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.

The NHS operating framework provides the blueprint for the NHS in England. Pf examines its objectives around quality and reform.

The Operating Framework for the NHS in England 2012/13 is an important document for UK medical sales professionals. It outlines the national priorities, system levers and mechanisms that the NHS in England must focus on to improve patient care. The strategic framework details expectations for the NHS’ ongoing efficiency challenge and the transition to the new commissioning and management system. It sets out the planning, performance and financial requirements for NHS organisations and the basis on which they will be held to account. With QIPP imperatives at the heart of the strategy, proactive pharmaceutical companies that can demonstrate an ability to help NHS customers deliver efficiencies and improve qualities in areas of national priority will be best placed to succeed.

The Framework identifies four key themes for NHS organisations in 2012/13:

1. Putting patients at the centre of decision making in preparing for an outcomes approach to service delivery
2. Completing the final year of transition to the new system
3. Accelerating the delivery of the QIPP challenge
4. Maintaining a strong grip on services and financial performance.

Quality - a focus on outcomes

The Operating Framework says that the NHS’ model of delivery must be overhauled in 2012/13 to become a system driven by quality and outcomes. It identifies the Outcomes Framework as the catalyst for this – with its focus on clinical outcomes and the reduction of health inequalities driving changes in culture, behaviour and service delivery. The Outcomes Framework sets out the improvements against which the NHS
Commissioning Board will be held to account from 2013/14.

These measurements are set out within five domains:

Domain 1: preventing people from dying prematurely.

Domain 2: enhancing quality of life for people with long-term conditions.

Domain 3: helping people recover from episodes of ill health or following injury.

Domain 4: ensuring people have a positive experience of care.

Domain 5: treating and caring for people in a safe environment and protecting them from avoidable harm.

The Operating Framework details a range of indicators for each domain, all of which are explored in the NHS Outcomes Framework. These will be supported by NICE quality standards, which provide definitions of what high-quality care should look like for a particular pathway of care. The document also advises NHS organisations to meet the service specific outcomes strategies that have already been published in areas such as mental health, cancer, COPD, asthma and long-term conditions.

Each domain in the NHS Outcomes Framework has a strong relevance to pharma, whether through the development of medicines to treat disease in priority areas, or via collaborative service design to move care closer to patients’ homes and reduce hospital admissions. Organisations that are able to show how their innovations can improve a care pathway or be used as part of a redesigned service will enjoy
more positive NHS engagement.

The Operating Framework identifies dementia and care of older people as a key priority, and sets clear goals to integrate health and social care. It also highlights examples of initiatives where NHS organisations have successfully improved services in line with each of the four key elements of QIPP; quality, innovation, productivity and prevention.

Reform - the transition blueprint

The Operating Framework outlines the key milestones for the reorganisation of the NHS. Whilst the headlines are widely known, it is interesting to track current progress against a timetable that was set out many months before the Health & Social Care Act was passed. The Framework notes that by
the end of 2012/13:

“The NHS will have transformed the commissioning landscape into one focused on local clinical decision
making, with the development and authorisation of CCGs, assisted by commissioning support vehicles and overseen by the NHS Commissioning Board. Local authorities will take the lead role in public health, alongside the new Public Health England. Central to the new system will be the establishment of Health & Wellbeing Boards (HWB), who will provide local systems leadership across health, social care and public health. Alongside this, developments will continue to the provider landscape, through the extension of Any Qualified Provider (AQP), progress with the NHS Foundation Trust (FT) pipeline and the establishment of the new NHS Trust Development Authority.”

