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.

The Care Quality Commission (CQC) was formed in 2009 to replace three separate inspection bodies: the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. Since October 2010 all providers of healthcare and social care, whether in the public or private sector, have had to register with the CQC – which now regulates more than 21,000 providers.

This massive registration task was divided into phases: the Commission registered NHS secondary care providers, then re-registered adult social care and independent healthcare providers, then registered primary dental care and independent ambulance providers. Its next challenge is to register all GP practices. Most importantly, it will need to continue monitoring the quality and safety of all these providers’ services.

The CQC’s declared purpose is to eliminate poor quality care, defend patients’ rights and ensure that care is centred on people’s needs. Initially it adopted a ‘risk-based’ strategy of using evidence of potential danger to determine the frequency of inspections. In 2011/12 it shifted to annual inspection of all care providers. Next year, however, it will revert to a ‘riskbased’ approach – as well as participating in local Quality Surveillance Groups, alongside CCGs and local Healthwatch.

These changes follow a year in which the CQC has faced criticism of its leadership and its overall performance. The Mid Staffordshire Foundation Trust enquiry led to criticism (for different reasons) of its Chief Executive, Cynthia Bower, and its Chair, Dame Jo Williams. The recent scandal of sustained patient abuse at Winterbourne View Care Home led the CQC to be accused of failing to conduct regular inspections and respond to ‘whistleblowers’.

In March a Commons Public Accounts Committee concluded that the CQC had “a long way to go” before it could be considered an effective regulator. The recent resignations of Bower and Williams have reduced the shadow over the leadership. The new CQC Chief Executive, David Behan, has a background in social care rather than healthcare. But can the problems of regulating provider quality in the new health and social care system be solved by such changes, or are they systemic issues beyond the scope of the CQC?

In safe hands
The CQC’s annual report for 2010/11 noted that by April 2010 it had licensed all 378 NHS provider trusts, and had required 22 trusts to take specific actions to improve their services. By October 2010 it had re-registered 12,000 adult social care and independent health providers, and had required almost 1,000 care homes to put in place qualified managers. By July 2011 it had registered 18,000 dental care and independent ambulance providers. The inclusion of primary medical services will add 8,000 providers to the list.

Each provider is accountable for each separate ‘regulated activity’ it provides, and must show that the service meets acceptable standards of quality and safety. CQC standards cover these areas:

• Informing patients and involving them in decisions about their care.
• Personalised care, treatment and support.
• Safeguarding and safety of the care environment.
• Suitably qualified and capable management and staff .
• Risk management and incident reporting.

A further responsibility of the CQC is to respond to complaints about services – and in particular, to provide a safe and responsive port of call for ‘whistleblowers’: care provider staff who report failings in quality or safety.

Winter in social care
Financial pressure was a feature of the CQC’s role from the outset. Its initial budget was 30% less than the combined budget of the three organisations it had replaced. The Labour Government set a ‘light-touch’ agenda for inspection: unless there was evidence of risk, providers would be left uninspected for
up to two years.

The coalition Government’s review of arm’s length bodies in July 2010 reinforced the CQC’s role as regulator for health and social care. However, it was not exempt from the general requirement that the NHS ‘do more with less’. Its annual budget for 2010/11 was set at £16.4m – £10m less than it had told the DH it needed to cope with the combined task of registering and inspection.

As a result, the number of inspections carried out by the CQC fell by 70%. Concern over its performance came to a head in the Winterbourne View scandal, where action to stop the mistreatment of learning-disabled patients in a care home run by private firm Castlebeck had been unacceptably slow. The regulator had failed to act on information from a ‘whistleblower’, and only a BBC Panorama report had brought the abuses to public attention.

In the aftermath of the scandal, a Health Select Committee report accused the CQC of devoting too much of its resources to registration, a sign of “distorted priorities”. However, Kings Fund Director of Policy Anna Dixon observed: “It is no good preaching the virtues of light touch regulation, and then blaming the regulator for not taking a more interventionist approach when problems emerge.”

