The train ride towards a new commissioning landscape will reach its final destination next April, but is already encountering leaves on the track along the way.

It’s been another eventful few weeks as the commissioning structure continues to take shape. On Monday 1 October, the NHS Commissioning Board (NHS CB) was finally formally established as an independent body with executive powers and exceptional responsibilities. But it will have to wait until April 2013 to take on its full range of responsibilities.

Professor Malcolm Grant, NHS Commissioning Board Chair, said the formal establishment was a “new phase
in the history of the NHS”. Sir David Nicholson, Chief Executive of the Board, called the new responsibilities the Board now holds a “once in a lifetime opportunity to do things differently”.

The transition completes a hectic twelve months for the Board. Having only been established at the end of October last year, it has played a fundamental role in the Government’s vision to modernise the health service as outlined in the Health and Social Care Act. Arguably its main and most important task, before it takes on full statutory responsibilities next April, has been to assist in the development and authorisation of more than 200 evolving clinical commissioning groups.

As you would expect, this has not been an easy process. Alongside the introduction of clinical commissioning, it has also been given the responsibility for authorising Commissioning Support Units
(CSUs), who will assist clinicians in the procurement of certain services. While this may seem a routine task compared with the authorisation of a raft of CCGs, the Board has been criticised for the time it has taken them to appoint managing directors for the CSUs when clinicians are finally in a position to tender services.

The Board has also issued its response to the Government on the draft mandate for its NHS care objectives. Professor Malcolm Grant agrees the mandate is “fundamental” to the Government’s vision of a ‘liberated NHS’. However, he urged David Cameron and Health Secretary Jeremy Hunt to be “ambitious” in searching for new opportunities to focus on the “outcomes that matter to patients and the public.”

Professor Grant said that the “critical tests” of the mandate will be whether newly empowered CCG leaders can address and analyse the mandate and then say ‘‘Yes, this gives me the necessary freedom to address the needs of my local population.” Grant added that the mandate “provides a unique opportunity to make this happen.”

The Commissioning Board has also been informed by the Department of Health of an initial set of specialist
services it will be expected to commission nationally. Although the central powers for commissioning have now been transferred locally, the NHS CB will still retain responsibility for certain services which are defined as treating rare and uncommon conditions and illnesses. The 38 specialist services, which were selected by the Clinical Advisory Group for Prescribed Services, include:

• Specialised Cancer Services (adults)
• Haemophilia and related bleeding disorders (all ages)
• Cystic Fibrosis services (all ages)
• HIV/AIDS treatment and care services (adults)
• Specialised Mental Health Services (all ages)
• Morbid Obesity Services (all ages).

A final set of regulations will be established later in the year on which services will be commissioned nationally – following a consultation between the DH and the NHS CB on the initial recommendations.

Board under fire
But it hasn’t all been clear sailing for the NHS CB. Alongside being accused of delaying the authorisation of certain CCGs because of its stuttering CSU MD recruitment drive, the Board has admitted that it has failed to recruit a significant number of individuals from ethnic minority backgrounds. Jo-Anne Wass, HR Director, admitted the Board’s recruitment data did “not make easy reading”.

Questions have also been raised about the huge variation between clinical commissioning groups’ internal staff levels when compared to support service organisations. Critics have argued that CCGs will be forced to rely heavily on support units after analysis showed huge variations in staffing levels. Recent estimates from the DH show there are 4,200–6,300 staff employed by CCGs. Commissioning support units are expected to employ around 8,000 people.

Dame Barbara Hakin, National Director for Commissioning Development, has also been put under the spotlight by the General Medical Council. The GMC has commenced an investigation after a complaint against the commissioning director, who allegedly placed United Lincolnshire Hospital Trust under unnecessary pressure in 2009 when she was Chief Executive of the now disbanded East Midlands Strategic Health Authority. It’s claimed that waiting times and A&E targets were prioritised ahead of patient safety, despite warnings the trust was over capacity. Depending on the outcome of the investigation, the GMC may decide to take no action, issue a warning, refer Dame Barbara to a fitness to practise panel where she may be ‘struck off’, or decide on undertakings to allow her to keep her registration.