Key 2012/13 objectives in the transition are as follows:

• PCTs and SHAs will remain statutory organisations until April 2013. They will be held to account on delivering performance and support the development of new organisations for clinical leadership. Clinical Senates and networks will be established
• PCTs will support CCG authorisation and the transition of power before March 2013
• HWBs will be established in shadow format, becoming statutorily operational from April 2013. They will act as the local system leader through JSNA and HWB Strategies
• CCGs must be coterminous with a single HWB ‘as far as possible’
• CCGs must: play an active role in planning and budgeting, develop relationships with local partners
  including social care, deliver their share of the QIPP agenda and identify how to secure commissioning support services in line with their running cost allowance
• Public Health England will become a statutory executive agency from April 2013
• NHS Trusts are expected to achieve FT status by April 2014
• PCT clusters should start to offer patients choice of AQP in at least three services that are local priorities. There should be a presumption of choice for most services from 2013/14.

The failure to reduce the cost of acute care is threatening the development of clinical commissioning groups and may lead to disastrous PCT cuts, the General Practitioners Committee (GPC) has warned.

PCTs are struggling to achieve savings via the QIPP agenda which may result in budget deficits being inherited by CCGs in April next year.

Board papers from a number of PCT clusters show that acute costs are currently spiralling out of control at a time when the NHS aims to make £20bn of efficiency savings.

In NHS Bedfordshire Cluster, acute and specialist care costs were £11.2m over budget. Overspending was also recorded at the Arden Cluster in Warwickshire and by the NHS Greater Manchester Cluster – which was deemed “totally unacceptable” in the board’s minutes.

Meanwhile at England’s largest Primary Care Trust NHS North Yorkshire and York, a £19 million deficit for this financial year will be passed on to the CCGs which will take over responsibility in the region next year.

Dr Chaand Nagpaul (pictured), GPC negotiator, said that short-term savings by PCTs are increasing future costs inherited by CCGs. “The whole rationale of (cutting) secondary care costs depends on a primary care infrastructure to absorb care in the community,” he said. “It would be illogical, counterproductive and damaging to cut primary care.”

Prospective CCGs are to be assessed on their commissioning intentions for 2013–14 as part of the CCG authorisation process, latest guidance from the NHS Commissioning Board Authority (NCBA) has revealed.

Applicants will need to submit key documentation such as Joint Strategic Needs Assessment plans and Health & Wellbeing Board strategies as part of a robust review process.

The shadow organisations will also need to provide a list of collaborative commissioning arrangements, joint commissioning agreements and any 2012–13 contracts approved via PCT clusters. An Integrated Plan for the current year will also be assessed.

The parameters for assessment are outlined in a new guide issued by the NCBA: Clinical commissioning group authorisation: draft guide for assessors undertaking desk top review, which is designed to support assessors participating in the CCG application process. The guide focuses on the first phase of NHSCB assessment, ‘desk top review’, the completion of which will lead to the production of a key reference document to support CCG authorisation.

The guide follows the April publication of a draft guide for applicants and aims to ensure that evidence submitted by CCGs is assessed ‘transparently, consistently and fairly’. It outlines assessors’ roles within the authorisation process, its overarching principles and methodology, and the criteria by which evidence submissions should be judged. This evidence, it says, should be a ‘by-product of core business’ for CCGs.

Full details of the authorisation process at the desk top review stage are available here.

Doctors should be more involved in the development of Clinical Commissioning Groups (CCGs), BMA chairman Dr Laurence Buckman has said.

Speaking at the Local Medical Committees Conference, Dr Buckman warns that the development of CCGs is continuing without the involvement of many ordinary GPs.

Dr Buckman insists that doctors should stand up to “regulation, bullying micromanagement and dissipated effort” as CCGs head towards authorisation.

CCGs are due to take over the responsibility for commissioning care from PCT clusters by April 2013.

They will need by authorised by the NHS Commissioning Board Authority before they become statutory bodies.

However, many GPs feel the Government has not kept its promises and are no longer in control of how CCGs are being developed.

“CCGs are ‘membership organisations’ as we keep on being told, they are our creatures not just another version of the PCTs they replace,” Dr Buckman said.

“GPs should be telling them what to do, not the other way round.  We were told it was going to be different… the Government needs to make it so.”

The BMA raised serious concerns during the passage of the Health and Social Care Act. The Association insists it continues to have “grave concerns” about the reforms, but will “ensure that implementation is evidence-based and sensible”.

