The NHS Commissioning Board has launched a new national operating model to commission specialist services in a bid to drive standards of care.

A national approach will deliver consistent, high quality services which will provide patients with the same standards of care provided throughout the NHS.

Ian Dalton, Chief Operating Officer and Deputy Chief Executive at the NHS Commissioning Board, said the new model is a “real opportunity to dramatically improve the way we provide services for people with rare and specialised conditions.”

Specialised services account for around a tenth of the NHS budget. The number of patients who require such services is small and facilities are located across the majority of towns and cities across England.

The NHS CB hopes the new model will improve the experience of care patients receive and allow specialist staff to be more easily recruited and levels of necessary training maintained.

Specialised services will be delivered on behalf of the NHS CB by the ten nominated Local Area Teams around the country.

Currently, there are ten different systems for commissioning specialised services across the country. The new single approach provides commissioners with the opportunity to innovate and introduce new technologies to benefit patients and improve health outcomes.

“This improved system will ensure national consistency in accessing services, reduce variation, and set clear quality standards leading to better health outcomes for patients,” said Ian Dalton.

The Board will take on the responsibility of commissioning specialist prescribed services from 1 April 2013.

Around £3bn of NHS funding has been returned to the Treasury over the last two years, the Government has confirmed.

A spokesperson for the Treasury confirmed that the DH underspend in 2010-11 totalled £1.9bn. It also recorded an underspend of approximately £1.4bn in 2011-12.

A spokesperson for the Department of Health said the savings came as a result of “reduced inefficient spending” and reductions in “bureaucracy and IT”.

The billions returned to the Treasury come during an era of austerity for the NHS. It has been tasked with saving £20bn by 2014-15.

The £1.4bn returned last year comprised £866m revenue funds and £577m in capital funds, a Treasury spokesperson confirmed. The year before £1.2bn was returned in revenue funds and a further £700m in capital funds.

The Department of Health said that despite the billion pound returns, frontline services had actually risen by £3.4bn in 2011-12. Of the £1.4bn which DH failed to spend in the last financial year, only £316m has been carried over for it to use in 2012-13 – of which the Department claims has been used to “fund vital projects across the NHS to benefit patients.”

Is QIPP really about ‘doing more with less’?

The NHS Quality, Innovation, Productivity and Prevention (QIPP) Challenge was launched in March 2010 as a strategy to facilitate major cost savings within the NHS, in response to the impact of the global recession. The principle of QIPP was that given the need for austerity budgeting, serious planning and rethinking were needed to ensure ‘smart’ cost-cutting that did not harm patient outcomes. The QIPP agenda was about identifying solutions that held together the four key principles, reducing overall costs by making interventions more timely, efficient and effective.

The new Government’s NHS reforms promised to facilitate QIPP by empowering local providers and commissioners to develop the best solutions for their communities. However, the economic pressures on CCGs and Foundation Trusts within the new system, combined with the ‘Nicholson challenge’ of cutting £5 billion out of the NHS budget in each of four successive years, have meant that the dominant theme of QIPP at a local level is cost reduction.

The first full year of QIPP (2011–12) delivered savings of £5.8 billion against a target of $5 billion. However, reports of NHS rationing and ‘postcode prescribing’ have proliferated. QIPP was devised as a strategy to combine two goals: the shift towards community-based healthcare and the urgent drive towards NHS cost-cutting. Is that still the agenda, or have the pressures of NHS reform reduced its four principles to one: reducing expenditure? Is QIPP really about “doing more with less”, as Andrew Lansley claimed, or is it just about doing with less?

A new healthcare paradigm
The DH booklet introducing the QIPP challenge in March 2010 set the context: “The NHS needs to identify £15–20 billion of efficiency savings by the end of 2013/14 that can be reinvested in the service to continue to deliver year on year quality improvements.” The booklet placed emphasis on improving quality while reducing overall costs through strategies such as early intervention, improved infection control and home-based care. Its authors included Jim Easton, then National Director for Improvement and Efficiency. The DH described a series of QIPP ‘workstreams’ it was setting up to help clinical teams and NHS organisations “improve quality and productivity across care pathways”. The first of these related to care of long-term conditions, urgent care and end-of-life care. Further workstreams would examine safety challenges, such as pressure ulcers (bedsores), and ‘right care’ issues such as referral management and identifying “low-value treatments” (later to become controversial issues).