Commissioning Groups
Yet despite the disparity in numbers, evolving CCGs appear to be in good shape. Following the successful scheduling of all of the wave one applications, the NHS CB confirmed that all 67 CCGs in the second authorisation wave had submitted their applications on time. In fact, every proposed CCG is now involved in an aspect of authorisation with the Board – be it a 360° stakeholder survey, a desk-top review, a case study or a site visit.

However, the authorisation process has been delayed. Initially the Board moved the ‘waves’ back by a month each. It subsequently moved the waves back by an additional month, meaning all CCGs will now be authorised by March 2013.

CCGs have also learnt when their final commissioning budgets will be confirmed. Commissioning Groups will have to wait until December to find out how much money they have been allocated to organise local services to meet the needs of their residents. The budgets will be decided using a system called the Fair Shares formula, which analyses the unique circumstances practices face and the health and wellbeing
of local populations.

Commissioners have aired frustration about the amount of ‘red tape’ they face when trying to organise new local health services. NHS Clinical Commissioners, who represent CCGs across the country, say bureaucracy is hindering doctors in their attempts to redesign new services. Dr Charles Alessi, Chair of the National Association of Primary Care, said there was an “overwhelming number of rules and regulations” which were having a significant impact on commissioners.

Supporting units
But it seems the frustration many commissioners have aired at the slow rate at which CSUs are being established may soon be coming to an end. David Stout has left the NHS Confederation to lead CSUs in Essex and Hertfordshire; Tim Andrews has also been given joint responsibilities at Cheshire, Warrington and Wirral CSU and at Merseyside CSU; Derek Kitchen will lead Staffordshire CSU and Lancashire CSU. Dr Leigh Griffin has also been appointed as the MD of Greater Manchester CSU – meaning only two of the 23 CSUs are still awaiting a permanent managing director.

While the NHS Commissioning Board is readily completing the authorisation process for CSUs it has recently been distanced from employing their support staff. The NHS Business Services Authority has agreed to employ some 8,000 staff during the hosting period up to 2016. The move means that although the NHS
CB will provide oversight and direction to CSUs it will not be the legal employer of CSU employees to avoid conflicts of interest. The new distancing arrangements were welcomed by the Board, who said it would help CSUs “develop appropriately as organisations in their own right.”

After confirming four lead CSUs to provide communications and engagement services around the country last month, the Commissioning Board will now focus on assisting support units to provide services and help to CCGs through the authorisation process, to ensure they are as individually autonomous as possible, to
help CSUs develop to become specialist suppliers and to ensure units seize opportunities open to them.

As the NHS reforms continue to evolve it would seem the commissioning landscape is far from being complete. It’s going to be a busy few months.

The controversial NHS reforms are expected to cost £300m more than was previously expected, Health Secretary Jeremy Hunt has said.

The fallout from the Health and Social Care Act is now believed to have cost in the region of between £1.5 billion and £1.6 billion. Originally, the reforms were estimated to total between £1.2bn and £1.3bn.

Ironically, the increase comes at a time when the NHS is tasked with making £20bn of efficiency savings.

Health Secretary Jeremy Hunt revealed the additional £300m reform costs in a written statement to the House of Commons.

The Act, which was passed through Parliament in March this year, has been formally opposed by a number of high profile organisations, unions, charities and royal colleges who argued it will increase privatisation within the health service and lower standards of care for patients.

The Government’s controversial Health and Social Care reforms have left the NHS and doctors across England in distress, Dr Clare Gerada has claimed.

The chair of the Royal College of GPs again voiced concerns about the introduction of the Health Act and the consequences of the reforms for the NHS and healthcare professionals.

Speaking at a conference in Glasgow, Dr Gerada claimed the NHS is experiencing the “mother of all top-down reorganisations” – which were the most “radical” in its 60 year history.