Patients have been tasked with helping Leicester, Leicestershire and Rutland (LLR) PCT Cluster save £5.6 million worth of wasted medicines each year.

An eight-week campaign has been launched to target individuals in an attempt to reduce the misuse of repeat prescriptions and to return any unwanted medicines to local pharmacies.

Dr Paul Danaher said the issues can only be solved by “patients and the health community working together”.

Posters and leaflets have been put on display in GP surgeries and in pharmacies to raise awareness of the campaign.

Individuals are urged to think before ordering repeat prescriptions; talk to healthcare professionals for advice on medicines; and bring unwanted medicines to pharmacists for safe disposal.

“Unused prescriptions cost the NHS in LLR an estimated £5.6 million each year and this is money that could be used to pay for other important health services locally,” said Dr Danaher.

“We want to encourage patients only to order repeat prescriptions if they are needed and not to stockpile medicines at home. We are also encouraging patients to have a medicines review with their GP or pharmacist to make sure they get the most out of the drugs which are prescribed for them.”

The PCT Cluster estimates that across the LLR region the misuse of medicines is the equivalent of 219 more nurses, 5,600 more treatment courses for Alzheimer’s disease, more than 1,500 hip replacements or 5,833 cataract operations.

Tracking and responding to NHS change in a highly competitive Olympic year will be a test of endurance for medical sales professionals. In a light-hearted article, David Round examines why winning a place amongst the medals will depend upon getting your preparation right.

It’s a well-worn cliché that a little knowledge is a dangerous thing. But as the UK pharmaceutical industry heads into an Olympic year when the pace of change amongst its NHS customer-base will undoubtedly increase, medical sales professionals will need to demonstrate more than a little knowledge to achieve a podium position for their products. The Health and Social Care Bill may still be some way from the finishing line, but as the health service continues its transition towards the seemingly inevitable, changes on the ground are already taking place. And the implications for pharma are huge. The industry cannot afford to sit and wait – it needs to act now to ensure its sales and marketing communications are reaching the right customers, with the right message at the right time. For pharmaceutical sales executives, it’s about developing more than knowledge: it’s a question of intelligence. And the answers may be right at their fingertips.

It has been widely documented that the NHS is working its way through a period of unprecedented change – both in its working practices and, of course, in its organisational structure. As a result, pharmaceutical companies – often criticised for being ‘data rich but information poor’ – will, more than ever before, need to maximise their data assets to deliver a more customer-centric approach to selling. And sales professionals will need to draw on all the information at their disposal to develop and deliver relevant and robust value propositions that satisfy customer need.

The noise-driven, share of voice model of pharmaceutical sales and marketing has become like Monty Python’s parrot: it has ceased to be. Today’s approach, which relies on a reduction in call volumes, is less linear, more selective and much more sophisticated. Key Account Management is leading the industry pack. But whilst the approach is, in theory, more measured, making it work requires quality customer data as a platform to identify ‘key accounts’ and, crucially, the ability to translate that data into meaningful market intelligence. Companies are becoming much smarter in segmenting their key customers – but faced with moving targets across a changing NHS, maintaining the accuracy, and in the process the efficiency, of the approach is not easy. It is, however, imperative.

The race to reform
The transition towards the new environment is already well under way. Last year in England 152 Primary Care Trusts (PCTs) were reorganised into 51 PCT Clusters of variable size, while the ten Strategic Health Authorities (SHAs) were restructured to form four large regional clusters. By April 2013, PCTs and SHAs will be extinct and Clinical Commissioning Groups (CCGs) and the National Commissioning Board will spearhead the commissioning of NHS services under a new-look structure. If you throw into the mix the onset of Clinical Senates, Health and Wellbeing Boards and new Commissioning Support units (which may well emerge as private organisations and therefore new customers), it is easy to see that an already complex customer matrix is set to become even more complicated. And that’s simply the start line.

