated
into changing behaviour in every day practice. NAPC will be
discussing with the system leaders about changing the culture
in all the teams delivering primary care, creating leadership as
a style of practice and will champion the alignment of clinical
thinking and activity with economic consequences.
We are the advocates of real budgetary ownership and
accountability within the clinical teams that deliver the care
across all sectors of the NHS.
With the Best Practice show hosting the National Association of Primary
Care’s (NAPC’s) annual conference, Dr James Kingsland OBE,
President of the NAPC, identifies some of the highlights
GRANTING WISHES AND REWARDING
BEST PRACTICE
To reserve your complimentary
pass for Best Practice 2015 go to
www.bestpracticeshow.co.uk
GIVEME
AREAL
BUDGET
22 COMMISSIONING
UPFRONT
24. There isn’t enough money to carry on as we are
The NHS needs increased funding, and soon.As the excellent
Five Year Forward View highlights, the increasing demand and
costs of treatment means the NHS will need more money. Funding
of the NHS is a political decision, and any discussion about the
future of the NHS, must include a realistic view of funding.
NHS staff need support
I am constantly impressed by the discretionary effort shown
by NHS staff, both clinical and administrative.We cannot simply
expect them to continue to work harder and faster. Compassion
and care take time, and we need to value staff, celebrate their
role and make the NHS an employer of choice.This is about more
than money,and professionalautonomy,respectandsupportarevital.
Talkingdown theNHSandmakingitapoliticalfootballharmspatient
trustand staffwellbeing.
Commissioning is vital
Commissioning is the means of delivery for local and national
priorities.We have seen the effect of a lack of local commissioning
for General Practice, and it is essential that commissioners
are given the tools to succeed and enable meaningful change.
Regulation is a useful tool, but it is commissioning that makes
change happen and improves quality. It does not make sense to
reduce running costs and managerial support when the NHS needs
commissioners to deliver. NHS commissioning has a defined limit
for running costs and an inflexibility that is almost unknown in the
wider business world. Commissioning needs support, not shackles.
The NHS needs clinical leadership
Clinical leadership is essential, and has increased
significantly since the introduction of clinical commissioning.
Many providers have welcomed the clinical relationship with
nurses and doctors designing pathways and working together
on local issues, supported by managers.This is at risk.We
should stop the debate about reorganisation and the mandated
transfer of NHS budgets to local authorities. Such a change
would lose clinical leadership, end the ring-fenced NHS budget
and risk delivery of the changes the NHS desperately needs.
Partnership working must happen, social care must be delivered
alongside the NHS, but this is delivered through effective
relationships, which are already developing and need to be given
the time to mature even further.
Transformation takes time and money
As recognised in the Five Year Forward View, significant
changes are needed if the NHS is to remain sustainable and
effective. Services need to integrate and transform to respond to
demand and clinical service change. But this transformation takes
time, a clear vision and a significant transformation fund if it is to
happen.The Better Care Fund, for example, may be a useful tool,
but it is difficult to deliver significant change in a short timeframe
and without the funds to double run some services.As social care
services retract, there is a danger we focus on supporting this
rather than delivering true change.That is not enough.
Focus on information
For most services in the NHS, information means an activity
report – numbers, times to first appointment, time in the AE
department.There is little information on outcomes. Not getting
a hospital acquired infection or not getting a pressure ulcer is
not an outcome, we need to know if patients get better, benefit
from surgery, get the services they need.A patient who has a
stroke, is admitted to a stroke ward, but who has delayed access
to physiotherapy and a poor social care experience will not
appear on any information reports.We have, for example,
very little information about General Practice other than
the Quality and Outcomes Framework indicators and
national surveys, which now determine practice ratings.
We can improve information, but it needs a focus
on outcomes, patients and pathways not simply
numbers seen and process indicators.
