Regional directors of the NHS Commissioning Board and Trust Development Authority will take over operational responsibility from PCT and SHA leaders from 1 October.

NHS Chief Executive Sir David Nicholson announced the decision to appoint new NHS leaders six months ahead of the formal transition date in a letter to all chief executives of current NHS bodies.

This will be the “last significant organisational change” before April 2013, Nicholson said, and its aim is to “achieve the right combination of resilience in the current system and effective leadership of the new system”.

Regional directors of the NHSCB and NHS TDA will manage ongoing operational delivery for 2012/13 and planning for 2013/14. They will be accountable to the PCTs and SHAs for current system delivery and to the Board and TDA for future planning and development.

The SHAs and PCTs will retain their statutory functions and governance arrangements until April 2013, but will no longer have operational responsibility. There will be no formal transfer of budgets or staff before then.

Regional directors of the NHSCB will take on management responsibility for the teams managing operational delivery and planning. NHS TDA regional directors will do the same in relation to Foundation Trust activity.

Health Education England will take on responsibility for workforce planning, education and training from 31 October 2012. Public Health England will take on its functions from January 2013. The new arrangements will not affect the schedule or roles for CCGs or local authorities.

How the NHS Outcomes Framework can help KAMs align value propositions with customer need.

The NHS Outcomes Framework is an important information tool for both the health service and the pharmaceutical industry in the UK. The framework sets out to provide a benchmark for measuring NHS performance against agreed national indicators in areas identified as health priorities. First introduced in 2010, the framework has subsequently been updated annually to reflect patients’ evolving healthcare needs and encourage a stronger focus on tackling known health inequalities. It aims to provide an accountability mechanism between the Secretary of State for Health and the NHS Commissioning Board, and to act as a catalyst for driving quality improvements and outcome measurements throughout the NHS. Crucially, the framework is designed to help NHS organisations understand what a focus on health outcomes means in practical terms – and as such provides a powerful level for the pharmaceutical industry to engage with customers in ways that help them deliver local and national objectives.

Integrated frameworks

The 2012/13 framework follows the passing of the Health & Social Care Act and advocates an increased emphasis on improving the alignment of care sectors, encouraging collaboration and integration between health and social care. The Adult Social Care Outcomes Framework and the Public Health Outcomes Framework – which was published in March 2012 – compliment the Government’s ambitions to improve the integration of services. Collectively, the three frameworks are an attempt to create an “outcome-based health and social care system where success is measured in terms of the actual results achieved for patients, service users and whole populations.” The Government hopes that this approach at a national level will cascade down to local level, where Health & Wellbeing Boards will play a critical role in identifying shared outcomes goals for local populations – and also in understanding the contribution that different commissioners can make individually and collectively in achieving these goals.

The NHS Operating Framework is divided into five domains:

1. Preventing people from dying prematurely.
2. Enhancing quality of life for people with long-term conditions.
3. Helping people to recover from episodes of ill health or following injury.
4. Ensuring that people have a positive experience of care.
5. Treating and caring for people in a safe environment; and protecting them from avoidable harm.
   

Each domain has a series of overarching indicators covering its broad aims. These combine to form:

• One framework defining how the NHS will be accountable for outcomes
• Five domains articulating the responsibilities of the NHS
• Twelve overarching indicators covering the broad aims of each domain
• Twenty-seven improvement areas looking in more detail at key areas within each domain
• Sixty indicators in total, measuring overarching improvement area outcomes.

Whilst pharma can help the NHS drive improvements in all five domains, it is perhaps in the first three domains where medicines can make their biggest and most obvious contribution. Domain four includes outcomes that relate to the quality of the patient experience. Here, pharma can potentially support the NHS in areas such as redesigning care pathways or joint working arrangements. The final domain includes outcomes that relate to patient safety.

Indicators and coverage

Since the last Outcomes Framework was published, the DH says it has made considerable progress in refining the definitions of indicators. The majority now have been finalised, although work is continuing to develop further indicators to ensure the breadth of NHS activity is covered.

Two new indicators have been identified for 2012/13: improving recovery from stroke and improving children and young people’s experience of healthcare. Both of these are now subject to technical work to ensure they are suitable for inclusion to the Framework. Additionally, work is also being conducted by the DH to identify outcomes for groups or areas which the original framework failed to cover and capture. One such group is people with learning difficulties and another area is the quality of life of people with dementia. Again, these are being considered for more focused inclusion, and have been added as ‘placeholders’ on the 2012/13 framework.

Key aims

The main improvement areas in domain one include reducing premature mortality from the major causes of death such as cardiovascular disease, respiratory disease and liver disease in those aged under 75. Additionally, improvement is sought in one and five year survival rates in colorectal, breast and lung cancer. The domain also outlines metrics for improvement in: premature death in people with serious mental illness, reducing deaths in babies and young children and reducing premature death in people with learning disabilities. Undoubtedly, pharma can help shape new care pathways in these areas.

Domain two focuses on helping patients manage their condition, improve the functional ability in those with long-term illnesses and reducing the time these patients spend in hospital. In particular, a reduction of unplanned hospitalisation for chronic ambulatory care sensitive conditions in adults and unplanned hospitalisation for those under the age of 19 with asthma, diabetes and epilepsy is a key focus.

Domain three highlights the need to reduce emergency admissions for acute conditions that should not usually require hospitalisation and readmissions within 30 days of discharge. Improvement areas focus on continuing the development of Patient Reported Outcomes Measures for hip and knee replacements, groin hernia and varicose veins. The Framework also outlines a requirement to prevent and reduce emergency admissions in children with lower respiratory tract infections and improve recovery from fragility fractures, injuries, trauma and stroke – although these indicators are to be developed.