Critics of the reforms claim that the situation on the ground is fast approaching chaos within the NHS, as the wider organisation struggles to implement changes even before the Health and Social Care Bill has achieved Royal Assent. But in the interim period while the health service readies itself for the inevitable, UK pharmaceutical companies cannot afford to let their sales and marketing operations become similarly chaotic. Tracking and more importantly responding to change throughout the transition period will be vital for medical sales professionals if they are to support their customers through the metamorphosis and, in the process, meet their own commercial objectives.

Access to quality data that can not only enable Account Managers to make the right targeting decisions, but can also help them engage in the most appropriate customer dialogue, will be critical to success. It is not simply a case of knowing who to target – understanding why and how they should be approached is equally important. It is this understanding that separates knowledge from intelligence. And separates winners from also-rans.

Keeping on track
Sales professionals not only need to identify their ‘key accounts’, they also need to understand the varied environments in which these individuals operate. What challenges do they face? What are their key priorities? Do they carry out more than one role – or sit on a variety of boards and committees in addition to their main job? If so, how does this impact their spheres of influence? How pivotal are they in driving service redesign, influencing formulary decisions, or facilitating joint working within their local organisation? Where do their roles and their needs overlap with your product or service?

This is standard market access. And it’s vital. Pharmaceutical sales professionals need to define how they engage with the NHS and why their customers should want to engage with them. They need to establish how they are going to deliver value and improve outcomes for the health service and its patients. And to achieve this, they must understand their local health economy, its priorities and objectives, and identify the key stakeholders whom they can help support to meet those needs. What is the structure of the local organisation? What is its indicative budget and its strategic plan? Who is responsible for commissioning in your disease area? What areas are emerging Commissioning Support Units going to be supporting commissioning in – and what are they not? As PCT clusters evolve and CCGs take shape, which customers are most relevant today, and how relevant will they be tomorrow or indeed in two years’ time? Only by tracking customers in real time as they make their transitional journey towards the new NHS can sales professionals be sure that their interactions are aligned with that change, and be prepared to respond accordingly when required.

Technology in a team sport
The Key Account Manager in the modern market must, therefore, have the mental preparation of an Olympic athlete – but work on the basis that the race is never won. The NHS is a dynamic marketplace where change is continual. The Key Account teams that are best able to track, capture and share intelligence will be best placed to emerge victorious. The role of the Key Account Manager is, after all, an individual pursuit in a team sport.

The tools to support ‘informed’ Account Management are already here. Customer Relationship Management (CRM) systems that help capture and share vital customer intelligence have been in common currency across the UK drug sector for many years. But never before has their value to the medical sales professional been so important. Industry surveys suggest that CRM usage amongst front-line sales professionals could still be improved – and this is essential. CRM systems are only as good as the data that is put into them. But when collected and shared properly, that data is there to help medical sales professionals. In a fast-evolving customer environment that will almost certainly intensify as the NHS continues its inexorable march towards a new structure, key account management can only be enhanced by the knowledge and intelligence a good CRM system can help deliver.

In fact, the sheer volume of likely NHS change in the next 12 months could provide a catalyst for 2012 to become the year when CRM finally comes of age. And those sales professionals who recognise its potential to significantly support customer interactions – and make for a more intelligent and appropriate engagement – will undoubtedly reap the rewards.

But the time to act is now. In an Olympic year, the fast track is the only option. After all, a little knowledge is a dangerous thing.

David Round is UK General Manager, Cegedim Relationship Management.

The NHS will receive an immediate cash injection of up to £100m to support local community-based services during the winter months.

The additional ‘frontline commissioning funding’, which has been allocated to the emerging Clinical Commissioning Groups (CCGs), must be committed for specific purposes by mid-February or returned to the DH.

The money, amounting to £2 per patient, is to be spent on developing local care services and reducing unnecessary hospital admissions; as such, its remit may include prescribing.

While it may soften the immediate frontline impact of cuts in NHS spending, the new cash injection is only 2% of the £5bn ‘efficiency savings’ required of the NHS in 2012.