Dr Gerada said that as a result of the reforms the health service and GPs had been left “in distress” after the Act was “rushed through at breakneck speed.”

“We GPs will always make the system work for our patients,” she said. “But we will never compromise the founding values of our NHS. And each of us must continue to play our part in raising concerns wherever we see inequalities and unfairness in our health system.

“We’ll show courage, just as our forefathers did as they rose to the extraordinary challenges posed by post-war austerity and the uncertainties of the new NHS.”

“Yet despite her opposition to the Health Act, Dr Gerada called upon doctors to embrace our future with optimism and confidence.” A statement echoed by the Department of Health.

“Local doctors are the right people to lead the NHS,” said a spokesperson. “They will make this system work and make sure the NHS is locally led. They know what their local health and care issues are and will ensure patients are treated as individuals – with dignity and respect – improving services and the quality of care.”

JSNAs have suddenly been thrust into the limelight. But why are they so important?

Key account managers and other commercial team members in pharmaceutical companies should already be well aware of joint strategic needs assessments (JSNA). JSNAs were initially introduced in 2008. Since then local authorities and Primary Care Trusts have been under a statutory duty to produce assessments to outline operational plans for health services to meet the needs of the local population.

However, since the introduction of the Health and Social Care Act the importance of JSNAs has increased tenfold, with them being recognised as a key driver of improvement. JSNAs are now a fundamental part of the planning and commissioning cycle at a local level. Under the reformed health system there is a greater emphasis placed on the process and outputs of JSNAs than had previously been attributed – and there is a clear expectation regarding their influence on commissioning plans.

From April 2013 onwards, local authorities and clinical commissioning groups (CCGs) will have an equal and explicit obligation to devise the needs assessment document.

Local leaders and commissioners will be tasked with identifying the health needs and requirements of the local population and addressing these either through the services they commission, through the introduction of new initiatives, or through joint working and collective action with local providers. In doing so, local authorities and CCGs will be able to plan and commission services in an integrated fashion to allow health and care services to efficiently and effectively meet the needs of all members of the community.

In turn, JSNAs will be used by regional health and wellbeing boards to understand and take action to tackle local challenges. The assessments will also play a fundamental role and heavily shape the design of joint health and wellbeing strategies to set and measure outcomes; and also align these with local priorities established in the NHS Outcomes Framework – plus similar public health and adult social care frameworks.

‘Picture of a place’
Assessments must consider all of the current and future health and social care needs in relation to the area a local authority and CCG are responsible for. It must include requirements which report authors believe are achievable and which can be affected to a significant extent by the actions of the local authority, CCG or NHS Commissioning Board.

The Health Act has a clear expectation that JSNAs – and the strategies which are created as a result – will provide the basis for all local health and social care commissioning. JSNAs are a treasure map for pharmaceutical companies and their Key Account Managers. The documents, which must be published, provide a framework to examine factors that impact on the health and wellbeing of communities. Although these range from employment and education to housing and environmental factors, it is the overall impact of these on the physical and mental wellbeing of local residents that pharma should be targeting.

The DH says that JSNAs need to “articulate and address the unique ‘picture of a place’ in every region. In doing so, these valuable documents inform not only local commissioners, but their partners in delivering health services to provide a framework of objectives.

PCTs and local authorities have used JSNAs to establish the current and future health and social care needs of residents. Within the assessments there needs to be a focus over the short and medium term on taking into account anticipated changes in the demographic and infrastructure.

Captured data, information and intelligence underpin JSNAs. This evidence will also be published, giving pharma an insight into local priorities in areas where they can influence and target. But the assessments are far more than just a collection of evidence. They provide an analysis and narrative on the background of the region they cover. They process extracts while analysing evidence and allowing Health and Wellbeing Boards to develop a plan on the basis of these, using data to drive strategy and commissioning. They are a must read for a KAM to gain invaluable background information on local trends and targets.

