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Third Sector Learning Event

Welcome & Introduction

Melinda Letts OBE

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Strategic context for the Standard NHS Contracts

Anthony Kealy – Contract Development Lead

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Why do we need new contracts?

• To strengthen commissioning

• To improve NHS business processes

• To strengthen accountability and improve performance

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‘Failure of Commissioning’

NHS has ‘commissioned’ for over a decade, but …

• ‘Command & control’ model has consistently reinforced the ‘provider line’

• Commissioners have lacked robust levers

• Not all available levers have been used

• Inadequate regulatory regime

• Low investment in developing commissioners

• Highly variable & fragmented practice

• Lack of legitimacy (linked to ‘voice’ & patient /public engagement)

• Very limited range of providers

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Re-launching commissioning

– Commissioning Framework (July 06)

– Third Sector Commissioning Task Force – (July 06)

– Practice-Based Commissioning Guidance (November 06)

– Interim New NHS Contract (December 06)

– Commissioning Framework for Health & Well-being (March 07)

– A Vision for World Class Commissioning (December 07)

– New standard acute contract (December 07)

– New standard community, mental health & ambulance contracts (December 08)

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A new approach to contracting

• The need for new NHS contracts was introduced with in the

Commissioning Framework, July 2006

• This was reinforced by the Third Sector ‘No excuses…’ report

• Contracts becomes the main tool for achieving accountability and

improving performance in a system with more autonomous providers

• The final version of the acute contract was published with the 08/09

Operating Framework

• New contracts are now being developed for

– Ambulance

– Community

– Mental Health

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Structure of the Contract

‘Must have’ elements for local negotiation

1. Are contractual or legal requirements

2. Are defined centrally

3. Require local detail so local agreement is necessary

4. Provide flexibility within a framework

5. Co-ordinating Commissioner defines consortium rules (by agreement)

6. Must be completed to make contract executable

Elements for local agreement

1. Are locally defined, with no national or legal requirement

2. Must be internally consistent and not ‘trump’ required elements

3. Could cover any issues, but typically might cover care pathways, treatment protocols, quality standards

Nationally Applicable Standard Terms

1. Are set centrally

2. Can be changed generically only through the NHS Operating Framework

3. Could be considered as “Standard NHS Terms and Conditions”

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Main features

• A standard – not a model contract

• A new model of co-ordinated contracting

• Activity planning and review

• Demand management requirements

• National and locally-agreed quality standards

• Requirements on information flows and provision

• Dispute resolution arrangements

• Contractual Control mechanisms.

• Sanctions and / or incentives for performance on a small number of

priority issues

• Locally-defined service specifications

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Stakeholder Principles

The contract should:

• Reflect vision, long term planning and change

• Recognise the community interest

• Provide clarity on commitments that need to made to stakeholders

• Clarify and define respective roles and responsibilities

• Recognise that open information is required from both parties to manage the contract

• Underpin a relationship between equals

• Understand mutual dependency and benefit of the parties in aiming for a partnership approach

• Support co-operation and collaborative behaviours that benefit both parties and cement the positive relationship between them.

• Be based on terms that are deliverable in practice

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Expected behaviours

• Find and support win-win solutions

• Achieve appropriate risk sharing, and sharing of any benefits that are

realised by mutual effort

• Maintain mature, regular dialogue within a professional code of conduct

• Ensure flexibility where there are genuine problems in delivery

• Provide incentives as well as penalties

• Recognise investment required to achieve requirements over a

reasonable time period

• Support providers to change their service offer over time in relation to

changes brought about through patient choices

• Maintain honesty and transparency – across both parties and with

patients and the public

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Project management

Mark Britnell

Contract National Steering Group

Stakeholder Reference Group

Mental Health Project Group

Ambulance Project Group

Community Services

Project Group

Task Sub-Groups

DH Contract Project Support

Group

Task Sub-Groups

Task Sub-Groups

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Developing a new Standard NHS Contract for Community Services

- Overview of scope and structure

Tracy CannellSystem Management and New Enterprise Directorate

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Aims, Strategic Links and Potential Barriers of Community Services Contract

Strategic Links

Next Stage Review including Primary & Community Services Strategy

System Management

3rd sector & SE Programme

Wider programme re. community services development

Links to CQC re standard setting, monitoring and response to failure.

Aims

Flexibly support innovative commissioning approaches

Improve care outcomes,

Catalyst to maximise quality and productivity

Support both joint commissioning & pathway based care

Develop benchmarking.

Potential Barriers

Wide scope of coverage

Cross-departmental approach for Section 75 agreements

Joint approach to be agreed with DCSF re. childrens’ services,

Legal agreements already in place with non-NHS bodies may delay implementation

Current lack of standards/ targets in relation to quality and activity

Community MDS not in place, metrics not yet available for majority of services

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Out-Patient careIn-Patient Care Community drop-in

Domiciliary Care21 43

Includes Rehabilitative and palliative care in community hospitals, hospices, nursing or residential homes

Includes therapy services such as physiotherapy and podiatry as well as district nurse clinics.