Consistent with the DH policy of shifting the focus of healthcare from acute to community-based services, the funding could (for example) be spent on improving patient access to GP services, improving services provided to nursing homes, or developing home-based services.

Health Secretary Andrew Lansley said: “I am pleased to be able to give the NHS up to £100 million in extra funding to spend directly on local frontline care for their patients during the winter months.”

He emphasised that giving a cash boost to the new CCGs would strengthen the role of local clinicians and thereby ensure that patients “receive the right care according to their individual needs”.

The money must be signed off by the PCT clusters for specific service improvement purposes: it cannot be used to help cover the cost of existing services.

This is the first time that the DH has specifically identified funding to be allocated to the new CCGs, though PCTs already delegate commissioning funds to support the CCGs in providing services.

CCGs will need to inform their PCT clusters how the funding will be utilised by mid-February 2012; each PCT cluster will similarly need to inform the relevant SHA cluster by the end of February 2012, and money not allocated will be returned to the DH.

This funding window provides an added incentive for pharmaceutical companies to demonstrate the value of their solutions for community-based healthcare.

As the PCTs form clusters from which the Clinical Commissioning Groups will hatch, a new generation of NHS commissioners is being born. Thoreya Swage examines how medtech can help these new customers to redesign services.

Irrespective of the progress of the Health and Social Care Bill currently going through the House of Lords, the momentum of reform of the NHS in England continues to gather pace.

Following a four-month hiatus while the wise and the good of the NHS Future Forum pondered and produced recommendations for the adjustment of the Bill, the Department of Health published further guidance on the developing role of the PCT Clusters. Although the 151 Primary Care Trusts have been squeezed into 51 PCT clusters in preparation for their demise in April 2013, it appears that they have a vital part to play in the development of the emerging Clinical Commissioning Groups (CCGs).

The guidance or ‘shared operating model’ for PCT clusters has been produced by the mandarins at the DH to ensure that the commissioning landscape is as consistent and smooth as possible in time for the takeover by the CCGs. This is to ensure that the nascent NHS Commissioning Board inherits a robust enough system to take charge of further developments and improvements in healthcare in early 2013.

The shared operating model identifies six main functions or ways of working, where consistency of approach is considered to be important. They are listed as commissioning development, financial and operational issues, ensuring quality, emergency planning, development of providers as Foundation Trusts and communications.

CCG commissioning development

The most important function of the PCT clusters is the preparation of CCGs for authorisation as soon as possible following the successful passage of the Health Bill through Parliament. The process of authorisation to become fully-fledged commissioners is due to begin in the second half of 2012. Although this is a year away, CCGs can commence their preparations now using a self-diagnostic tool: an interactive computer-based assessment that helps them to determine their capabilities and identify their development needs. The areas covered include:

• A clear clinical focus for the CCG commissioning plans to include tackling health inequalities and improving primary care.

• Demonstration of meaningful involvement of patients and the wider community.

• A plan for development that is clear and credible and that, in particular, delivers the QIPP (quality, innovation, productivity and prevention) agenda.

• Capacity and capability of the CCG, i.e. robust constitutional and governance arrangements that enable the CCG to commission care effectively and ensure financial control.

• Collaborative arrangements for working with other CCGs, local authorities and the NHS Commissioning Board.

• Capacity and capability of the CCG leadership, which ensures effective working.

The tool helps the CCGs to identify priority development areas, which form the basis of the developmental plan paving the way to full authorisation.

To support all this work, CCGs will receive £2 per head from the PCT clusters, as well as extra management resources to help the groups hone their commissioning skills and capabilities.

CCGs experiencing difficulty in defining their boundaries will have guidance from PCT clusters on how to resolve this. PCT clusters also have the unenviable task of engaging the reluctant practices that so far have not participated in their local CCG discussions, with the aim of making them part of a viable CCG by October this year.

Separation of functions

Through the last quarter of this year, a detailed exercise is being carried out by the PCT clusters to identify and segregate the service areas that CCGs and NHS Commissioning Board will be responsible for.