The authors called for “a collective response at local, regional and national level” to address the QIPP priorities. These included early diagnosis, primary and secondary prevention and patient self-management. The need for “better partnerships between primary, community and secondary care to support people with long-term conditions” was emphasised. QIPP extended from the “daily clinical practice” of individual HCPs to “the wider care pathway”, the booklet said. Each SHA had its own QIPP lead and innovation lead, and was establishing an online regional ‘quality observatory’ and Innovation Fund to help clinical teams improve quality and productivity.

These ideas were illustrated by case studies where local NHS organisations had developed better and more affordable healthcare solutions. These included the use of an electronic system to ‘re-engineer’ blood transfusion, reducing waste and improving safety; and systematic guidance on antibiotic prescribing to reduce rates of C. difficile infection. These solutions all involved using teamwork and sharing information to make the best use of available resources.

The booklet ended on a warning note: “If we do not respond to this challenge there is a real risk that the need to cut costs will overtake our best intentions to improve care for our patients.” More than two years later, the crucial question is: has QIPP averted that outcome or brought it closer?

Innovation is ‘core activity’
In June 2012, Nicholson’s annual report claimed 2011/12 had been “a remarkable year” for the NHS. He highlighted the contribution of local initiatives to maintaining service quality while cutting costs. Austerity would dominate the NHS “for the foreseeable future”, he said. However, the innovation agenda promoted by the previous Government’s Office for Life Science and revived by the current Government in December 2011 would engage dynamically with that challenge: “Innovation has to... become the core activity of the NHS.”

His report went through the elements of QIPP, noting achievements in each area. Quality achievements highlighted included: in cancer care, the achievement of key treatment standards across all eight performance measures, as well as improved early detection figures; and in stroke care, better access to specialist stroke units and faster treatment of people with transient ischaemic attacks. Community-based asthma services in South East Essex were used as an example of a successful local initiative.

The brief section on innovation focused largely on the use of technologies in the community, including telehealth and home dialysis. The preventative care section emphasised the growing role of health visitors, and drew attention to the success of a national screening campaign for risk of venous thromboembolism (VTE) with prophylactic drug treatment given where needed.

In the productivity section, Nicholson noted QIPP savings of £5.8bn and praised the “modest reduction in activity levels” across the NHS – placing these in the context of the QIPP Long-term Condition Workstream, which aims to reduce unscheduled hospital admissions by 20%, reduce hospital stay length by 25%, and maximise the role of “supported care planning” in helping people to manage their own health. However, no reference was made to the rationing of procedures or the cuts in hospital nurse staffing.

Milestones or millstones?
A recent Health Service Journal report on the DH’s QIPP tracker indicates that the PCTs (soon to be abolished) plan savings worth £13bn nationwide between now and 2015, with £4.5bn of this to be achieved through the 53 local QIPP plans. The planned savings are front-loaded: £3.8bn this year and £3.6bn, £2.9bn and £2.6bn in the next three years. However, only £2bn of the planned QIPP savings are currently being achieved on schedule, and only six local QIPP plans are on track with all of their workstreams.

According to the tracker, productivity gains are the main objective of most local initiatives. Common features include the redesign of care pathways for long-term conditions, including diabetes and COPD, and the development of integrated care teams for dementia patients. However, many local plans have the single goal of reducing the cost of services – for example, South of Tyne and Wear PCT notes as an objective: “reduce price paid for Gateshead Health Foundation Trust older people’s mental health service”.