POLITICAL
SPOTLIGHT
As we near the General Election, the Spotlight on the NHS becomes ever
brighter. The glare can be uncomfortable, but it does offer an opportunity to
debate some of the key decisions facing politicians and the electorate
By Dr Steve Kell, Co-Chair of NHS Clinical Commissioners, Chair of NHS Bassetlaw CCG
COMMISSIONING 23
VOICES
25. PHARMACISTSIN
PRIMARYCARE:
TIMETOINTEGRATE
ANDDIVERSIFY
Currently there is a lot of focus on the crisis in
general practice workload capacity, a reduction in
young doctors choosing general practice for training
and the proposed NHS reforms seeking to have seven
day access to GP practices. This scenario is akin to
a bubbling volcano! It is teetering on the brink of
eruption and many grass root GPs are considering
early retirement. However, doing nothing to relieve
these pressures on GPs is not an option, as it will be
detrimental to delivering essential NHS services to
the patients who need them the most.
One option (and it is not unheard of) is to consider
having a clinical pharmacist in a GP practice. The
King's Fund1
in its independently commissioned report
stated that “the GP should no longer be expected to
operate as the sole reactive care giver, but should
be empowered to take on a more expert advisory
role.” This needs a skill mix in General Practice
to evolve. Effective team working in general
practice is the only way forward. Hospitals
have benefitted for decades by having robust
clinical pharmacy services, so why is it such
an alien concept in general practice?
The focus should be on integration
and not segmentation. Pharmacists
can act as an integration catalyst
when placed within general practice,
leading on medicines optimisation,
influencing care for the patients
at a local level, but at the same
time helping to improve patient
outcomes. As a pharmacist
working in GP practice for the
last 10 years I know this only
too well.
ByRenaAmin,JointAssociateDirector,
MedicinesManagement/ClinicalAssociate,
NHSGreenwichCCG/HartlandWaySurgery
24 COMMISSIONING
VOICES
26. The Centre for Workforce Intelligence,2
commissioned by the government to analyse future
workforce requirements, has predicted an oversupply
of pharmacists by 2040. This skilled healthcare
professional is, therefore, ideally placed to relieve
pressure on GPs. Additionally if the pharmacist is
an independent pharmacist prescriber this can be an
added benefit for the practice. In return the pharmacist
will work autonomously when appropriate and take
accountability for their role, thereby reducing the
burden on the GP.
There are many innovative examples of pharmacists
working in primary care. These truly integrated
roles not only deliver improved efficiency and safety
outcomes, but also reduce prescribing care costs.
Efficiencies in the prescribing budget can deliver
improved health outcomes especially for patients
with long-term conditions, patients with complex
polypharmacy issues and in terms of adherence
and interface issues. GP practices managing
care homes can also benefit from having a
clinical pharmacist integrated within the
practice, as they lessen the load on the GP
and also help with the care of patients
with complex co-morbidities in these
settings. With the current emphasis
on reducing hospital admissions
and emergency admissions to
Accident and Emergency (AE)
units, medicines optimisation
agenda delivered by the practice
pharmacists will certainly
support those aims.
The Royal
Pharmaceutical Society
“The focus should be on
integration and not
segmentation
”
COMMISSIONING 25
VOICES
27. set up a commission on the future models of
care for pharmacy services, chaired by Dr Judith
Smith, Director of Policy at the Nuffield Trust in
November 2013.3
In its recommendations, it states
that pharmacists have a vital role in helping the NHS
make a shift from acute to integrated care. However,
the profession is challenged by the insufficient public
and medical awareness of the range of services a
pharmacist can offer.
Pharmacists working in general practice currently
justify their roles by running clinics, managing their
own case loads, managing medicines optimisation,
playing a medicines information role, through to
supporting the business viability of general practice
by assisting the implementation of directed enhanced
services, local enhanced services and Quality and
Outcomes Framework (QOF) targets.
Evidence from my own personal experience as a
pharmacist working in GP practice since 2004, demonstrates
the enhanced outcomes for the key deliverables, thus
supporting the establishment of the role.
In terms of prescribing related outcomes, the
practice achieved 15 out of 16 objectives in 2013-14. The
practice has managed to stay within the prescribing
budget for the last 10 years since the start of my role,
and subsequently in 2012, I became a managing
partner, further validating the role of a pharmacist
working in GP practice and the opportunity for career
progression for future pharmacists.