Although the CCGs will be commissioning acute, mental health, community and ambulance care, other services that PCTs currently commission will need to be transferred to the umbrella of the NHS Commissioning Board:

• GP and other primary care contractor groups (primary care dental, pharmacy and optical services)

• secondary dental care

• prison, specialised and military health services.

Even though the contracts for GP services are held by another body, the CCGs are expected to have an input into primary care development and improvement.

Quality assurance

A vital component of the commissioning process is ensuring the quality of healthcare. Practices may have been involved to a greater or lesser degree in various quality assurance processes in the past; however, CCGs are required to take these responsibilities seriously on board.

There is a whole raft of procedures and measures including delivery of better health outcomes for patients, meeting the Care Quality Commission (CQC) requirements for safety and quality of services, standard contracts, the NHS Operating Framework, professional guidance and other relevant requirements that CCGs need to get to grips with.

This could potentially be a vulnerable time for the development of the CCGs if attention wanders and serious patient safety incidents are not acted on promptly. Clinical governance processes must therefore be extra-secure.

Budgets and responsibilities

Over the next year or so, there will be a period of dual functioning and handover as the CCGs mature and the PCT clusters delegate more and more responsibilities until April 2013. The handing over of the baton has started now, with PCT clusters having identified a ‘clear percentage of budgets’ to CCG pioneers or pathfinders in August and set plans for future delegation of budgets in October.

Sandwiched in between these two was the agreement in September on which mental health and community services will be subject to ‘Any Qualified Provider’ (AQP). This policy is set to be implemented from April 2012, when GPs can refer to providers of certain services eligible for AQP from a list of approved organisations, including private sector companies, drawn up by the DH.

A review of the commissioning support required by CCGs was undertaken in July, with clear arrangements to be agreed by the end of this year.

In March 2012, CCGs will be required to enable the development of the local health and wellbeing boards (the mechanism for joint health and social care planning and local commissioning) supported by their PCT clusters.

Meanwhile, individual PCTs will continue to carry out their statutory functions through the PCT clusters until their abolition in April 2013. The statutory functions include contract monitoring, ensuring that providers meet their QIPP obligations, and other statutory requirements such as safeguarding children and vulnerable adults.

The big challenge for CCGs begins when they are required to lead the next planning round for 2012/13. This will start towards the end of this year, and is a function previously undertaken by the PCTs. It involves doing a needs analysis, identifying local inequalities, understanding demand and resources for local services, negotiating and setting priorities with partners, and developing a local strategic vision. Handover of commissioning functions will continue, with CCGs being an active participant in the subsequent contract negotiations and agreements.

How medtech fits in

It is apparent that despite the pause for reflection on the proposed changes in the English health service earlier this year, the momentum of dissolving and restructuring healthcare organisations continues. The picture remains a little confusing, however, as CCGs are in varying stages of development and maturity and it is not clear that all are now truly viable although the October deadline has passed.

What is clear is that that the work of commissioning and delivering healthcare has to go on, and now is a good time to find out who the key movers are within the CCGs. At this point the developmental needs of CCGs are uppermost, and it is here that medtech companies can provide some input. Skills and knowledge in leadership development and highlighting evidence-based medical technologies that really make a difference are two key areas of potential input.

CCGs will be keen to redesign services in order to make patient pathways across primary and secondary care more consistent and to move more care into the community setting. It is here that telehealth and telecare will come into their own as a means to facilitate the transition.

Demonstrating the effectiveness of home monitoring of blood pressure, supporting community services such as HIV or stoma care, and promoting medical devices that offer continuous subcutaneous infusion of insulin are examples of technology implementation where a vital case can be made to these prospective healthcare commissioners. CCGs will also look favourably on management of their patients in the surgery with video links to consultants for advice, rather than sending them to outpatient services.

Clinical services that utilise new or different medical technologies will require staff who are appropriately trained and have the skills and competencies to use the equipment. This training can be provided by the medtech industry.