John Appleby, chief economist of the King’s Fund, commented that this emphasis on savings denied the original point of QIPP: “to improve value to patients”. He also said there was no evidence of the money saved being reinvested in future services, which was a key principle of the original QIPP agenda. The Audit Commission has since reported that the NHS has £4bn in “uncommitted finances”: cash reserves created by aggressive cost-cutting. Mike Farrar, Chief Executive of the NHS Confederation, has argued that this money needs to be invested in community and primary care.

Jim Easton, the NHS Commissioning Board’s Director of Improvement and Transformation, warned in July that too many NHS organisations were relying on spending cuts without any element of service redesign. The “deeper change” of shifting healthcare to the community was not being undertaken, he said, and
QIPP was becoming a “label” for “cost improvement plans”. As a result, the QIPP savings of the past year would be very difficult to repeat. Instead of building a new healthcare model, the NHS was just cutting
parts of the old one.

Easton has since announced that the Board will fund a new innovation body to deliver a “system-wide” response to the QIPP challenge. From April 2013, the new organisation will replace all existing NHS innovation and technology adoption bodies. He anticipates that it will “provide hands-on support for great models of care” developed within and beyond the healthcare sector. However, his resignation has cast a shadow over these plans.

According to the King’s Fund, 27 of 42 NHS finance directors it surveyed believe there is a high risk that the NHS will fail to meet the ‘Nicholson challenge’. A key question for industry, and for patients, is whether QIPP can help the NHS deliver on the more important challenge of transforming healthcare to meet the
changing needs of the population.

Health Secretary Jeremy Hunt has said it’s “not possible to make a prediction” on whether the NHS budget will remain protected.

In his first interview in his new role, Hunt said that whether Lansley’s promise to ‘ring-fence’ the NHS budget could be honoured would depend on “the eurozone”.

Hunt also said the Government was trying to decide whether there was “any way at all” of following the Dilnot recommendations on social care reform, including cheaper variations on it.

Speaking to The Spectator, a strongly Conservative journal, he said his aim as Health Secretary was to “safeguard Andrew Lansley’s legacy”.

The shift in leadership at the DH was due to a need for it to communicate how the reforms will “make a difference to patients”, he said – confirming speculation that Hunt’s more ‘personal’ presentation style was a key factor.

While he said his “instinct” was to protect the NHS budget, Hunt insisted that it could no longer be a commitment due to economic “uncertainty”.

Asked whether the Dilnot proposals might be realised from the NHS budget (as the Treasury is said to favour), he said that would be “extremely difficult”. However, he said, “other versions” of the Dilnot plan with a lower cost would be considered.

In clinical terms, Hunt stated his priorities to be: care for the elderly and those with long-term conditions, dementia care and achieving “the best cancer, heart and stroke survival rates in Europe”.

Finally, he expressed the aspiration of delivering a “measurably better” NHS that patients would recognise as such.

Sir David Nicholson has predicted “big changes” on the day the NHS Commissioning Board (NHSCB) takes over its new responsibilities.

The NHS Commissioning Board Chief Executive said Monday 1 October 2012 was a “landmark” day in the history of the NHS as the NHSCB takes full control of its budget.

Writing in The Guardian, Sir David outlined how the Board plans to split the health service’s £85m budget.

He explained how around £60m will be allocated to clinical commissioning groups to “plan and pay” for local health needs.

The remaining £25m will then be used by the Board on “community services” and on more “specialist services” for conditions that are more complex and rarer.

Sir David said that patients “won’t notice a difference” immediately as a result of the changes, but was confident “they will start to experience real improvements” soon.

The Board’s CEO outlined how it had recruited experienced healthcare professionals to “key positions” so it can make the correct decisions “made on the best clinical advice.”

However, Nicholson said the “most significant shift” in emphasis is the way “we underpin all that we do” with a single focus on “improving the quality of care for our patients”.

Nicholson added that there are “no better words” to explain the work of the NHSCB than the principles and values set out in the opening paragraph of its constitution. The four short sentences describe how the NHS “belongs to the people”, how the health service aims to support patients “mentally and physically well”, to work at the “limits of science”, and to touch the lives of individuals at “times of basic human need, when care and compassion are what matter most.”