JSNAs do not have to be completed on an annual basis. In fact, it is only in recent months that a number of PCTs have updated their initial JSNA. However, the DH states that assessments should build on and align with similar needs assessments in local areas to avoid duplication and to develop a “comprehensive local assessment” to inform integrated services. The aim for local authorities and commissioners is to create a single, consistent story on any given issue and to remove duplication whilst contributing across the local system.

‘Putting localism in action’
In the 2011 DH document Joint Strategic Needs Assessment and join health and wellbeing strategies explained – commissioning for populations Paul Burstow, then the Minister for Care Services, highlighted the importance of JSNAs and resulting strategies, saying they are “key to putting localism into action.”

In the foreword of the document he commented: “The strengthened role of JSNAs and joint health and wellbeing strategies will enable the local health and care system to go further than ever before. For the first time, decisions about health and care will be made on the basis of clinical expertise, evidence from the JSNA, and the valuable input of locally elected councillors and the public, via local HealthWatch and wider engagement with the community. This means decisions about action, investment and disinvestment can be genuinely local, rather than a reflection of national priorities.”

Burstow added that he was “clear” the assessments will not have a “galvanising effect on their own”. But when in combination with health and wellbeing strategies and aligned commissioning plans JSNAs have the “potential to be transformational in improving health, care, and wider services for people in our communities.”

The NHS Confederation agreed about the importance of JSNAs but warned about the quality of these assessments. It pointed out that a “good quality” assessment has the “potential to drive improvements, highlight health inequalities and closely inform commissioning.” But a “weak” JSNA is “disconnected from key decision-makers and commissioning and, therefore, removed from local communities.”

“Relatively few have been balanced by an assessment of the assets, strengths and capacities of local communities, which is clearly more desirable,” the Confederation said. “We believe that JSNAs have not yet reached their full potential for commissioning in local authority areas. The reform proposals provide a welcome opportunity to extend JSNAs to include health and voluntary partners.

“If the JSNA remains focused on health services, public health and social care alone, it may require fewer resources but will provide a limited analysis of the needs and assets of the community and may not engage or inform key partners, which is surely one of the key benefits.”

Exploiting JSNAs
JSNAs are and will be a valuable tool for pharmaceutical companies to identify the local health and wellbeing needs of specific regions across England. Although these documents contain important information on how pharma can drive improvements through system redesigns, pharma still needs to devise innovative care pathways to drive outcomes which will be financially attractive to commissioners.

A quick search of the internet reveals that no two JSNAs look the same – some are 14 pages long, others 114. The DH sees JSNAs as a means to outcomes “not just within single years, but over time.” Key Account Managers, using joint strategic needs assessments and the data available to them, must ensure they have an in-depth insight into the local challenges commissioners face and provide solutions now and in the future to create lasting relationships.

NHS rationing is affecting the relationship between doctors and their patients, a new survey has found.

The survey by Pulse Magazine revealed that three quarters of GPs believe the doctor-patient relationship has been tainted by cut backs to certain treatments.

Dr Clare Gerada, Royal College of General Practitioners, said the problems of the Health and Social Care Act have resulted in patients holding GPs responsible.

Typical treatments which have been affected by a rationing include GP referrals for bariatric, hip and knee and cataract surgery.

Out of the 237 doctors questioned, nine out of 10 reported pressure to ration treatments or services over the past twelve months. Two-thirds of respondents admitted local rationing was adversely affecting standards of patient care.

More than 40% of doctors said they had changed the therapy of patients to less effective options due to rationing guidelines in the past twelve months. A third also raised issues with getting patients to guideline-directed targets.

GPs also exposed other forms of rationing with 89% finding patients had been referred back to them after missed hospital appointments and 31% claimed hospitals were overemphasising the risks of surgery in an attempt to off put individuals.

A spokesperson for the Department of Health said they would be writing to the NHS to remind them that rationing on the grounds of cost was wrong.

A leading trade unionist has claimed there are just six months left to prevent the NHS from ending as we know it.