The later Commons Public Accounts Committee report highlighted several CQC failings: lack of inspections,
failure to fill key vacancies in its inspection team, and the decision to scrap a helpline for whistleblowers. The committee said the CQC risked becoming a mere “postbox” for complaints.

Jo Williams described the Winterbourne View case as a “watershed moment” for the CQC, triggering its abandonment of the ‘light touch’ approach. The regulator asked for – and got – a £10m increase in its budget for 2012/13 to increase its number of inspectors by 15%, enabling it to adopt a policy of inspecting each provider at least once a year.

Crisis of leadership
The issues affecting the CQC leadership reflect some of the conflicts of interest that can arise for care regulators. The Mid Staffordshire inquiry – the greatest hospital safety scandal in the NHS’s history – concerned events that took place before the formation of the CQC. However, Cynthia Bower was head of the West Midlands SHA at that time, and the inquiry was critical of her role.

The Healthcare Commission (HCC) had warned the SHA about the unusually high mortality rate at Stafford General Hospital. According to the Guardian, Bower responded by commissioning a known critic of the HCC at Birmingham University to write a report on the HCC’s methodology. When the CQC was formed, Bower disbanded the HCC’s inspection team.

The Mid Staffs inquiry led to severe damage within the CQC. Senior operations analyst Rona Bryce claimed the testimony of CQC Board members was “aspirational”. Board member Kay Sheldon contacted the enquiry to voice concerns she said she had raised internally without result. Dame Jo Williams then asked the Health Secretary to dismiss Sheldon, but he declined. Williams also commissioned a third-party investigation of Sheldon’s mental health.

The way forward
David Behan, who took over as CQC Chief Executive in July 2012, had been Director General of Social Care at the DH since 2006. His appointment suggests a shift towards greater focus on social care regulation. The DH has set three core goals for the CQC going forward: to become more strategic in its approach and define quality more clearly in terms of outcomes; to make its Board stronger and more accountable; and to make the regulatory process more systematic and proportionate to risk.

The reversion to a risk-based approach is clearly driven by the cost-cutting agenda. However, Behan promises a “more ambitious” use of performance data to highlight success as well as failure, helping to drive widespread improvements in care. He also plans a “differentiated regulation” of health, mental health and social care providers.

In addition, from April 2013 the CQC will work alongside CCGs and local Healthwatch to develop a network of local and regional Quality Surveillance Groups. According to the NHS Commissioning Board, this system will “act as a virtual team” across health and social care, and will “need to manage itself ” without governance. It will use a ‘risk summit’ model to deal with problems, but who takes primary responsibility will depend on the circumstances.

These changes show the CQC becoming more devolved, but also more able to assist the integration of health and social care. However, as providers become more diverse while funding both for inspection and for care becomes steadily tighter, the future is unlikely to be problem-free for the regulator. The CQC will need to continue walking a tightrope between a ‘light touch’ agenda and urgent reactions to healthcare disasters – its success will depend primarily on getting better at it.

The NHS has billions of pounds which is being unused, according to a new report by the Audit Commission.

Research into the NHS’ financial year 2011/12 discovered there was nearly £4bn in ‘uncommitted finances” after PCTs, SHAs and NHS trusts restricted spending.

The NHS Confederation said the money should be given to CCGs across England to help transform local health services.

The report revealed NHS organisations had a combined under-spend and surplus of £1.6bn. However, the number of NHS trusts and foundation trusts in deficit increased from 13 in 2010/11 to 31 in 2011/12. A small number of trusts did report improved finances during the same period.

It also highlighted the financial difficulties NHS trusts have in different parts of the country. The majority of NHS trusts in deficit were either in London or around the south east.

Andy McKeon, Managing Director of Health at the Audit Commission, said the findings show there is “financial room for manoeuvre in the future.”

“The NHS has also delivered the first tranche of its £20bn savings required by 2014/15,” he said. “While nationally the NHS appears to be managing well financially, and preparing itself for the changes and challenges ahead, a number of PCTs and trusts are facing severe financial problems.