How will Public Health England bring together the NHS and local government?

Public Health England (PHE) is the national executive agency of the new public health system, which will be driven by local government. PHE will be responsible for improving public health and reducing health inequalities through a range of local policies aimed at reducing health risks to individuals and communities.

From 1 April 2013, when PHE becomes a statutory body, public health services will shift from the NHS to local government. PHE will take £4 billion (5%) of the annual NHS budget with it, and will form an economic and organisational bridge between health and social care.

Like the NHS Commissioning Board, PHE will provide national leadership and guidance for local organisations but will not control them. According to Duncan Selbie, its Chief Executive designate, PHE will combine “a national voice with local action”. It will bring together experts from newly-dissolved public health bodies such as the Health Protection Agency and the National Treatment Agency.

Local authorities will commission public health services, employing local Directors of Public Health as ‘health ambassadors’ to lead discussions on public health spending. To engage with this locally-controlled system, PHE will develop public health outcome indicators and a ‘public health premium’ incentive system.

PHE’s broad function has been defined as “helping people to lead healthier lives”. That covers a wide range of interventions, from driving health awareness campaigns to a more practical role in vaccination programmes. In terms of impact on behavior, PHE will follow the Nuffield ‘ladder of interventions’ model, which relies on using evidence-based arguments rather than regulatory controls.

Leaders, not bosses
PHE will operate through 15 centres across the four regions identified by the NHS CB: North, Midlands and East, London, and South. This structure articulates the national role of PHE with local authorities: the regional bodies have more responsibility for national initiatives such as health emergency response, while the centres are more involved with local initiatives such as specialised commissioning.

The senior leadership team of PHE, like that of the NHS CB, will combine medical and commercial expertise. The medical leadership will consist of a Director for Health Protection, a Director for Health Improvement and Population Health, and a Chief Knowledge Officer. These will be supported by a Chief Operating Officer and Directors for Strategy, Programmes, Finance and Corporate Services, and Human Resources.

Chief Executive designate Duncan Selbie promises that PHE will offer the new public health system “leadership without hierarchy”. Selbie is an experienced NHS leader who was recently Chief Executive of Brighton and Sussex University Hospitals NHS Trust. He has been described as ‘popular’ and ‘likeable’, despite being a man of relatively few words. Notably, he survived the 2005 crisis of NHS governance under Sir Nigel Crisp with his professional credibility intact.

PHE is currently engaged in setting up its board and management team, and in matching roles between the old and new public health systems.

Health of the nation
The underlying medical goals of the new system are defined by the Public Health Outcomes Framework (January 2012), which groups outcome indicators into four domains:

1. Improving the wider determinants of health – improving against wider factors that affect health and well-being.
2. Health improvement – helping people to live healthy lifestyles, make healthy choices and reduce health inequalities.
3. Health protection – protecting the population from major incidents and other threats.
4. Public health and preventing premature mortality – reducing the numbers of people living with preventable ill-health and people dying prematurely.  

Selbie’s document My vision for Public Health England (July 2012) states that the agency “will lead nationally and enable locally a transformation in the health expectations and, in time, outcomes of all people in England”. He promises a focus on “collaboration” to provide a national voice for local public health expertise in councils, and says PHE will achieve “transformation” by changing people’s behaviour.

PHE’s three directorates, described in a separate factsheet, indicate the agency’s chief responsibilities:

• Health protection – concerned with reducing infectious disease and environmental harm. PHE will lead the field epidemiology service, the national immunisation programme, and emergency preparedness, resilience and response. It will also be responsible for investigating and managing environmental hazards such as radiation and chemical exposures.
• Health improvement and population health – concerned with reducing health inequalities and improving preventative healthcare. PHE will advise NHS commissioners on policies for disease screening and specialised commissioning, and will use social marketing to achieve behaviour change. It will promote innovation in this area of public health, reaching out to all providers and commissioners of health and social care, with the long-term goal of achieving improvement across the first, second and fourth domains (see above) of the Public Health Outcomes Framework.
• Knowledge and intelligence – concerned with delivering “a new national evidence and intelligence service” to support assessment of public health need and track performance against key outcomes. PHE will seek to raise the national standard of disease registration, and will work in partnership with NICE to assess the effectiveness of treatments in improving public health. Notably, cancer registration will migrate from the NHS to PHE by April 2013, when PHE will launch a new Cancer Registration Service to “collect consistent high quality, near real-time data” on all cancers diagnosed in England.

