The PCT Procurement Guide supports NHS commissioners in deciding whether and how to procure health services through formal tendering and market-testing exercises. The Guide sets out the policy and regulatory context for procurement, and issues to consider when developing a procurement strategy. The Guide should be read in conjunction with the Principles and rules for Cooperation and Competition, published as Annex D of the 2008/9 Operating Framework, and the Framework for Managing Choice Cooperation and Competition

The Framework for Managing Choice Cooperation and Competition supports SHAs and PCTs in understanding the roles, responsibilities, values and behaviours required for the effective management of choice and competition within the NHS. The Framework is the outcome of a series of workshops and seminars with senior SHA and PCT leaders. The Framework should be read in conjunction with the
Principles and rules for Cooperation and Competition (Annex D of the 2008/9 Operating Framework) and the PCT Procurement Guide (published 16 May 2008). Additionally, the Framework signals a further series of tools and guidance for system managers to be released throughout the year.

Project: London is a clinic of Medecins Du Monde (UK) which aims to support migrants that need help accessing healthcare.  It has just  published its second annual report the Project: London report and recommendations 2007: Improving access to healthcare for the community’s most vulnerable.

The report finds no evidence of health tourism, with patients had been in the UK for an average of 3 years before accessing care from Project: London. Migrants are no more likely to have expensive, complicated medical needs than anyone else. It also identifies difficulties for pregnant women in accessing proper care. Although they were entitled, nearly 70% of the women had no access to care, a situation which puts both mother and child in jeopardy, and must be addressed as a matter of urgency.

Proposed changes to NHS access for migrants are unlikely to be cost effective because:

• Lack of GP access means no chance of preventing diseases
• Lack of GP access means no chance of early and affordable treatment of diseases – including those which are contagious
• Lack of GP access is likely to lead to increased pressure on already burdened A&E department.

• Improving Access to Psychological Therapies (IAPT) Commissioning Toolkit
• CSIP Better Commissioning programme
• New NICE Commissioning guides: Cognitive behavioural therapy and Faecal continence service
• West Kent PCT: World Class Commissioning strategy and delivering a commissioning model
• National Cancer Intelligence Network
• Commissioning Specialist Library: Have you say
• A resource to help primary care pharmacists in England involved in PBC
• Revised guidance: primary care dental contracts Advice on managing end of year issues
• Other documents, websites and conferences

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The NHS Next Stage Review has been led locally by clinicians in each NHS region. Seventy-four local clinical working groups, made up of some 2000 clinicians, have been looking at the clinical evidence and engaging with their local communities. They have developed improved models of care for their regions to ensure that the NHS is up to date with the latest clinical developments and is able to meet changing needs and expectations.

NHS Next Stage Review Leading Local Change sets the context for these local visions and the principles which will guide their implementation.

The Evaluation of Early Medical Abortion (EMA) Pilot Sites - final report has been heavily reported in the mass media today.  It was commissioned by the Department of Health to assess the safety, effectiveness and acceptability of early medical abortions (EMAs) in non-traditional settings, and to help establish a protocol to cover the elements and processes required for the delivery of a safe EMA service in non-traditional settings.

Conclusions

• Subject to the fairly considerable limitations of the current study, and from a range of
  sources, including medical records, and staff and client views, there are no discernible
  differences between the pilot sites and their matched comparator sites in terms of the safety,
  effectiveness or acceptability of non-traditional sites for the administration of early medical
  abortions.

• Detailed protocols and guidelines should be developed to cover staffing requirements as well
  as clinical aspects of care.

• Given the importance of reassurance and support throughout the process, the centrality of
  suitably motivated and skilled nursing staff to any expansion of EMA provision cannot be
  overestimated.

Patient Experience Scores for the PSA target – April 2008 updates the patient experience scores published on 29 January 2007. They include scores derived from survey results published by the Healthcare Commission for 2006/07. There are new data points for ‘adult inpatients’ and ‘community mental health’ in 2006/07. These figures report on progress against the PSA target for sustained improvement in patient experience.

