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.

• 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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• 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

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.

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.

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.

Extensively discussed in the mass media Choice at referral: guidance framework for 2008/9  provides best practice guidance and information for referrers, providers and commissioners on how the roll-out of free choice in elective care in 2008/9 will operate.  It is supplemented by the Impact of Free Choice policy in Choose and Book R4.0.

Local Pharmaceutical Services (LPS) - guidance notes provides information on aspects of LPS permanence which allows PCTs to enter into LPS contracts without requiring prior approval of the Secretary of State for Health and provides PCTs with flexibility to make LPS arrangements in response to local needs within timetables of their own choosing. The guidance also details the commissioning process and may be of use to those PCTs that wish to use LPS

The Commissioner Volume 3 Issue 3 from the North West Primary Care Librarian’s Group was published today with its podcast ( Standard Podcasts [6:22m]) contents are:

• PBC: Personalise your Improvement with the No Delays Achiever

• Dental Commissioning and Contract Monitoring - Tendering, Procurement & Contracting

• Evaluation of One-Stop Shop (Oss) Models of Sexual Health Provision

• Improving Access to Psychological Therapies implementation plan

• National Infarct Angioplasty Project (NIAP) interim report

• Practice-based commissioning : tips for preparing and pitching a proposal

• Strategic commissioning for older people

• Apply for Beacon Status

• Other documents and conferences

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The Diabetes NSF and transformation of care services is crucial to addressing the escalating Diabetes epidemic thought to be affecting the lives of 2 million people in the UK and imposing a £3.5 billion a year cost on the health service, equivalent to 5% of the NHS budget

Dr Sue Roberts, National Clinical Director for Diabetes, reviews the key factors and changes required to manage the scale of the epidemic and to deliver better outcomes for people with diabetes. It considers:

• Impact of the transition from Acute to Primary Care setting for diabetes services
• Building capacity to screen and treat 750,000 hidden sufferers
• Revolutionising commissioning
• Scaling up patient education programmes to support self-care

In 2001, the Government published the National Sexual Health and HIV Strategy and one of the recommendations is the provision of more comprehensive and integrated sexual health services. One of the commitments in the strategy was to undertake an evaluation of different models of One Stop Shops. 

Evaluation of One-Stop Shop Models of Sexual Health Provision, which has just been published provides valuable findings and information for PCT commissioners and service providers considering an integrated approach as well as those already providing integrated services. 

It finds:

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David Stout, Director of PCT Network at the NHS Confederation, shares his vision for World Class Commissioning and its potential to transform health services and drive improvements in health outcomes.

He advises on how Trusts can step-up their current approaches in World Class ways - for example, planning for the longer term needs of the population through more effective public engagement and techniques such as risk stratification.

In particular, Mr Stout defines the role of the NHS Confederation and how they are supporting PCTs in their transition.

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The World Class Commissioning initiative provides a major opportunity for Trusts to transform care services and develop new ways of maximising the value of limited healthcare budgets.

While Trusts wait for the WCC Assurance Framework, there are many ways to start planning the transition to World Class Commissioning. Evidence-based analysis of population requirements, how money has been spent and how other organisations are approaching commissioning is a key starting point.

In this interview, Andrew Beale, Executive Director of Matrix Knowledge Group consultancy, discusses how evidence-based analysis can help Trusts to better understand their current position, population healthcare patterns and to maximise the benefit of their investments within the available resources.

Genitourinary Medicine 48-hour Access: Getting to target and staying there  is a good practice guide for primary care trusts to help support clinics to reach the Genitourinary Medicine (GUM) 48-hour access target by March 2008.  It builds on the 10 High Impact Changes for Genitourinary Medicine 48-hour Access (HIC).

High impact changes detailed are:

1. Measure demand and capacity across the local health economy
2. Begin a process improvement project to inform service redesign
3. Analyse and improve utilisation of the multidisciplinary teams in GUM
4. Develop a separate pathway to manage screening of patients at low risk for STIs
5. Review current access system and make it easier for patients to access the service
6. Reorganise clinic opening hours to improve access
7. Reorganise the physical environment to maximise the space available for seeing patients
8. Reduce unnecessary clinical activity to increase capacity for new patients
9. Assess the state of readiness of STI service providers outside GUM, and prioritise developments that will help meet and sustain the GUM access target
10. Make costs of GUM services transparent and develop commissioning consortia which reflect patient flows

The Right Result? Payment by Results 2003-07 details how Payment by Results (PbR), has been embedded across the NHS and has helped hospitals to be more business-like.  It should start to deliver the significant increases in productivity and efficiency across the NHS that the policy was designed to achieve.The PbR policy was introduced by the government four years ago and is a system of paying hospitals nationally set prices for the number of patients and types of conditions they treat. It is designed to encourage hospitals to treat more patients, more efficiently without compromising quality of care.

This Audit Commission report finds that under PbR most hospitals have improved their financial management and now have a better understanding of how much it costs them to treat patients. The impact on the NHS in terms of efficiency and activity has been smaller than expected, however, and PbR seems to have contributed to positive trends rather than driven them.

The report sets out a number of priorities for future development of the policy that need to be addressed if PbR is to deliver further improvements:

For Primary Care Trusts

• Further develop commercial, legal and contracting skills, identifying gaps in line with the developing World Class Commissioning competencies, to improve their ability to operate in the PbR environment.

• Ensure that 2008/09 contracts contain appropriate incentives and penalties to support appropriate, high quality care, for example, readmissions targets, and that information requirements are clearly specified and enforceable. Progress against these targets should be reported regularly.