Making communities safe
The health protection functions of PHE bear a complex relationship to the NHS. The agency will investigate risks to public health including infectious disease outbreaks, and assess the availability and effectiveness of drug treatments for these threats. PHE will take over the functions of the Health Protection Agency, which will impact on the health protection activities of CCGs, the NHS CB and local authorities.

For example, PHE will have a strategic role in immunisation. The NHS CB will commission vaccination services, but PHE will set their quality standards, assess their performance, fund and manage the development of new programmes and the extension of existing ones, and even purchase, store and distribute the vaccines; while CCGs will commission treatment of infectious disease and work with PHE and local authorities on outbreak control.

It is not surprising, therefore, that the Faculty of Public Health has expressed concern about the “complex new arrangements” for disease control and warned that the system will require “excellent communication and very close collaboration between GPs and their teams, public health staff and hospital services”. This, rather than changes in people’s lifestyles, is most likely to be the area on which the effectiveness of the new public health system is judged.

Pharma and public health
Public Health England may only have 5% of the NHS budget, but its impact on prescribing and other NHS services should not be disregarded. The agency will act as a communication network and body of expertise to guide the new public health system within local government – which in turn will influence and work collaboratively with CCGs and primary and secondary care providers.

PHE’s impact on immunisation and disease control is likely to be particularly important. However, in keeping with the Government’s ‘nudge’ approach to unhealthy lifestyles, it is unlikely to intervene decisively in ‘lifestyle’ and ‘wellness’ issues.

Where the pharmaceutical industry can contribute in concrete terms to PHE’s agenda – for example, by providing better immunisation solutions or affordable drugs that help to prevent serious illness – it may find the agency a willing ally that can impact on GP and hospital prescribing.

At other times, it may find PHE inclined to promote non-drug solutions to public health issues, especially in terms of behaviour change; the industry needs to engage constructively with these issues.

As well as public health outcomes, PHE will be concerned at all times with helping the NHS and local government to save money. Pharma will thus have opportunities to align itself with PHE’s agenda by offering solutions that reduce the cost of public health improvements.

The ABPI has raised concerns around the public’s general knowledge on the cost and value of medicines in the UK after a survey highlighted a series of misunderstandings.

The survey showed that the majority of respondents thought new medicines cost less than £10m to research and develop and more than a third believed drugs take up a large proportion of the NHS budget.

Stephen Whitehead, ABPI Chief Executive, said it was vital the public understands the facts of medicines and how they compare to the economic and health benefits they provide.

More than 1000 people were interviewed as part of the survey commissioned by the trade body. It revealed that 59% seriously underestimated the cost of R&D efforts with new products generally costing £1bn and taking 12 years to create.

Also, 35% of respondents indicated a belief that the NHS spends a fifth of its budget on medicines. Whereas in reality, the ABPI said, that only 9.7% was spent on drugs last year – a fall from 12.5% in 1999.

More than three-quarters of respondents (77%) indicated that more should be spent on medicines.

Stephen Whitehead said the survey highlighted some concerning outcomes. “To create new treatments in the UK, the pharmaceutical industry undertakes huge risk and investment and is still able to provide the NHS with amongst the lowest priced medicines in Europe,” he said. “These medicines are the bedrock of the NHS, and have saved and changed the lives of millions of people.”

The Chief Executive added that serious health problems such as HIV, diabetes and heart disease are now “manageable conditions” due to the effect of medicines and that treatments become cheaper in time due to generics entering the market.