As ever, good information forms the basis of good commissioning and the demonstration of successful patient outcomes. Data systems in the community setting have always lagged behind their counterparts in the acute setting. Given that CCGS will need to develop services in the community, new and better IT systems will be required.

Get ready!

The next few months will be busy while the NHS sorts itself out at a structural level. Once the picture begins to clear, the medtech industry will need to engage with the new clinically skilled commissioners who now have the financial responsibility for making decisions about healthcare.

Dr Thoreya Swage was formerly an NHS clinician and a senior manager in various NHS organisations covering acute and primary care. She has expertise in commissioning health services and is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.

Despite the ongoing criticism of the Health Bill as it passes through the House of Lords, structural changes are still happening at ground level. Dr Thoreya Swage outlines the timescale for changes as PCT clusters switch responsibilities to CCGs.

The momentum of reform of the National Health Service in England continues to gather pace. Following a four month hiatus while the wise and the good of the NHS Future Forum pondered and produced recommendations for the adjustment of the Bill, the DH published further guidance on the developing role of the Primary Care Trust (PCT) clusters.

Although the 151 PCTs have been squeezed into fifty-one PCT clusters in preparation for their demise in April 2013, it seems that they have a vital part to play in the development of the emerging Clinical Commissioning Groups (CCGs).

This guidance or ‘shared operating model for PCT clusters’ has been produced by the mandarins at the DH to ensure that the commissioning landscape is as consistent and smooth as possible in time for the takeover by the CCGs. This is so that the nascent NHS Commissioning Board inherits a robust enough system to take account of further developments and improvements in healthcare in early 2013.

 

A shared model

There are six main functions or ways of working for the shared operating model for the clusters. These have been identified where consistency of approach is considered to be of importance and they are listed as commissioning development, financial and operational issues, ensuring quality, emergency planning, development of providers as Foundation Trusts and communications.

 

CCG development

The most important function is the preparation of CCGs for authorisation as soon as possible following the successful passage of the Health Bill through Parliament. The process of authorisation to become fully fledged commissioners is due to begin in the second half of 2012.

Although this is a year away, CCGs can commence their preparations now using a self diagnostic tool – an interactive computer-based assessment that helps them to determine their capability in six domains and identify their development needs.

The areas covered include:

• A clear clinical focus of the CCG commissioning plans to include tackling health inequalities and improving primary care
• Demonstration of meaningful involvement of patients and the wider community
• A plan for development that is clear and credible which, in particular, delivers the QIPP (quality, innovation, productivity and prevention) agenda
• Capacity and capability of the CCG, i.e. robust constitutional and governance arrangements which enable the CCG to commission care effectively and ensure financial control
• Collaborative arrangements for working with other CCGs, local authorities and the NHS Commissioning Board
• Capacity and capability of the CCG leadership which ensures effective working.

The tool helps the CCGs identify priority development areas which form the basis of the developmental plan paving the way to full authorisation.

To support all this work CCGs will receive £2 per head from the PCT clusters as well as extra management resource to help the groups hone their commissioning skills and capability.

CCGs experiencing difficulty in defining their boundaries will have guidance from PCT clusters on how to resolve this. PCT clusters also have the unenviable task of engaging the reluctant practices that so far have not participated in their local CCG discussions, with the aim of being part of a viable commissioning group by October.

 

Separating commissioning functions

All through the last quarter of this year a very detailed exercise is being carried out by PCT clusters to identify and segregate the service areas that CCGs and the NHS Commissioning Board will be responsible for. Although CCGs will be commissioning acute, mental health, community and ambulance care there are other services that PCTs currently commission which will need to be transferred to the Board.

Services such as GP and other primary care contractor groups – primary dental care, pharmacy and optical services – secondary dental care, prison, specialised and military health services are set to go under the umbrella of the NHS Commissioning Board. Even though the contracts for GP services are held by another body, the CCGs are expected to have an input into primary care development and improvement.