“The Department of Health and other relevant national authorities need to focus their attention on the minority of organisations whose financial position is deteriorating, and on their geographical distribution and service standards.”

Mike Farrar, NHS Confederation Chief Executive, said the funds should be used for “big investment in community and primary care” to ensure services can meet demand in the future.

“Fundamental changes to the way we provide care are necessary if the NHS is to maintain financial balance and become more responsive to patients’ needs,” he said. “Doing this will require some difficult decisions and in some cases will require changing or closing down some services, but this can only happen if we build up the capacity in the community and in primary care to enable people to be treated at home.”

The Government’s controversial NHS reforms have resulted in a host of health officials being paid more than Prime Minister David Cameron, research has found.

Figures released by the Treasury show that more than 50 NHS employees earn more than the £142,000 annual salary David Cameron receives for running the country.

The well paid roles include 15 team director posts at the NHS Commissioning Board.

Rachel Reeves, the shadow Treasury Chief Secretary, said it was “staggering” that whilst NHS employees are losing their jobs the Government is “forking out on dozens of salaries” higher than the PM’s.

A freedom of information request by The Sunday Telegraph found that originally 77 posts would earn more than the PM’s annual salary as a result of NHS restructuring. “In relation to these roles, consideration was given to the skills and remuneration of existing NHS employees, ensuring that salaries were approved within an equivalent range,” said a statement by the Treasury.

The Treasury added that a further ten posts were approved in the four temporary Strategic Health Authority clusters, which are set to be disbanded in April next year.

“No one voted for these changes to the NHS, and it is shocking to learn that they are costing taxpayers millions of pounds in these salaries alone,” said Rachel Reeves.

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.

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.”

CCGs in North Yorkshire and York must be included in the development plans to overcome the commissioning deficit in the region, NHS North of England has said.

Board papers from the SHA reveal that measures to tackle the £19m deficit will not be completed within 2012-13 and strategies must be developed by CCGs to ensure financial plans are affordable.

The document outlines how “significant work” is continuing to address both short-term and long-term challenges to bring “the situation back to a financially sustainable position”.

It said that the “engagement” of commissioning groups in tackling the deficit is “essential” to ensure the delivery of activity levels that are “manageable and deliverable” in the future.

Papers also revealed that Mid Yorkshire Hospitals Trust has submitted a plan to tackle its own £26m deficit in 2012-13 after it received £10m in financial support from NHS Yorkshire and York PCT cluster.

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.

The Strategic Health Authority which controls London has transferred £2.2m from its budget for mental health services to fund its latest cancer programme.

Its Delivery Group approved the cut in mental health services to match priorities set by the board after it was decided that care could still be provided “under more streamlined” arrangements.

Minutes from the recent board meeting show the budget switch was made following a “detailed process of challenge and scrutiny”.

Cancer services in the capital were recently merged in a move the NHS hopes will save up to 1,000 lives a year.

London Cancer combines hospital specialists, GPs and scientists and allows patients to receive specialist care closer to their homes.

Professor Kathy Pritchard-Jones (pictured), Chief Medical Officer, London Cancer, said the capital has “some of the best scientists and clinicians in the country” but the challenge is to get them working together “much more effectively”.

“I think this is a real opportunity to do something ground-breaking for our patients,” she said. “We’ve been given the opportunity to think really big and to plan services for a population of three and a half million people in north and east London, so this means we can now compete with the very best in the world.”

It’s estimated that around 13,600 people die from cancer each year in London, and around 27,000 people are diagnosed with the disease.

THE NHS Commissioning Board’s role in NHS reform is still widely debated. Pf looks at how it will direct the NHS of the future.

The new NHS Commissioning Board (CB) is unique in three respects. Firstly, it stands to take on more power than any arm’s length body in NHS history. For up to three years at a time, it will be entrusted by the Government to run the NHS and allocate its entire commissioning budget, without regular scrutiny by Parliament.