“As well providing real value, we also contribute billions annually to the UK economy and provide 67,000 jobs.”

The ABPI said it will now increase its efforts to educate people about the facts of medicines in the UK.

How does the NHS Operating Framework influence pharma’s engagement with the NHS?

Economics continues to dominate the healthcare headlines. There has been much conjecture in recent weeks about NHS spending and how crucial promises of a ‘ring-fenced’ NHS budget appear to have been broken. Treasury statistics show that frontline spending on the NHS has increased by £3.4 billion since last year. But opponents claim the £1.6 billion surplus reported by PCTs and SHAs in 2011/12 has not been ploughed back into the health service – breaking David Nicholson’s 2010 vow that ‘every penny’ saved by the NHS would be reinvested in patient care. The DH says the surplus is being made available in the 2012/13 budget. With the NHS facing up to the realities of the ‘Nicholson Challenge’, the political debate over healthcare spending will run and run.

Operating Framework

The latest NHS Operating Framework clearly outlines the spending plans for 2012/13. It confirms that SHA/PCT surpluses will continue to be made available during 2012/13 and final year-end surpluses will be carried forward to the NHS Commissioning Board in 2013/14. PCT surpluses are expected to be made available to the relevant local health systems in future years. Conversely, PCTs carrying a legacy debt will be required to clear it during the year. Incoming CCGs will not be responsible for PCT legacy debt but they are expected to work closely together to ensure the situation does not arise.

PCT recurrent allocations will grow by at least 2.5% in 2012/13. PCTs are required to set aside 2% of their recurrent funding for non-recurrent expenditure. SHA clusters will hold these funds, with PCTs required to submit business cases to access them. The cost of organisational change during 2012/13 will need to be met from the 2%.

Tariffs and incentives

The framework outlines developments to the payment system in 2013, to incentivise the realisation of QIPP efficiencies and drive the quality and integration of services. Payment by Results has been expanded to encourage best clinical practice and better patient outcomes. Best practice tariffs are extended to:

• Incentivise more procedures being performed in a less acute setting
• Incentivise same-day emergency treatments where appropriate
• Increase the payment differential between standard and best practice care for fragility hip fracture and stroke
• Promote the use of interventional radiology procedures

Quality improvements are also incentivised in areas such as adult mental health, chemotherapy delivery, HIV services, podiatry, trauma, maternity care and paediatric diabetes. CQUIN is also being developed to provide a stronger incentive to deliver QIPP objectives. The amount providers will be able to earn for incremental quality increases above the standard contract will rise to 2.5% – across all standard contracts. Existing national goals for VTE risk assessment and responsiveness to the personal needs of patients will remain. In addition, two new national goals are introduced:

• Improving diagnosis of dementia in hospitals
• Incentivising the use of the NHS Safety Thermometer

Planning and accountability

The final chapter of the Operating Framework outlines the accountability arrangements for the final year of transition to the newly structured NHS. In 2012/13, the DH will continue to work through SHA clusters to hold PCT clusters to account – handing the baton for accountability over to the NHS Commissioning Board in April 2013. The framework warns that NHS organisations must improve the quality of services provided through the year, while delivering transformational change and maintaining financial stability – with under-performance likely to include ‘intervention from the centre.’
In 2012/13, the key accountability arrangements are:

• The current statutory framework – where SHAs and PCTs remain the statutory units of accountability
• The NHS Constitution – securing patient and staff rights
• Contracts between commissioners and providers
• CQC – regulating NHS providers
• Monitor – ensuring Foundation Trusts are meeting their terms of authorisation and delivering against priorities

Transition plans

The transition to the newly structured NHS is a dominant theme throughout the 2012/13 Operating Framework, and measures to plan for it within the current accountability arrangements are clearly articulated. In fact, given the ambitious nature and close proximity of the reorganisation, details around the planning arrangements for the final year of transition are surprisingly brief.