The TUC’s John Lister, Director of Health Emergency, insisted efforts to resist the controversial Health and Social Care Act must be increased before it is too late.

Mr Lister said an “urgent clarion call” is needed to “resist the privatisation, cuts, closures and wage reductions”.

He said that the Act aims to “fragment the NHS, marketise it, commercialise it and privatise the services that offer profits, while leaving the rest as an underfunded, understaffed shambles.”

Despite being at the heart of the health reforms, Mr Lister claims that GPs “will be in the hot seat for future cutbacks.” “In reality all of these plans are cash-driven, cynical efforts to meet Lansley’s £20bn target for ‘efficiency savings’,” he said.

The activist has now called for a “firm rejection of the Act” by union members, increased publicity to raise “public alarm” over the proposed reforms and a planned demonstration as a “landmark” to “highlight the lethal threat the coalition poses to the health service.”

“We need to get people aware, angry, campaigning and reclaiming our NHS before the private sector reclaims the bits they have wanted since 1948 and dumps the rest into permanent crisis,” he said.

Commenting on the appointment of the new Health Secretary Jeremy Hunt, Mr Lister added that Andrew Lansley’s replacement has “all of the neoliberal politics” of his predecessor but “none of his declared attachment to the NHS”.

“He has made none of Lansley’s conciliatory gestures and promises to GPs during the progress of the Bill through Parliament and will no doubt find all of its worst proposals most congenial,” he said.

“His appointment as part of a rightward lurch by Cameron seems likely to result in accelerating the implementation of the Bill, while no doubt briefly diverting the energies of the British Medical Association and others who will feel obliged to give him the benefit of the doubt for a few weeks, wasting a bit more time before recognising the need to crank up the fight.”

Health Secretary Andrew Lansley has been replaced by Culture Secretary Jeremy Hunt as part of David Cameron’s cabinet reshuffle.

Mr Lansley has been demoted to the role of Leader of the House after serving as Secretary of State for Health for two controversial years.

Mr Hunt said the new role was the “biggest privilege of his life” and that he was looking forward to starting work within his new department.

Lansley’s controversial reign will be remembered for the introduction of the Health and Social Care Act – which abolished Strategic Health Authorities and Primary Care Trusts in favour of GP-led clinical commissioning.

The move – which was which contested by a host of national organisations representing healthcare professionals – resulted in thousands of NHS workers losing their jobs during an era of austerity within the health service.

Dr Kaliash Chand, who was recently elected as BMA Deputy Chairman, welcomed Mr Lansley’s removal and hoped his replacement would end the marketisation of the NHS.

He commented: “He has done an utterly miserable job. Especially considering he was shadow health secretary for six years. He was unable to explain what he wanted to achieve. He was not a good communicator. In my view he has not been a very good health secretary. He epitomised everything that has gone wrong in the last two years in the NHS.”

Stephen Whitehead, ABPI Chief Executive, “welcomed” Mr Hunt to the new role and thanked the outgoing Andrew Lansley for his efforts over the last two years. “The NHS is highly regarded both here in the UK and around the world and Jeremy Hunt will face a number of challenges in not only safeguarding its short term success, but its long term future.”

Mr Whitehead said that one of the first challenges the new health secretary faces is getting the latest medicines to patients. He added that the pharmaceutical industry will continue to work closely with the DH to “design a pricing system” that provides value for money for taxpayers whilst “ensuring a healthy and productive environment for companies to research and develop the medicines of the future.”  

Mr Hunt, the MP for South West Surrey and the former Secretary of State for Culture, Olympics, Media and Sport, faced widespread criticism earlier this year when he urged David Cameron to support Rupert Murdoch’s bid for BSkyB – a month before he was due to decide whether the bid should be allowed.

CCGs are the core of the new NHS – but are they running the game?

The emerging clinical commissioning groups (CCGs) embody a core principle of the new NHS: that commissioning decisions should be made locally, by clinicians, and be focused on community-based care. According to Andrew Lansley, the defining feature of the NHS reform is a “shift of power” from national and regional organisations to local ones, of which the CCGs are the most important.

