Health and wellbeing boards (HWBs) across the country will have to work closely with local providers of health and care services if they are to be successful, a new report warns.

The NHS Confederation’s report argues that the new responsibilities of the boards, such as creating joint strategic needs assessments and health and wellbeing strategies, can only be met effectively with the help of local assistance.

Jo Webber, Interim Director of Policy at the NHS Confederation, said HWBs would need to take a flexible approach to working with local providers if they are to successfully tackle regional priorities.

The report, Stronger together: how health and wellbeing boards can work effectively with local providers, outlines how local providers must be engaged with to build and establish strong links for service users.

“Over the past year (with funding from the Department of Health) we’ve produced a toolbox of resources to support newly-established health and wellbeing boards,” said Jo Webber. “With this latest publication, all the learning and advice from those with direct experience of engaging with health service providers – from big acute trusts, community service providers, and voluntary sector organisations – is being shared throughout the system, so the new boards can make use of the best tools for their local needs.”

The report was developed as part of the National Learning Network for health and wellbeing boards, which was funded by the DH and supported by the NHS Confed, the Local Government Association and the NHS Institute for Innovation and Improvement with the aim to share the learning and support of well-functioning HWBs.

The NHS Confederation has appointed Michael O’Higgins as its new chair.

Mr O’Higgins replaces Sir Keith Pearson who departed in June 2012 to take up a similar position with Health Education England.

The new chair said he has “long admired the work of the NHS Confederation” and is “excited about making the most of this position to speak on behalf of the NHS.”

He joins the Confederation with immediate effect after leaving as chair of The Pensions Regulatory. Mr O’Higgins has previously held similar high-profile roles at the Audit Commission and the Treasury Group Audit Committee.

Mike Farrar, NHS Confed Chief Executive, said the new recruit is a highly respected figure following his work within the NHS and local government. “His extensive knowledge of the health and social care sector means that he will be invaluable in developing our relationships right across the wider care sector.”

The NHS needs to involve the general public in making important decisions when managing their care and encourage greater interaction in their health and wellbeing, the NHS Confederation has said.

Mike Farrar, Chief Executive of the Confederation, said the NHS needs to go further to meet statements in its constitution to combat future challenges.

Farrar, writing in an editorial in The Guardian, said “NHS organisations need to do more to involve patients and the public” in how services are run.

The NHS Confed leader referred to the statement in the NHS Constitution that: the NHS belongs to the people.

But he admitted that the “daily reality for patients and the public” is somewhat different – and highlighted poor clinical practice and senior NHS leaders ignoring public opinion when making difficult decisions.

He said: “Take all this into account and you sense the NHS is a ‘public service’ with a long way to go.” Farrar added that the solution must change rapidly if the “NHS is to survive its next decade of challenges.”

Farrar pointed towards greater patient engagement in the future to obtain “faster and more sustainable results.” He said this was “business critical” if the NHS is to provide better standards of care and outcomes “for less money as healthcare demands grow”.

“There is no doubt that healthcare issues are complex,” he said. “But NHS managers and doctors do themselves no favours by their attitude of ‘arms around their work, no peeking’. We have to change.

“There is a huge need for more transparency, honesty and openness about why we need to modernise health services. There is an even bigger need for revealing to the public information about the economics, finances, and costs of health and social care.”

The £2bn gap in long-term social care funding will have a detrimental effect on NHS services, a new report by the NHS Confederation has predicted.

The report, Papering over the cracks, suggests that a failure to resolve the funding issue will have a severe impact on patients as more people require services.

Jo Webber, NHS Confederation Deputy Director of Policy, said the NHS “cannot keep on picking up the pieces of a broken social care system.”

The NHS Confed has now called for a cross-party political consensus to address the immediate cash surplus and find a long-term funding solution.

If a solution is not found, the Confederation warns that even basic social care services which are currently provided may not be available in the future.

The report advises that the health and social care system must respond to the needs of a population where people are living longer with long-term conditions. It found that more people are accessing NHS services due to cuts in social care, and that funds allocated to transform services have been used to ‘paper over the cracks’ in the social care system.

At a time when the NHS is being asked to find £5bn of efficiency savings, the report adds that it is not sustainable for the health service to continue covering the social care funding gap.

“The NHS and our local authority colleagues need to look at how we can radically redesign care and be more innovative in the way we integrate services for people with care needs,” said Jo Webber.

“We cannot solve this problem on our own. Increased funding is a key part of this solution. Without the involvement of the Treasury, including a clear outline of how we will address long-term social care funding in the next Spending Review, we will see a decline in services and greater pressure building on the NHS.”

The NHS Confederation backed the short term transfer of NHS funds to support local social care services. But it added that a continued policy of “robbing Peter to pay Paul would be very short sighted.”

Various rules and regulations introduced as part of the redesign of the NHS are undermining CCGs’ abilities to commission new services, clinicians have warned.

NHS Clinical Commissioners, who represents CCGs across England, insist bureaucracy is hindering GPs in their attempts to redesign new health services as part of the reforms.

Dr Charles Alessi said there was an “overwhelming number of rules and regulations being produced at speed, which will have significant impact on commissioners.”

The organisation has now urged the Government to provide CCGs with the “time, space and support necessary” to make decisions about how to deliver the best outcomes for patients.

“Just at the time when CCGs are having to focus on their own authorisation, there are important commitments being made that potentially affect their ability to plan care in line with the local priorities they have identified,” said Dr Alessi.