• The overall patient experience score for adult inpatients in 2006/07 has increased slightly to 76.4 from the score of 76.2 in 2005/06. The score is 0.7 points higher than in the earliest fully comparable year of 2003/04 (75.7).
• The overall patient experience score for community mental health services in 2006/07 has increased to 75.2, up 0.7 points from the score of 74.5 in 2005/06. 
• Scores for ‘involvement in decisions about healthcare’ cannot be compared across sectors.  The baseline scores for emergency services (2004/05) is 77.1.  The baseline score for outpatients (2004/05) is 81.7.  For adult inpatients, the latest score of 70.9 is unchanged from 2003/04.  Results for community mental health services show a slight increase to 63.7 in 2006/07 (from 63.3 in 2003/04) whilst primary care results are slightly lower at 81.9 in 2005/06, compared to 82.1 in 2003/04
• The baseline score for ‘choice of provider’ is 27.3 from the 2005/06 DH survey of PCTs.  This score represents the baseline position in the last year before the choice of provider policy was introduced. 

Interim Guidance on Directed Enhanced Service - Extended Opening Hours is intended to help PCTs implement arrangements for GP practices to extend their opening hours, and arrangements for monitoring progress.  This in line with The Operating Framework for the NHS 2008/09 and is issued with the Dear Colleague Letter from Ben Dyson - Extended Opening Hours.

The Ideas from Darzi: Polyclinics report (again from the NHS Confederation) examining polyclinics, the key design rules for them and three possible models, as well as key lessons learned, and the misconceptions and concerns associated with them.

The debate about organisational models for community provider services has been ongoing since 2005. One model being examined is that of a community foundation trust (CFT), allowing community service providers to acquire the same freedoms as acute and mental health foundation trusts.

Towards autonomy from the NHS Confederation draws on the experiences of eight CFT pilots and looks at what other organisations can learn from them. The pilot CFTs have had different experiences but some common themes emerge, most importantly the potential to bring benefits for patients.

The researchers for this paper interviewed 28 GPs working in different settings and environments. They identified four factors that might affect the way GPs work and influence the decisions they might make.

• Updated Child Health Promotion Programme
• Towards World Class Commissioning Competency
• Education Commissioning Briefing
• National Dementia Strategy
• More strategic, timely information needed in primary healthcare
• Putting you in the picture
• Choice at referral
• Refocusing the care programme approach: Policy and positive practice guidance
• National Primary Care Research & Development Centre: Practice Based Commissioning
• Other documents and conferences

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This is the third quarterly practice survey (National summary of results), covering a sample of practices from each primary care trust (PCT). The aims of the survey are to get feedback from practices on their perception of the support offered by their PCT and on the clinical and financial engagement of practices with PBC.  The survey is part of a group of indicators that will be assessed together to give a picture of PBC implementation.

Key findings:

• There has been a rise in the number of practices commissioning new services through PBC (+8 percentage points since Wave 1 and +5 percentage points since Wave 2). 41 percent have commissioned new services through PBC.
• The percentage of practices who have agreed a commissioning plan with their PCT has continued to increase (+11 points since Wave 1 and +3 points since Wave 2). 57 per cent of practices have now agreed a commissioning plan.
• 62 percent of practices support the policy of PBC (a rise of 5 percentage points since Wave 1, and 3 percentage points since Wave 2).
• The percentage of practices agreeing that PBC has improved patient care has marginally increased from 12 percent in Wave 2 to 16 percent in Wave 3. The proportion who disagree that PBC has improved patient care is in line with that of the previous two waves (31% in Wave 3, 30% in Wave 2, and 31% in Wave 1).
• 71 percent of practices claim to have a good relationship with their PCT, a decline of 3 percentage points on Wave 2.
• The proportion of practices who have received a financial incentive scheme has marginally declined since Wave 2 to the levels recorded in Wave 1 (down 4 percentage points since Wave 2 - now 62 percent).
• There has been a rise in the proportion of practices who engage with their local population from 61 per cent in wave 2 to 70 per cent in Wave 3 (an increase of nine percentage points).
• Around 4 in ten practices continue to rate their PCT’s managerial support for PBC as good (40 per cent in Wave 3, 42 per cent in Wave 2 and 37 per cent in Wave 1), however, half continue to rate managerial support for PBC as poor (49 per cent in Wave 3).
• As in previous waves, around a third of practices continue to rate the quality, format and frequency of information provided by their PCT as being good

The devolution of increased power to local NHS bodies and front-line professionals,has resulted in calls to ensure that those who take on increased responsibility are held to account. There is no clarity on how this may be achieved or the extent people want more control over how their primary care trust (PCT) spends its money.