The role of CCGs in the new NHS is both structural and dynamic. They will commission healthcare at a local level, spending £60 billion of the £80 billion NHS commissioning budget, and will hold together the relationship between patients and providers. They will also work with providers and business partners to redesign local services, and those new solutions will spread through the NHS. The CCGs will thus be the drivers of healthcare innovation.

However, given that GPs are meant to lead the CCGs, the concerns raised by many GPs about the new system are significant. Will CCGs really have the opportunity to improve care, or will they simply have to drive through spending cuts? Will they really be run by clinicians or by the private sector? Is the heart of the new NHS dynamic and responsive, or divided and unstable?

Development of CCGs

In July 2010, the white paper Equity and Excellence: Liberating the NHS spoke of “putting GP commissioning on a statutory basis” through the development of ‘GP consortia’. These new organisations, to which every GP practice would belong, would run each local health economy: they would contract providers, partner with local authorities, and be accountable to patients and the public for outcomes. They would be authorised by a new national body, the NHS Commissioning Board, which would also commission GP services.

The initial reaction of the GP community was positive. Being in the driving seat of a fast-evolving NHS, able to redesign local services for their patients, appealed strongly. However, the codification of the reforms in the Health and Social Care Bill led to growing opposition among GPs. Issues raised included the power of the Board to direct GP consortia and the requirement that consortia embrace provider competition. Above all, the deepening economic crisis made GPs fear their role would be one of rationing services, not finding solutions.

The Government’s ‘listening exercise’ did not resolve the concerns about competition and rationing, but it led to a stronger assertion of the autonomy of the consortia. An important change concerned the scope of clinical representation: the new ‘clinical commissioning groups’ were defined as including specialist consultants and nurses as well as GPs. That was a step towards the ‘integrated care’ that the BMA had highlighted as a priority.

Breaking the waves

The NHS Commissioning Board Authority, set up in October 2011, has the primary responsibility of putting in place a nationwide system of CCGs to replace the PCTs by April 2013. A total of 212 CCGs have been approved to go through the authorisation process in four waves: 35 in wave 1 (commencing in June 2012), 70 in wave 2 (July), 67 in wave 3 (September) and 40 in wave 4 (October).

The authorisation process is designed, according to the Board, to ensure that CCGs have a “strong clinical and multi-professional focus”; have meaningful patient engagement; have credible plans to “deliver the QIPP challenge”; have proper governance arrangements; are set up to collaborate with other CCGs, local authorities and the Board; and have strong leadership.

It has not always been a smooth road, however. The Board, concerned at the prospect of CCGs competing for providers of commissioning support, announced it would take over the appointment of leaders to Commissioning Support Services. One CCG has already protested that its authorisation has been delayed by this.

Another issue is lack of GP leadership. Clare Gerada, chair of the Royal College of GPs, said that only “about 25 GPs” in England were actively interested in leading local commissioning. The reason, she said, was that the “transactional” aspects of commissioning as a business did not appeal to them. 

GP-led commissioning

CCGs will be responsible for commissioning community health services (including mental health care and services for children and elderly people) and hospital care (both A&E and elective care). The NHSCB will be responsible for commissioning primary care as well as pharmaceutical and dental services. Local authorities will be responsible for public health, with the NHSCB covering certain aspects.

Collaborative working between CCGs and the other statutory organisations involved in healthcare is anticipated, but the model is not one of top-down control – rather, it is one of business partnership. The NHSCB can provide assistance or support to CCG commissioning; this may take the form of extra funding or access to staff and other resources. CCGs have a duty to co-operate with local authorities in supporting aspects of public health, including child health and mental health.

CCGs are able to buy in support from external organisations, including the CSUs whose development is currently being governed by the NHSCB. For more details on the CSU landscape. CCGs can also buy in support from the private and voluntary sectors, but will retain control of commissioning decisions. These relationships will differentiate CCGs, as some are keener than others to engage in private sector partnerships.