‘As the industry waits for clarification of individual CCG plans, broader strategies designed at PCT cluster level are already available.’

According to the framework, PCT clusters are each required to develop an integrated plan for the period 2012/13 to 2014/15. The plan should have a clear focus on quality and the national priorities outlined in the Operating Framework. The narrative should be supported by ‘data trajectories for each PCT’, and bring together elements around QIPP, finance, activity, workforce, informatics and transition to the new structure.

Shadow CCGs must support the plan, so they have a strong base on which they can develop their own planning for 2013/14. Likewise, the integrated plans need to reflect the outcomes of local Joint Strategic Needs Assessments. As with the NHS Outcomes Framework, emphasis is placed on integrating all care sectors – with PCT clusters urged to ensure that the public health transition elements of their plan are supported by local authorities.

Implications for pharma

The Framework stated that all PCT clusters’ integrated plans needed to be prepared – and approved by SHA clusters and the DH – by the end of March 2012. These plans are of major importance to pharma. They will contain vital information on the priorities, population needs and long-term ambitions of local health organisations. With the four-wave process to authorise 212 CCGs in England well under way, further data on the specific needs of individual local health organisations will emerge in the coming months. The requirement to publish Commissioning Intentions, updated JSNA and a whole variety of other forward-looking documentation as part of the authorisation phase promises to provide pharma with a comprehensive view of its market environment at the local level. But as the industry waits for detailed clarification of individual CCG plans, broader strategies designed at PCT cluster level are already available.

At a time when finances across the NHS are being squeezed yet the bar for quality and clinical outcomes is being raised, insight into the challenges facing key customers is a valuable commodity for medical sales professionals. The transition of the NHS to a new structure can be a catalyst for proactive medical sales professionals to improve their environmental monitoring, and significantly develop their understanding of customer need. The challenge for the industry is to ensure that key account managers speak in the same language – the same currency – as the customers with whom they seek to engage. The nature and scope of that currency is defined in national documentation such as the NHS Operating Framework and NHS Outcomes Framework, and within the vast local plans that are emerging as the NHS transition gathers pace. And well beyond it.

Success is about finding a common currency with your customers. The clues are out there.

What does the ‘single operating model’ for primary care commissioning mean for GPs?

The NHS Commissioning Board Authority’s ‘single operating model’ for primary care commissioning represents a major step in defining the relationship between GPs and the new NHS. As such, it is essential reading for anyone with a stake in prescribing behaviours and, more widely, in patient pathways.

A major question posed by the Lansley reforms is: who should commission the commissioners? If GP-led groups are responsible for commissioning secondary care, who can commission primary care? The answer, the NHS Commissioning Board, was greeted with mistrust by many GPs who asked why they needed some Big Brother watching over the job they had always done.

In addition, the passage of the Health and Social Care Act left a lot of broken glass scattered through primary care. The relationship between clinical outcomes and money, the involvement of the private sector in the NHS and the apparent fragmentation of the health service are issues that divided
the GP profession.

So the single operating model has the task not only of outlining new clinical and business relationships, but of building professional bridges. The Board tackles this challenge by saying up front that it seeks to
achieve “the right balance between national consistency and local decision making”.

Unlike earlier documents describing the infrastructure of the new NHS, Securing excellence in commissioning primary care does not list concrete developments to be in place by April 2013. Rather, it outlines a pattern of relationships that will develop from that date, when the new single operating model
for primary care commissioning becomes operative. It represents the parts of the new
NHS working together with a clear goal of outcome improvement.

The commissioning challenge
According to Dame Barbara Hakin, National Director for Commissioning Development, the new system aims to “tackle unwarranted variation and take positive steps towards raising the overall standard of primary care”. The document notes that primary care, while accounting for only 15% of the NHS budget, has a
profound role in making “preventative interventions” and influencing all the care patients receive.

The challenge of replacing “many different systems” for primary care commissioning with “a single national
operating model” without losing “vital local responsiveness”, the Board says, depends on “establishing relationships and arrangements across the new organisations” – including CCGs, whose health strategies
will set the context for primary care.