 

Quality assurance

A vital component of the commissioning process is ensuring the quality of healthcare. Practices may have been involved to a greater or lesser degree in various quality assurance processes in the past. However, CCGs are required to take on board these responsibilities seriously.

There is a whole raft of procedures and measures including delivery of better health outcomes for patients, meeting the Care Quality Commission (CQC) requirements for safety and quality of services, standard contracts, the NHS Operating Framework, professional guidance and other relevant requirements that CCGs need to get to grips with.

This could potentially be a vulnerable time for the development of the CCGs if attention wanders and serious patient safety incidents are not acted on promptly. Clinical governance processes must therefore be extra secure.

 

Budgets and responsibilities

Over the next year or so there will be a period of dual functioning and handover as the CCGs mature and the PCT clusters delegate more and more responsibilities until April 2013. The handing over of the baton has started now with PCT clusters having identified a “clear percentage of budgets” to CCG pioneers or pathfinders in August and plans for future delegation of budgets set by October.

Sandwiched in between will be the agreement on which mental health and community services will be subject to ‘Any Qualified Provider’ (AQP). This policy is set to be implemented from April next year when GPs can refer to providers of certain services eligible for AQP from a list of approved organisations, including the private sector, drawn up by the DH.

A review of commissioning support required by CCGs has already been undertaken in July with clear arrangements agreed by the end of the year.

In March next year, CCGs will be required to enable the development of the local health and wellbeing boards supported by their PCT clusters – health and wellbeing boards being the mechanism for joint health and social care planning and commissioning locally.

Meanwhile, individual PCTs will continue to carry out their statutory functions through the clusters until their abolition in April 2013. The statutory functions include contract monitoring, ensuring that providers meet their QIPP obligations and other statutory requirements, for example, safeguarding children and vulnerable adults.

The big challenge for CCGs will begin when they will be required to lead the next planning round for 2012/13. This begins in the latter part of this year and is a function previously undertaken by the PCTs.

This will involve doing a needs analysis, identifying local inequalities, understanding demand and activity for local services, negotiating and setting priorities with partners and developing the local strategic vision. Handover of commissioning functions will continue with CCGs being an active participant in the subsequent contract negotiations and agreement.

 

The outside world

It is apparent that despite the pause for reflection on the proposed changes in the NHS earlier this year, the momentum for restructuring and dissolving healthcare organisations continues. The picture remains a little confusing however, as CCGs are in varying stages of development and maturity and it is not clear that all will be truly viable by the tight deadline set for October.

What is clear is that that work of commissioning and delivering healthcare has to go on and now is a good time to find out who the key movers are within the CCGs.

It is at this point in time when the developmental needs of CCGs will be uppermost and it is here that pharma can provide some input. Skills and knowledge in leadership development and highlighting therapeutic areas where evidence-based care really works are two such possibilities.

CCGs will be keen to smooth patient pathways across primary and secondary care and nowhere is this more pertinent than in prescribing effectively. Delegated prescribing budgets are now very real for CCGs and they will be keen to ensure value for money and improvements in care for their patients. This provides a good opportunity for pharma companies to demonstrate the effectiveness of their drugs in specific disease areas.

On the commissioning front, by December of this year, CCGs and PCT clusters will have had to agree what commissioning support they need to carry out this function. Given the requirement to reduce costs, commissioning skills and expertise may actually be thin on the ground within CCGs.

Bearing in mind that effective commissioning will be judged by outcomes achieved as outlined in the NHS Outcomes Framework, pharma is well placed to demonstrate how their products can meet the requirements of domain 1: preventing premature deaths, domain 2: enhancing the quality of life of people with long-term conditions and domain 3: aiding the recovery of people who have an acute illness or injury.

The next few months will be busy while the NHS sorts itself out structurally. Once the picture begins to clear, pharma will need to engage with the new clinically skilled commissioners who now have the financial responsibility for making decisions about healthcare.

Dr Thoreya Swage was formerly an NHS clinician and a senior manager in various NHS organisations covering acute and primary care. She has expertise in commissioning health services and is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.