Commissioning of hospital services is also likely to differentiate CCGs, especially as many hospital trusts are facing financial challenges as they shift to foundation trust status. CCGs will influence the development of FTs through their commissioning strategies – for example, they may promote private providers both within and beyond FT-provided services. The acute sector will have a voice in CCGs, though its representatives on a CCG board cannot come from the local area.

The GP-led nature of CCGs is variable. Fewer than 50% of current CCG board members are GPs, and there is potential for the management of local commissioning to be outsourced. CCG boards should include a non-practice nurse and a specialist consultant, but local government are excluded.

Life after April 2013

Securing GP ‘buy-in’ remains an issue for the NHS reforms, but those GPs who support the reforms have been most active in developing CCGs. The CCG boards thus represent a more pro-market segment of the GP profession. Pharma companies may find that their CCG customers and GP customers require a nuanced and varied approach.

Each CCG will have a different mix of GPs, hospital clinicians and financial or management specialists. It will also be dealing with local health issues, which are also impacting on local government and the local Healthwatch body. Every CCG will have to find its own balance between clinical outcomes and economic success.

CCGs will also face a tension between the ‘autonomy’ stressed by the NHSCB and the need for partnership with other stakeholders, within and outside the NHS. Will this tension lead to fragmentation and paralysis, or to dynamic innovation driven by the local synergy of clinical and commercial talent? Whatever the answer, the CCGs hold the key to the success or failure of the new NHS.

The switch to GP-led commissioning is already proving to be a success, according to the Conservative MP Chris Skidmore.

The Kingswood MP – who also sits on the Health Select Committee – said that results from new schemes introduced by CCGs across the county were encouraging.

Writing in a blog on the Conservative Home website he admitted that the Health and Social Care Act was one of the “most controversial pieces of legislation” to pass through this Parliament.

But he insists that despite the structural reforms the NHS “remains alive and well”, and Andrew Lansley’s plans to localise decision making are improving health services.

Mr Skidmore pointed to three examples where CCGs have used new powers to introduce local health improvements. These include NHS Nene CCG where nurses have been trained to provide minor injuries care to keep patients out of secondary care; NHS Corby CCG where referrals were cut by 25% and saving £300,000; and at NHS South Devon and Torbay CCG where blood tests are taken locally instead of in outpatient centres.

“As Conservatives, we have always been there for the NHS,” he said. “But we are also prepared to take bold decisions in order to deliver the best service possible, maximising its productivity and reducing waste. In the teeth of the vested interests of those who would preserve the status quo, enacting change can be uncomfortable. But we must argue our case, continuing to press home that the changes we make will benefit every patient. We know that for their sake, reform is not an option but a necessity.”

What priorities does Andrew Lansley’s draft mandate for the NHS Commissioning Board reveal?

The draft mandate for the NHS Commissioning Board (NHSCB), published on 5 July 2012, is a manifesto for the new NHS: the first clear public statement of the anticipated course of NHS reform since the Health and Social Care Act became law. It offers a snapshot of the emerging structure for local commissioning, and highlights the Government’s key priorities for an NHS reform that is now a reality.

Introducing Our NHS Care Objectives: A Draft Mandate to the NHS Commissioning Board to Parliament, Health Secretary Andrew Lansley said: “Today we will be laying the foundations of the new, more independent NHS.” By this, he explained, he meant an NHS “free from constant political interference” and “tasked with continuously improving the care that patients receive”.

Transfer of powers
A key background document to the draft mandate is Lansley’s letter to the new Chair of the NHS Commissioning Board Authority, Malcolm Grant, in April. The letter stated his primary objective as being
“to design the Board so it transfers power to local organisations”. Other priorities included integrating health and social care and promoting patient choice.

Another important background document is the NHS Outcomes Framework, published in December 2010 and updated a year later. This defines the patient outcomes the NHS has to work towards – a counterpart to the business processes defined by the reform agenda.