• Adopt a robust yet proportionate approach to monitoring and challenging provider activity and costs under contract, prioritising investment in practice level information systems so that practices can engage in the planning and monitoring of hospital activity.

• Actively monitor provider actions in response to the Audit Commission’s PbR data assurance audits, and use the findings from these audits to supplement existing information on potential data quality issues.

For Acute NHS Trusts

• Ensure that robust information and reporting systems are in place that meet all internal and external requirements within the minimum reporting deadline of 30 days following the end of the month, and that local information systems are in place to complement SUS as necessary.

• Embed and promote service-line management and reporting, paying particular attention to the use of surpluses and how this will be managed within the organisation.

• Understand the costing data they require to manage the business, and invest in improving internal costing systems, considering the business case for introducing patient level costing systems where appropriate.

• Prioritise the implementation of the OPCS-4.4 classification system for procedures, to improve coding internally and to support the introduction of HRG4.

• Engage in discussions with commissioners about changing patient pathways, demand management and use of local flexibilities, such as unbundling the tariff into its component parts.

For the Department of Health

• Identify and explicitly prioritise the changes that will be most effective in achieving policy objectives, and ensure that the development programme for addressing these priorities is realistic, properly resourced and communicated to stakeholders.

• Ensure that timely guidance, support and direction continues to be provided to both commissioners and providers in a balanced way, including more effective mechanisms for receiving and providing feedback, particularly in relation to contract and information issues.

• Review and address the perceived limitations of SUS in supporting PbR, ensuring there is a clear vision for NHS data and organisations’ responsibilities that is shared by NHS Connecting for Health and the Information Centre for Health and Social Care, and that the expectations of the NHS are consistent with this vision. Additional steps should be taken to ensure that guidance from these bodies is consistent.

• Invest in information systems to capture and report on community services and support the development of an appropriate payment mechanism.

• Monitor usage of the new standard contract and reinforce the move toward a consistent approach to contracting across the NHS, providing guidance as appropriate to ensure that balanced, fair contracts, that support nationally agreed principles, are negotiated.

• Use the tariff as a policy lever to drive desired behaviours, rather than purely as a reflection of average costs, signalling likely changes to the NHS well in advance.

• Explore the use of separate payment streams in addition to the tariff, for example to reward quality or to fund capital costs, where this is necessary to provide the right incentives to NHS bodies.

• Carefully monitor the implementation of HRG4 to ensure that the additional complexity of the payment classification is warranted and is not undermining policy objectives.

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World Class Commissioning is set to transform Primary Care and promises to drive unprecedented improvements in patient outcomes. But what should World Class look like, how is it different from current commissioning approaches and what must PCTs do to make the transition?

In this interview from HealthExec TV, Gary Belfield, Director of Commissioning at the Department of Health, outlines the vision for World Class Commissioning, the skills and capabilities PCTs will need to get there, as well as examples of how PCTs might transform their existing ways of working to reach World Class status.

Also reviews:

• how Trusts can assess their readiness for World Class Commissioning
• Bridging skill gaps through sharing best practice and procuring external support
• the Assurance Framework as a tool to drive performance and development
• the DH Development Framework to support Trusts in their transition

The new edition of The Commissioner is out today.  Now with new added podcast!

• Commissioning NHS primary care dental services: meeting the NHS operating framework objectives
• The Future of Care Funding: Time for a change
• Practice Based Commissioning GP practice survey
• Best practice guidance for joint working between the NHS and the pharmaceutical industry
• New release of NICE commissioning tools
• Mental Health Act Commission’s Biennial Report; Risks, Rights, Recovery
• Implementing practice based commissioning
• Learning from investigations
• Working Across Boundaries for 18 weeks and beyond – registration now live

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The Reform think tank have produced NHS reform: national mantra, not local reality uses recent academic studies to show that the performance of the NHS across the lifespan is well behind other countries. Improving patient care will need new investment in many areas, but taxpayer funding is (and should be) restricted in coming years. The solution is improved productivity. The report finds that the internal market has altered to favour producers rather than patients. Patient choice and independent sector treatment of NHS patients are in decline.

The report defines two scenarios:

1. Current trends will lead to the negative scenario where the NHS delivers substandard quality and access for 11-12 per cent of GDP (c.£110 billion – c.£120 billion). In this scenario key staff leave the NHS increasing its problems.
2. Alternatively reform delivers immediate access to excellent quality services at a cost of 9-10 per cent of GDP (c.£90 billion – c.£100 billion). Fundemental to this reform is an economic constitution which requires value for money and guarantees patient choice and a diversity of providers. The report believes this would deliver significant improvement within 18 months.

Key findings are:

• In 2007, seven international clinical benchmarking exercises revealed a cradle-to-grave performance gap compared to peer group countries.
• The medium term requirement is investment in many areas. Funding will be restricted given the immediate pressures of a slowing economy and longer term concerns over economic competitiveness. The NHS must redesign and improve services within a ceiling of 9-10 per cent of GDP.
• NHS reform is increasingly a national mantra rather than local reality. Primary Care Trusts, practice-based commissioning and patient choice have failed to drive significant change in the interests of patients. There is no level playing field for independent sector provision. The short-term focus of policy from the Department of Health has prevented a focus on the medium term challenge.
• The return of the service to financial surplus does not signify a better position in which investment can take place. The surplus is due to a temporary combination of the last years of major funding increases and a pause in centrally-prescribed cost increases.
• Current trends therefore point to the scenario of decline. This could be altered with an economic constitution for the service that defines the duty to create value at all levels.