In this position I undertake a multitude of roles,
which are both clinically and business orientated.
The scope of work can be as varied or niche as the
practice wants it to be, however, one thing that can
be guaranteed is the successful implementation by
the pharmacist working in GP practice. Our practice
has one of the lowest AE attendances, further
demonstrating that we optimise our patients with
long-term conditions with self-management plans,
offer detailed medication review clinics and robust post
discharge assessment in terms of medication and other
related changes, e.g. changes, switches, optimisation,
follow up on biochemical monitoring.
AS A PHARMACIST WORKING IN GP PRACTICE, I ALSO HELP MANAGE COMPLEX PATIENTS AND
THIS TAKES A HUGE WORKLOAD OFF FROM THE GPS IN THE PRACTICE. SOME EXAMPLES OF
COMPLEX CASES I HAVE DEALT WITH ARE:
A patient with Parkinson’s Disease was seen in hospital and they recommended the practice to initiate a hospital
only medication. But with appropriate liaison with the hospital team, whilst ensuring the patient received the
appropriate care, I managed to direct the prescribing back to the specialist whilst also ensuring medico-legal
responsibilities rested with the specialist
A patient with atrial fibrillation fulfilled the criteria for a newer oral anticoagulant, as she demonstrated side effects
to warfarin. As part of the medication review clinic this was reviewed, and the switch was managed in a controlled
process without causing detrimental effects to the patient’s already stabilised condition
A stoma patient was requesting large quantities of stoma products due to lack of communication between primary
and secondary care. A stoma review was conducted, appliance review was also arranged with the stoma nurse,
patient expectations were managed, reduction in pharmaceutical wastage was minimised and patient satisfaction
was achieved
At an annual asthma review appointment, as part of physical health check, this patient was asked regarding his
activities of daily living and based on the response a prostate-specific antigen test was conducted, and due to the
early intervention, the patient’s prostate cancer was picked up at an early stage and fast tracked to the two week
cancer referral and is now in remission
A young stable patient with bipolar disease was reviewed in the pharmacist’s clinic and as part of her physical health
checks; she requested support with her medication as she was planning a pregnancy. Her case was referred to a
specialist obstetrician and psychiatrist and the pregnancy was successful. Ante and post natal care was optimised
due to the support given by the pharmacist including managing her medication
26 COMMISSIONING
VOICES
28. “Personally I feel it is time for
both professions to integrate,
innovate and transform
”
TASKS THAT CAN BE UNDERTAKEN BY A
PRACTICE PHARMACIST
QOF performance enhancement
In-house diagnostics e.g. reversibility tests,
spirometry, physical health checks etc.
Medicines optimisation by individualising patient care
via medication review and long-term condition clinics
Support the practice with repeat prescribing processes
Case finding and improvement in prevalence rates for
long-term conditions
Undertake prescribing audits
Support the practice with both directed and local
enhanced services
Post discharge reviews of all patients who have a
medicines related action
Lead on training, supporting the Care Quality
Commission and information governance assessments
for the practice
Increase access capacity in the practice
The list is varied, endless and shows that given the
appropriate clarification of the role, pharmacists can
improve patient and disease orientated outcomes,
improve access in general practice, and reduce
inappropriate hospital admissions and outpatient
appointments.
For the pharmacy profession this recent focus on
the GP workload crisis offers both an opportunity
and a challenge. If pharmacists diversify their roles
and demonstrate their value proposition to potential
GP employers, this can be seen as an opportunity not
to be missed. On the other hand the challenge the
profession has is to convince the medical profession
and its leadership organisations such as the Royal
College of General Practitioners and the British
Medical Association to revisit these innovative models
of pharmacists in GP practices to help avert a crisis in
the care of patients.
Pharmacists in GP practices do have the confidence
to deliver and if the future looks more towards
federated models and greater skill mix in General
Practice, members of Clinical Commissioning Groups
need to think about the whole system budgets and
not in silos. This option will enable interoperability
between professions and avoid dilution of expertise and
enhance medicines optimisation principles.4
Personally I feel it is time for both professions to
integrate, innovate and transform.