Domain four – which lists its overarching indicator as patient experience of primary and hospital care – cites eight improvement areas, such as improving people’s experience of outpatient care and improving hospitals’ responsiveness to personal needs.

Finally, the overarching indicators for domain five focus on patient safety incidents reported and safety incidents involving severe harm or death. The framework aims to reduce the incidence of hospital-related venous thromboembolism (VTE), infections such MRSA and C.difficile, category 2,3 and 4 pressure ulcers and incorrect medication errors which cause serious harm to patients. The admission of full-term babies to neonatal care and the incidence of harm to children due to ‘failure to monitor’ are also highlighted.

Moving forward

The DH says the NHS Outcomes Framework will continue to evolve as more indicators are developed. It will be refined on an annual basis to ensure the indicators are fit for purpose. In the meantime, it remains a vital resource for pharmaceutical sales and marketing professionals – enabling them to identify areas of national priority and develop value propositions that align with customer needs.

The development of CCGs in their authorisation process is being hampered by a lack of offers from commissioning support units (CSU), the NHS Alliance has said.

Dr Michael Dixon, Chair of the Alliance, said there were not enough CSUs across the country for CCGs to use – something which is creating a “bottleneck” effect.

The chair said there was a “shortage of sellers” which may influence CCGs to turn to the private sector for assistance.

In May this year the number of CSUs fell to 23 after three groups failed to pass the NHS Commissioning Board’s second ‘checkpoint’.

Dr Dixon said CCGs had anticipated a “take it or leave it” attitude when searching for a CSU but have found finding a CSU more difficult than many had imagined.

He added that if CCGs do turn to the private sector to assist their authorisation process they must be able to do so without any repercussions. “It is important that if CCGs want to look to privately-owned and run CSUs, they are afforded the flexibility to do so,” he said.

The NHS Commissioning Board said the recruitment for more leaders of CSUs is “well under way”.

The introduction of private sector health services may threaten the Government’s vision of integrated care in the NHS, the chair of the British Thoracic Society (BTS) has warned.

Professor Mike Morgan believes that a “multiplicity of providers” will make co-ordinated or integrated care “difficult to achieve”.

In a comment piece in The Guardian the charity’s chair claimed that a “multiplication of services will become confusing for the individual”.

He said the Government faces a dilemma over the management of the increasing amount of patients with long-term conditions.

These patients are likely to use the services of different providers of care from the private sector in the future. However, Professor Morgan said that these providers were “very unlikely” to share commercially sensitive information to achieve integration.

Professor Morgan pointed towards the system used in the US where disease management programmes have tacked this issue by ensuring one company provides primary care, secondary care and additional therapy services.

But this model, Professor Morgan said, was unlikely to be used in the NHS where a “free for all” tendering process from any qualified provider is expected.

He added that despite his concerns he still expects healthcare professionals to do their utmost to try and make the controversial reforms as successful as possible. “Healthcare professionals will try their hardest to introduce the good ideas and limit the damage caused by the ill-thought through aspects,” he said.

“One way of trying to encourage uniformly high standards of care is for the profession and patients to work together to identify quality standards for individual conditions that describe the best provision.

“Variance from the highest standards can then be used by patients to challenge commissioners and providers if they fall short.”

The national configuration of some key aspects of commissioning support has been outlined by the NHS Commissioning Board.

Business intelligence, clinical procurement and business support services will be provided by the emerging Commissioning Support Units (CSUs), individually or in collaborative networks.

Communication services are likely to be provided nationally by four or five centres, but details have not been finalised.

The NHSCB now uses the term CSUs to cover the 23 NHS commissioning support service providers that it will host until 2016, as opposed to the wider market in commissioning support services that will be open to CCGs.

Business intelligence services will manage and integrate clinical data. Nine providers have been approved: collaboratives for North West, North East and North Yorkshire and Humber, South and West Yorkshire, Greater East Midlands, London, and the South; and the single CSUs Central Southern, Best West and Birmingham, Black Country and Solihull.

Clinical procurement services will cover market analysis and engagement as well as procurement activities. Thirteen providers have been approved: North West collaborative, North East, South Yorkshire and Bassetlaw, Greater East Midlands, Norfolk and Waveney, Essex, North Central and East London, North West London, Surrey and Sussex, Commissioning Support South, Central Southern, Best West and Birmingham, Black Country and Solihull.

Business support services will include HR, payroll and legal support. All individual CSUs will be allowed to provide or source these services.

These announcements follow the assessment of CSUs’ ability to provide these ‘scale’ services according to defined standards, within an appropriate and sustainable cost framework, and with the capacity to deliver across the stated region.

Macmillan Cancer Support has attacked NICE for not including key cancer survival indicators in the first ‘menu’ of the NHS Commissioning Outcomes Framework (COF).

NICE published 44 indicators including ones for stroke patients, COPD, maternal care and access to mental health services.

However, Ciarán Devane, Chief Executive at the charity, said Macmillan is “shocked” at the omission of key cancer indicators.

He added that the absence of these indicators would result in commissioners lacking “strong incentives to improve cancer survival rates” and that NICE must include a revised list of indicators if the NHS is to hit survival targets.

From April next year, the COF will be used to hold CCGs to account for improvement in quality of local healthcare and patient outcomes through the services they commission.

The indicators have been developed using the Outcomes Framework, NICE Quality Standards and existing indicator collections, such as national audits.

A further menu of indicators will now be developed using NICE’s quality standards to ensure that all topics are covered.

NICE has defended its first ‘menu’ of indicators insisting the Framework will allow the NHS Commissioning Board to “identify the contribution” of CCGs in achieving national priorities.