The main political parties im to end the ‘democratic deficit’ and ensure local people have increased input on the delivery of local health care, and this will be a central theme of Professor Lord Darzi’s review of the NHS. The King’s Fund report, Should Primary Care Trusts Be Made More Locally Accountable?, makes a thorough assessment of the various options for making PCTs more accountable to their local communities.

It states that if the aim of involving the public is to give more democratic validity to the health service, systematic changes – such as giving local councillors control over PCT budgets, or electing PCT board members – would be appropriate.

However, improving the quality of services is the target, then an incremental approach would be better.  Targeted initiatives – such as citizens’ juries or enhanced Public Patient Involvement Forums – focusing on specific PCT functions may prove to be a more successful route to accountability.

Improving Access to Psychological Therapies (IAPT) Commissioning Toolkit aims to support the corresponding programme and has one principal aim - to help PCTs implement NICE Guidelines for people suffering from depression and anxiety disorders. The Government is committed to improving access to psychological therapies and announced additional funding to increase services over the next three years. This Commissioning Toolkit is designed to help PCTs improve or establish stepped care psychological therapies following NICE guidelines. The toolkit is structured around the commissioning cycle and is specifically linked to the World Class Commissioning competencies.

More than one in four adults admitted to hospitals, care homes or mental health units are suffering from malnutrition, the Nutrition Screening Survey and Audit of Adults on Admission to Hospitals, Care Homes and Mental Health Units has found. Women and the elderly were at greatest risk, says the report from the British Association for Parenteral and Enteral Nutrition (Bapen). More than 11,000 patients were screened for signs of being under-fed and 28 per cent were found to be malnourished.

It recommends:

• Screening should be undertaken in all institutions and repeated at interval according to care setting, using accurate and reliable instruments
• Results of screening should be included in care plans.
• Nutrition advice and nutrition support teams should be routinely available.
• Strategies to detect, prevent, and treat malnutrition should be in place in all care settings, including the community, where most malnutrition originates.

The Secretary of State has made two sets of Directions, both in respect of Local Involvement Networks (LINks). The first set of directions are to LINks themselves, setting out their duties when it comes to providing annual reports to the Secretary of State. The second set are to commissioners of health and social care services (primary care trusts, NHS trusts in England, strategic health authorities, and local authorities). These set out the requirements they need to include in their future contracts with independent providers. A briefing has been produced by the DH for providers of independent services about this second set of Directions.

Implementing the Health Act 2006: NHS (Pharmaceutical Services) (Amendment) Regulations 2008 Information for Primary Care Trusts on these directions that come into force on 21 April 2008.

Patients will be able to choose where they are treated from any provider meeting Healthcare Commission standards from 1 April, but Free Choice at the Point of Referral a King’s Fund’s briefing on the latest official data finds the policy has some way to go before it is likely to drive improvements in the quality of hospital services.

One of the ambitions of free choice is to create incentives for hospitals to drive up quality standards as they compete for patients, but official data shows that:

• use of ‘Choose and Book’ — the computer system designed to facilitate choice — whilst increasing still falls short of the government’s target, with only 50 per cent of referrals from GP to hospital being made using the system
• although increasing numbers of patients say they remember being offered a choice of hospital by their GP since the policy began in 2006, the proportion is still only 45 per cent
• of those 45 per cent, only 27 per cent said their GP gave them a booklet containing comparative information on hospital performance to help them make a decision.

The Report of the Office of Health Economics Commission on NHS Outcomes, Performance and Productivity identifies that the collection and use of outcomes measures in the NHS is both practical and essential.   In order to do so effectively the report makes the following recommendations:

• Measurement of patient outcomes and use of that information to drive better commissioning of services should be made an explicit element of the Government’s vision of “world class commissioning”.