The NHSCB will be responsible for planning, securing and monitoring primary care services. Its local area teams will manage the performance of GPs and other primary care providers (dentists, community pharmacists and opticians), and will help to support providers in difficulty and deal with major emergencies.

The local area teams will support patient “choice and control in designing services that respond to their needs”, focusing on “the basic service offer” (such as early diagnosis) to reduce variations and health inequalities. Likewise, they will support the development of “local area clinical leadership teams” that draw on the expertise of all types of primary care clinicians. Finally, their focus on patient outcomes means they will look for “improvement strategies” at all times.

All together now
Most primary care commissioning will take place through the Board’s local area teams working with CCGs, local authorities and health and wellbeing boards. The Board as a central authority will “ensure consistency” and provide the framework for performance management and quality assurance. Crucially, this system involves “fewer managerial resources” and “larger geographical footprints” than the previous system. It does not remove local initiative: it just removes the SHA and PCT management layer.

At the heart of the model are the common operating procedures for local area teams, of which the most important is “to standardise the performance management frameworks and processes at practice, provider and individual levels”. Managing variability and the healthcare market are also key priorities.

Commissioning support services may also assist local area teams: emphasis is placed on the value of
business intelligence in providing “a single flow of standardised information”, and the potential for CCGs to share support for primary care development and redesign with local area teams.

Micro commissioning
CCGs themselves will work closely with the NHSCB to review the “micro commissioning decisions” made by
GPs in “each referral and prescription”. The Board says that its work with CCGs has shown they can progress effectively together towards “quality improvement” through benchmarking, data sharing and peer review. It notes further that CCGs will be able to commission integrated “wrap-around” community-based services in which GP practices can participate, with care taken to manage conflicts of interest.

The local area teams will establish relationships with a range of partners, including CCGs, Local Healthwatch, health and wellbeing boards, local authorities, Public Health England local units and the CQC. Clinical networks will feed into the primary care system “with a particular focus on early diagnosis and timely treatment”. Public health commissioners will advise local area teams on priorities for the local
population, and work with them to develop health improvement initiatives that may include primary care.

The Board concludes: “During the next three to six months, we will fully explore all the interdependent relationships critical for the operating model and take any action necessary to ensure that they will work effectively.” It encourages discussion of the model within PCT clusters and feedback on
potential improvements.

A business network
The single operating model for primary care commissioning is not so much a ‘one size fits all’ as an ‘all things to all people’. It shows the old hierarchical NHS giving way to something much closer to a business network, with shared rules and goals but different cultures. The imprecision of the arrangements described displays the will to promote clinical innovation and business
development.

The emerging structure is designed to give GPs more confidence that they will be neither isolated nor controlled. Those who need guidance and support will receive it, while others will have the freedom to change treatment pathways and business models. This will help to defuse opposition to reform in the
profession, while setting the stage for further changes.

For pharma, the new model points to the development of a complex and flexible customer network with many points of contact. Key account managers are much concerned with how primary care operates and the factors influencing it. This model shows primary care in a dynamic field of NHS and other stakeholders, responding to ideas from all sides: an exciting prospect for suppliers.

Sir David Nicholson, NHS Chief Executive, has admitted taking control of NHS finances whilst the Government’s reforms to the health service take shape.

Speaking at the Local Government Association, Sir David said he had a greater hold of NHS finances than ever before to oversee and control budgets.

He told delegates that despite talk about “localism” he has “more control nationally” and he refused to apologise for that.

Despite taking control of finances nationally, Sir David stressed the importance of “joined-up, integrated services” when the NHS reforms were fully functional.

The Chief Executive admitted that patients in the past had been failed by a “lot of services on the cusp of health and social care” and said there was a “strong case for bringing in innovation from the wider sector” to address previous errors.

He also admitted that the health service had “raided the public health budget” to “bail out” other parts of the system. The admission is likely to affect future public health budgets after the Government said it would base council funding on historical NHS spending.