Mike Farrar, NHS Confederation Chief Executive and member of the NHS Clinical Commissioners steering group, said commissioners should “not feel pushed to make speedy decisions”.

The body is now working with CCGs on how to resolve these issues and will publish its findings later in the year.

Mike Farrar, NHS Confederation Chief Executive, has warned the new Health Secretary Jeremy Hunt not to overlook the main challenges the NHS faces in the future.

Andrew Lansley’s replacement is tasked with continuing the transition of the health service conjured up by his predecessor.

While the NHS Confed leader realises the importance of the reforms, he advised Mr Hunt to keep an “eye on the long-term issues the NHS is facing”.

An ageing population and growing rates of obesity, plus the rising number of diabetes cases, could put the health service at breaking point in coming years.

Farrar said it is these challenges which Mr Hunt needs to pay attention to. “He is taking on a critical brief at a critical time,” he said.

‘Top of Mr Hunt’s in-tray will be making sure the NHS is financially sustainable for the future and fit to respond to the needs of our changing population. Driving change in these areas will be the big test of the success of this Government.”

The former SHA head thanked the departing Andrew Lansley for his “commitment to the NHS” during his time in office and in shadow government. “He has held his brief in health for almost a decade and that is something that not many other politicians can say they have done,” he said.

David Stout, the deputy chief executive of the NHS Confederation, has been appointed as Managing Director for separate Commissioning Support Units covering Hertfordshire and Essex.

Mr Stout, who joined the confederation in 2007 as the first director of its Primary Care Trust Network, will begin his new responsibilities on 1 October 2012.

Mike Farrar, Chief Executive, NHS Confederation, said his deputy had made a “real contribution to the NHS as a whole”.

Commenting on his departure, Mr Stout said it will be a “big wrench” to leave but “it’s time to take on new challenges”. “I have really enjoyed my time at the NHS Confederation,” he said. “It has been a great privilege to represent both primary care trusts and the wider NHS on the national stage.

“I am really excited to have been given the chance to lead the two CSUs in Essex and Hertfordshire. I am sure we can make a huge contribution in the new reformed NHS.”

The CSU in Essex will cover a population of around 1.8 million people. In Hertfordshire, around 1.2 million people will be served by the CSU. The support units will be hosted by the NHS Commissioning Board until 2016 and assist CCGs in functions such as service redesign, procurement and risk stratification.

New organisations formed as a result of the NHS reforms may cause conflicting policies and bundles of red-tape for the health service, Mike Farrar, NHS Confederation CEO, has warned.

Mr Farrar said the reforms would lead to several new bodies interfering with the day to day operation of the health service and result in a “tsunami of new bureaucracy”.

He added that new organisations will need to “minimise the burdens their policies place” on the NHS in order for it to “stay focused on patient care” and not on “repeatedly providing information in different formats to multiple bodies.”

Writing in an editorial for the Health Service Journal, the NHS Confed chief executive was responding to a survey of NHS chairs and CEOs. The survey found widespread concerns by NHS leaders as a result of the reforms.

Managers warned that widespread structural changes will result in a lack of senior experience and that savings targets are causing serious financial pressures.

Mr Farrar argued that the reforms are not a magic wand to improve performance and that expectations must be realistic. “Performance in many parts of the system will be patchy at first,” he said.

“Those leading the change need to be open-minded and flexible to improve policy and practice as we go. We are losing many experienced leaders.

“We need to ensure that as new ones emerge, taking on these challenges, they are given the support and cover they need to succeed, even if that means tolerating some difficulty along the way.”

The former SHA leader added that for new organisations to be successful they must listen to NHS leaders and focus on “critical overarching concerns that will matter most in the end”.

“It’s essential that national bodies ensure they are driving towards the same goals, not subjecting the NHS to a myriad of conflicting policies,” he said. “Otherwise the NHS will be pulled in different directions and unable to make progress.”

Health Minister Simon Burns insists the reforms remove layers of administration and will actually result in less bureaucracy for the NHS. “Our reforms mean that doctors and nurses will be in charge of the NHS, not managers,” he said. “It makes sense for the people that know their patients best, doctors and nurses, to take responsibility for driving up standards in their local NHS, free from bureaucratic interference.

“Careful work is underway now to ensure that new NHS bodies are prepared, but this is not affecting patient care. Waiting times are low, infection rates are down and patient satisfaction remains high.”

The NHS Confederation has called for greater levels of transparency in order to stop patients taking cash-strapped trusts to court over prescribing decisions.

David Stout, NHS Confed Chief Executive, said trusts need to be honest about the financial challenges they are facing to help patients understand why certain treatments approved by NICE are not prescribed.

He was responding to comments made by NICE chair Sir Michael Rawlins who claimed that patients should take trusts to court if they were being denied recommended medicines.

Mr Stout agreed that trusts should be providing treatments to patients they are “legally entitled to”. But he added that “every NHS organisation has a finite amount of money available” and that funding for new treatments means “fewer resources for other treatments”.

“NHS organisations are faced with the difficult challenge of achieving the best outcomes and highest quality care for patients while balancing their budgets,” he said.

“The issue raised by Sir Michael Rawlins leads us on to the wider debate that we need to have about the fact that the NHS is facing an unprecedented financial challenge. All NHS organisations are facing budgetary pressures while striving to maintain high quality care.

“We need to be open and honest with the public about what the consequences of this financial challenge are, and the fact that trade-offs will be required if we are to improve standards of care while keeping the NHS affordable.”

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.