• Mortality and survival data should be collated and published for all condition/treatment areas at the same time as collection of other outcomes data is initiated. Data on casemix must be collected, so that the crude mortality/survival data can be adjusted for the casemix treated. Confidence intervals should be estimated and reported to permit comparisons to be made over time and between providers.

• For elective surgery, condition-specific measures should be collected beforeand after surgery simultaneously with the generic EQ-5D for all NHS patients undergoing common procedures.

• Measurement of mental health outcomes in secondary care should be reinvigorated with collection of HoNOS data being incentivised in addition to mental health providers being reminded of its mandatory nature as part of the Mental Health Minimum Data Set. Routine collection at annual intervals of the CORE-OM measure for all patients receiving community based mental health services be piloted in a range of NHS Trusts at the earliest practical opportunity in 2008/09.

• Research is required to identify a generic measure of health related quality of life that is suitable for application to mental health patients as well as recipients of other kinds of health care.

• The practicality and value of collecting and using measures of outcomes for COPD patients should be piloted by a range of commissioners and their secondary and primary care providers, commencing in 2008/09. The preferred disease specific measure is either the Chronic Respiratory Disease Questionnaire (CRDQ) or the St George’s Respiratory Questionnaire (SGRQ).

• For colorectal cancer patients, mortality data (1 year and 5 years after diagnosis) should continue to be monitored and assessed as an important but partial measure of health service productivity in this disease area given its relatively high rate of mortality. But at the same time instigation in 2008/09 of pilot programmes of routine use of the EORTC QLQ-CR38 instrument to measure outcomes in colorectal cancer patients simultaneously with the EQ-5D or an SF- series generic measure should be undertaken.

• Collection of data about the wider benefits from health services by addition of questions on patients’ experience of care to the patient questionnaires used to measure health outcomes. Aspects covered should include: access, care co-ordination, autonomy, choice, communication, confidentiality, dignity, quality of amenities and support for carers.Further research is needed into the relative values of the wider benefits referred to in recommendation 8 and by compassion with health outcomes.This should be commissioned during the course of 2008/9.

• Information on wider benefits is already collected in national patient surveys. Building on its ‘customer experience information’ project, the Department of Health should work with its counterparts in Northern Ireland, Scotland and Wales on a UK-wide stock-take of patient surveys in process and planned, and then use this as the basis for discussion with all the interested parties how to co-ordinate those surveys in future.

• After a short period of research to identify the most practical way of collecting such data, including working days lost, measurement of productivity effects should be commenced for patients being treated for mental health problems, diseases of the nervous system and diseases of the musculo-skeletal system should be identified.

• Modification of existing national surveys of a sample of the general population should be investigated as one way of collecting at a general level data relevant to the wider societal impacts of health care interventions, including impacts on carers.

• Health care professional bodies, including the Royal Colleges, should explicitly and actively support the collection and use by their members of patient outcome measures, including the provision of training in their collection and use for both existing and new clinicians.

• Training in understanding and using outcome measures should be provided to NHS commissioner and provider managers.

• Investment should be made in IT and appropriately trained staff to enable user-friendly information collection, collation and analysis of outcome measures.

• The NHS should, commencing as early as possible in 2008/09, pilot, monitor and evaluate explicit incentives to collect, collate, analyse, feedback and use patient outcome measures. Initially at least this would not be extended to rewarding providers for the measured levels of outcomes achieved, although that could be considered once experience with use of outcomes measures has accumulated.

• There should be an expectation that within 5 years (i.e. by the end of 2012/13) routine measures of patient outcomes comprising the impact of an NHS intervention in terms of patient survival, quality of life, and experience of care, are collected for the majority of NHS activity. Within 10 years it should be the exception rather than the rule to find an area of NHS activity that is not assessed and actively managed according to the outcomes achieved.

• The NHS should work with the ONS Centre for the Measurement of Government Activity to ensure that the health outcomes data used by the NHS can also used by ONS in its periodic assessments of NHS productivity and, subsequently, in the National Accounts.