Secondly, it stands to hand over more power than any arm’s length body in NHS history. Of its annual £80bn
commissioning budget, £60bn will be delegated to the 212 Clinical Commissioning Groups responsible for commissioning local services. While the CB will commission primary care from the CCGs and ensure that they deliver on the NHS Outcomes Framework objectives, it will allow them to devise their own solutions and choose their own partners.

The powers of the SHAs are being delegated ‘upward’ to the CB, while the powers of the PCTs are being delegated ‘downward’ to the CCGs. The widespread concern about a potential gap in responsibility led Sir David Nicholson to say: “The NHS Commissioning Board could turn into the greatest quango in the sky. So it needs to have clinicians at its heart and the powerhouse for change in the system must be the
clinical commissioning groups.”

Andrew Lansley’s letter to the CB’s Chair, Malcolm Grant, in April about the Board’s strategic objectives stresses that its first responsibility is to make a “shift of power from national and regional organisations to CCGs, Health and Wellbeing Boards, local providers and patients.” The CB will not be a monolith within a static system: it will be a facilitator of future NHS transformation. That dynamic role is the third unique
feature of the CB, and the most important.

TAKING THE REINS

The DH plan Developing the NHS Commissioning Board (July 2011) outlines the intended structure and functions of the Board. It will have two broad national roles: to commission primary care and specialised services, and to ensure that the entire commissioning system is “cohesive, co-ordinated and efficient”.

Using £20bn of its annual budget, the CB will commission GP services and specialist health areas, including dentistry, maternity, community pharmacy and ophthalmic services. The Board will not govern the CCGs in a traditional way: it will “support” them and “hold them to account” while allowing them “freedom to innovate.” This support includes authorisation, an outcomes framework, guidance tools such as model pathways, and a means of intervening when CCGs are in difficulty.

The CB will host clinical networks to advise on specific areas of care and multi-disciplinary clinical senates to support CCG decision-making. Another key role of the CB is to lead the NHS Outcomes Framework by supporting local clinical improvement, providing “more services outside hospital settings”, improving acute care and the management of long-term conditions, and ensuring that CCGs implement NICE and other national standards.

In addition, the Board will lead patient-centred care by overseeing “the extension of patient choice and the expansion of information available to patients” and promoting both integrated care and innovative self-care.

Finally, it will develop a “medium-term strategy for the NHS” that will combine with the local priorities identified by the Health and Wellbeing Boards to provide a basis for local commissioning plans.

LEADER OF THE PACK

According to the 2011 outline, the CB will work in “partnership” with many other organisations: patient groups, healthcare professionals, healthcare providers, local government, industry and national organisations such as NICE.

The Board’s relationship with suppliers will “support its strategic approach to innovation and development” – in other words, it will play a part in the dynamic evolution of services and provider relationships.

The CB will be organised nationally around the five domains of the NHS Outcomes Framework, with a national lead for each domain. It will also divide its local teams into four ‘commissioning sectors’ reflecting the four existing SHA clusters, each with a sector lead.

The Board will take over functions performed by 8,000 people. It plans to reduce that number to 4,000 – a reflection of its ‘light touch’ approach.

RIDING THE WHIRLWIND

According to Lansley’s letter to Grant, the CB has a responsibility to “contribute to” improved health for “the whole population”, improved care and outcomes “for all patients”, and improved efficiency. Within this context, the Board Authority’s strategic objectives include “transferring power to local organisations” and “establishing the commissioning landscape”. The new NHS will then develop under its own steam, with the clinical networks and senates providing “leadership and insight rather than oversight and compliance”. The authorised CCGs will have the “assumed liberty” to design local services independently.

In addition, Lansley says, the CB will have a “vital leadership role” in enabling the personalisation of care by improving patient choice. This includes the use of personal health budgets. At the provider level, the CB will play a “crucial part” in developing a “level playing field” for competition.

In short, the role of the NHS Commissioning Board is to facilitate the evolution of a rapidly changing healthcare system. These changes will come not from the Board or the DH, but from the decisions of CCGs and their commercial partners.