References:
1.The King’s Fund (2011). Improving the Quality of
Care in General Practice. Report of an independent
inquiry commissioned by The King’s Fund, London.
http://www.kingsfund.org.uk/publications/improving-
quality-care-general-practice; 2 Centre for Workforce
Intelligence, Pharmacy. Annual Review 2013-14
http://www.cfwi.org.uk/our-work/non-medical-
workforce-reviews-and-tools/pharmacy; 3. Now or
Never: Shaping Pharmacy for the future. The Report
of the Commission on future models of care delivered
through pharmacy. November 2013
http://www.rpharms.com/promoting-pharmacy-pdfs/
moc-report-full.pdf; 4. Medicines Optimisation:
Helping patients to make the most of medicines. Good
practice guidance for healthcare professionals in
England. May 2013
http://www.rpharms.com/promoting-pharmacy-pdfs/
helping-patients-make-the-most-of-their-medicines.pdf
Share your views via Commissioning by emailing your comments to
voices@commissioningmonthly.com. All emails will appear within the Voices blog on our website.
Visit the blog, see what fellow commissioners are saying and provide your own comments.
COMMISSIONING 27
VOICES
29. 1. Defining the value of healthcare around
outcomes that matter to patients including
health and wellbeing
• Promote a proactive approach to care, collaborating with
patients to build their resilience and increase their capacity
for self-care
• Ensure systems are designed to provide care based on an
individual’s health and wellbeing goals
• Promote healthy and active ageing and a salutogenic approach
2. Supporting new models of primary care provision
through collaborative networks for the purpose of
improving population health outcomes
• Enable collaboration through networks, federations and
accountable care organisations to deliver services more
effectively in appropriate settings
• Be receptive to new models of care that are focused on the
needs of the individual and population rather than the needs
of specific organisations
3. Aligning incentives and contractual models
that support improvements in local population
health outcomes, leading to accountable
care approaches
• Work with commissioners and providers to create a shift
in behaviour towards commissioning for individual and
population health outcomes
• Develop payment and contractual mechanisms that support
new approaches to the provision of care, sensitive to the
needs of individuals and local populations, contextualised
within the place they are delivered
4. Developing a workforce that is responsive to the
needs of a population, not fixating on any particular
professional group
• Promote the development of the multidisciplinary team
to ensure patients receive seamless care appropriate to
their needs
• Develop the skill mix of health professionals and re-engineer
the workforce to enable them to work across organisational
boundaries and in new ways
5. Supporting real time innovation across collaborative
networks, to demonstrate new models of provision
and promote integration of care around patients
and populations
• Improve collaboration between geographically aligned
providers to improve health outcomes through connected
technology and the right workforce
• Develop our Innovation Networks to implement and
spread best practice
6. Purposeful (not just positional) leaders representing
the breadth of primary care
• Promote leadership to become systemic as a style of practice,
enabling behavioural change and improvement in day-to-day
practice throughout the clinical and managerial community
within the NHS
• Champion the alignment of clinical thinking and activity
with economic consequences
• Redefine clinician’s productivity to focus on wellbeing,
prevention and reablement to reduce waste, inefficiencies
and duplication of service
• Develop advocates of real budgetary ownership and
accountability within the clinical teams that deliver care
across all sectors of the NHS
7. Influencing policy to support the ambitions above
• Working with key strategic partners and policy makers
to influence and develop policy, strengthening the voice
of primary care and providing greater co-ordination and
integration with secondary care
NationalAssociation of Primary Care’s (NAPC) seven point plan to delivering their priorities -
empowering primary care to deliver patient centred,population healthcare
NAPC IS THE PRIMARY CARE PROVIDER FOR THE
NHS CONFEDERATION WHICH WILL:
Ensure the primary care voice is fully represented on issues
affecting the whole NHS
Bridge the gap between primary and secondary care
Support new ways of working and develop whole-system
solutions to ensure a high quality, innovative and
sustainable NHS for the future
NAPC'S
POINT PLANT
28 COMMISSIONING
VOICES