Includes specialist services such as family planning & health visiting

Includes home visits by district nursing, occupational therapy, community midwifery and health visiting.

Community Services

Scope of community services contract

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Potential Contract Routes for Community Services (1 of 2)

Commissioner

Benefit: Reflects most common current practice with commissioner contracting on an organisational basis with each provider therefore easy to implement

Option 1

Option 2 Commissioner

Lead provider for geographical area

Benefit: Could reflect PBC or local approach with Local Authority with one provider accountable to commissioner

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Potential Contract Routes for Community Services (2 of 2)

Commissioner

Strong Commissioning

Commissioner

Lead provider

Benefit: One provider retains clinical and financial responsibility for the patient, as well as accountability to the commissioner

Benefit: Commissioner / provider split is maintained, and commissioner retains full control of commissioning care

Option 3

Option 4

SINGLE CARE PATHWAY

SINGLE CARE PATHWAY

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Core Requirements

Heads of Terms Local Issues Supporting Guidance

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Standard section containing nationally mandated approach with no local variation

Contains standard legal requirements

National core standards applicable to all community services, e.g. this could include HCAI targets, minimum data collection requirements

Nationally identified issues but local targets, e.g. Could include stretch targets for performance information and quality standards.

Service specification template to support locally determined commissioning

To include guidance re. liabilities

Community Services Contract

Structure of community services contract

For local determination

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Performance and quality issues being considered for inclusion

• Patient held records

• Patient based use of NHS number

• Use of national MDS (to be developed)

• Assessment & care plan

• Diagnosis & Treatment codes

• Outcomes

• Communication between professional/services

• Infection control

• Choice/convenience - appointment times, transport and location

• Waiting times – 18 weeks, 1st & follow up, referrals

• Patient satisfaction

• Patient information re service

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Key Policy Issues to address

• The role of sanctions and incentives

• Minimum information requirements and flows

• Mandatory performance and quality requirements

• Anticipating outcome of community metrics work and development of

tariffs

• Compact Compliance e.g. Flexible payment arrangements

• Transition and adoption requirements for very small providers

• Relationship with primary care contracts

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Key timescales & milestones

March - Collation of current best practice completed

April - Outline heads of terms available

- Stakeholder workshops

- Initial testing with stakeholders commences

June - Identification of test sites & initial workshops

- 3rd Sector Learning Event

September - Test sites complete Final Report

October - Impact assessment processes

Nov - Contract published & Transitional guidance issued,

Dec - Implementation support programme

Feb 2009 - Contracts agreed and signed

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Further Information

• Tracy.Cannell@dh.gsi.gov.uk

Monthly Bulletin available via ‘The Week’

(www.dh.gov.uk/en/managingyourorganisation/commissioning/DH_085048)

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Performance and quality issues being considered for inclusion

• Patient held records

• Patient based use of NHS number

• Use of national MDS (to be developed)

• Assessment & care plan

• Diagnosis & Treatment codes

• Outcomes

• Communication between professional/services

• Infection control

• Choice/convenience - appointment times, transport and location

• Waiting times – 18 weeks, 1st & follow up, referrals

• Patient satisfaction

• Patient information re service

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Workshop Discussions

• Each group to consider how the contract can provide a sound approach and clarity for both commissioners and providers re. responsibility and accountability, performance management, risk management

• Identify any barriers/enablers/vital links

• Consider what support will be required to implement the contract

• And also specifically:

– Performance Management

– Contract Terms

– Service Specification

– Quality Standards

– Flexibility

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Workshop Topics

Group 1- Performance Management• What are the key performance measures

that should be incorporated into the contract as a baseline platform?

• Are/should these be duplicated by regulation?

• What measures should have incentives or penalties attached?

Group 2 – Contract Terms• Are the generic heads of terms

appropriate in both its scope and detail?• Can/should we scale the documentation

according to contract value?• Should block contracts be permitted? Is

there sufficient understanding in the use of contracts vs grants?

• What if any variation or flexibility be given to the contract duration and notice periods?

Group 3 - Service Specification• Will the proposed specification guidance

be sufficient to support local commissioning?

• Is it structured appropriately?• What supplementary guidance would be

helpful?

Group 4 – Quality Standards• What are the key generic standards that

should be incorporated into the contract as a baseline platform?

• Are/should these be duplicated by regulation?

• What standards should have incentives or penalties attached?

Group 5 – Flexibility of ContractIs the contract appropriately structured to support both commissioners and providers of:-• Differing Organisations• Care pathways• Umbrella or lead provider arrangements• Section 75 arrangements• Co-ordinated commissioner arrangements

If not how should this be changed and/or what’s missing?