The draft mandate has been issued for consultation. The final NHSCB mandate will be published in October and will guide the Board when it assumes its full statutory authority in April 2013.

Improving healthcare outcomes
The draft mandate begins by setting the context: the NHS is facing “one of the tightest funding settlements in its history”, while elderly care, long-term conditions and mental health are growing priorities. It outlines 22 objectives for the NHSCB for the two years from April 2013, as well as ‘ambitions’ for the coming decade.

The first major section lists 11 objectives for improving outcomes. The first six relate to the NHS Outcomes Framework – one for each of the five domains and one for the whole – setting concrete targets in QALY and similar terms, but leaving the actual numbers to the final version.

While there are no objectives for specific conditions, this section refers to dementia and mental illness and notes the need for better integration of general healthcare with treatment of these conditions. The NHS should work towards treating mental health as “on a par with physical health,” it states. There are objectives for reducing health inequalities, including life expectancy at birth. However, the reference to “greater improvement in more disadvantaged communities” should be seen in the context of the planned shift of public health funding from the NHS to local government. Finally, there are objectives relating to service performance standards and support for patient self-care.

Patient choice and local control
While the first 11 outcomes are related to the agenda for NHS improvement defined by Lord Darzi in 2008, the last 11 belong wholly to the new reform agenda. One crucial objective relates to patient choice. The Board must ensure that people are “involved in decisions about their care and treatment”; that personal health budgets are available “to anyone who might benefit”; and that a patient who has waited 18 weeks for treatment is entitled to choose another provider.

The Board is required to develop integrated care through joint commissioning and other methods, particularly for “people with dementia or other complex long-term needs”. It should also improve the quality of NHS information, using IT to make the NHS “transparent” to patients and carers.

The Government’s innovation agenda is highlighted by an objective requiring the Board to “promote access to clinically appropriate drugs and technologies recommended by NICE”, as well as supporting the participation of NHS clinicians and patients in life science research.

The section on commissioning states that the Board should fully authorise “as many CCGs as are willing and able” by April 2013, and allow the CCGs “full control over where they source their commissioning support”. The new clinical senates and networks will provide advice, with CCGs “free to make their own arrangements”.

The Board must have a “transparent, principle-based system” for managing “poor performance” or “financial risk” by CCGs. It must “support a fair playing field between providers” and “ensure that financial incentives for commissioners and providers support better outcomes and value for money”. The latter objective includes the controversial Quality Premium, a bonus payment rewarding CCGs who achieve a surplus on their annual budget. This will be funded from within “the overall administration costs” available to CCGs.

Crucially for industry, there is an objective to support “changes in services that lead to improved outcomes for patients”. These must meet four criteria: support from clinical commissioners; strong patient engagement; a clear clinical evidence base; and consistency with patient choice.

On the critical issue of cost savings, the mandate says only that the Board must ensure that QIPP savings are made “in a sustainable manner” as dictated by the Treasury, but without reducing service quality.

Between the lines
Responses to the draft mandate have focused on its open-ended nature. Mike Farrar, Chief Executive of the NHS Confederation, commented: “Unlike documents that have gone before it, the mandate does not seek to develop an ever-growing ‘wish list’ of objectives. It rightly encourages commissioners to exercise their knowledge of the needs of their local communities to plan and deliver the best care.”

Shadow Health Secretary Andy Burnham argued that Lansley had missed an important opportunity to highlight the issue of healthcare rationing – which the Health Secretary had recently stated to be
“unacceptable”. The delegation of control to local commissioners, Burnham argued, was “a mandate for privatisation.”

Dr Richard Vautrey, Deputy Chairman of the BMA’s GP Committee, praised the mandate for not placing too many restrictions on GP-led commissioning. However, he was strongly critical of the Quality Premium, which he claimed would encourage rationing and increase health inequalities.

Whatever the consultation period delivers, the draft mandate for the NHSCB is a clear statement of the NHS reform agenda: to deliver improved patient outcomes through CCG autonomy and provider competition.