Commissioning Community Services – The challenge

1. Commissioning Community Services – The challenge Michael Sobanja 23 March 2006

3. Payment systems PBR – Contracts – C4H Supply side reform Plurality Foundation Trusts Competition User side reform Commissioning PBC Clinician engagement Patient choice Regulation Monitor NSFs – NICE-HCC

4. Three broad phases to NHS Reform Central Direction National Standards Financial Investment & Support “Constructive Discomfort”

5. "District nurses, health visitors and other staff delivering clinical services will continue to be employed by their PCT unless and until the PCT decides otherwise.“ • 25 October 2005

6. What is commissioning? • Commissioning is the process which determines how the health and the healthcare budget is used. • Meeting the needs and/or wants of local people? • At and affordable level? • From whom? • What's the evidence base? • Integrated access to health and social care services

7. Levels of Commissioning National Regional PCT Associations PCT/LA Practice Neighbourhood Locality Cluster

9. Who commissions Primary care? PCT 10 20 30 COMMISSIONING PBC

10. The real challenge? • To commission excellent services in the community that are built around the patient and to • develop and deliver effective community based approaches to keeping people healthy

11. THE DILEMMAS OF COMMISSIONING • Trying to improve the experience and health of the individual patient without micro-managing the providers • The trade-off between the interests of individuals and those of the wider community • Balancing national priorities with local aspirations and flexibility • Investment in health improvement (long term payback) versus investment in health services (immediate gratification)

12. COMMISSIONING Different components: • Equity • fair distribution of evidence-based benefits • Responsiveness • emotional consequences of decisions • Efficiency • economic considerations including cost-effectiveness

13. Different groups will tend to prioritise these components as follows: • Commissioners • equity, efficiency, responsiveness • Patients • responsiveness, equity, efficiency • Providers • efficiency, responsiveness, equity

14. EFFECTIVE COMMISSIONING • A clinical and managerial dialogue informed by patient and user views • Creating better patient/user services, pathways and experiences • A focus on improving process and outcomes - changing the fundamentals of the system • A focus on the key problems facing the health community • A focus on health economies rather than individual organisation

16. A new range of services • Traditional primary care services, such as district nursing, midwifery, health visiting, physiotherapy and podiatry • Diagnostics and specialist outpatient services previously delivered in hospital • Expanded walk-in services that include diagnostic tests, screening, clinical advice, basic prescriptions and health promotion • Additional services, such as sexual health services, treatment for drug and substance abuse, care for asylum seekers, prison healthcare, care for ethnic minority groups, services for care homes • Inpatient services at a community hospital or nursing home • Mental health services including community psychiatric nursing and counselling • Complementary medicine? • Local health information and advocacy • Pharmacy, dentistry and optometry

19. The New Providers

20. Supermarket chain Sainsbury's has announcedplans to open general practitioner services in itsbranches across the country.

21. Foundation trusts Private Companies Not for Profit companies Mutuals GP GMS/PMS Partnerships Clinician Chambers Voluntary Sector Pharmacos

23. Cardiac Surgery Direct Access Services Surgical Wards Cardiology A & E Emergency Medicine Primary & Community ‘Continuing Care’ Paediatric Diabetes Specialist Nurses & Doctors Medical Wards Wards Diabetes Specialist Services Clinical Psychology Receptionists and Support Workers Rheumatology Diabetes Specialist Nurses Supporting Specialist Services Services for Young People Nephrology On Call Service Vascular & Orthopaedic Surgery Diabetes Specialist Team Web Based Services Obstetrics Joint Diabetes Antenatal Service High Risk Foot-care Team Diabetologists NHS Direct Orthotists & Footwear Specialists Ophthalmology Laser & Cataract Services Eye Screening Hospital Dietetics Components of an Integrated Diabetes Care Service Community Dietetics Optometrists Community Podiatry Pharmacies Specialist Vitreo- Retinal Services Primary Care Diabetes Teams Primary Care Diabetes Teams Primary Care Diabetes Teams Primary Care Diabetes Teams Primary Care Diabetes Teams Primary Care Diabetes Teams Community Nurses Nursing Homes Call Centres

24. Information Services of the National Health System - Four Elements Where can I go? • CONTEXT – Health Services Providers • common descriptions and details of services and providers within the health system, their configurations and locations • INTENT – Standards for Health Services • Using clinical knowledge and adopting standards of care across the health system e.g. National electronic Library for Health • ACTIONS - Personal Health Management • electronic records, e- bookings, referrals, investigations, and prescriptions • OUTCOMES - Measuring Performance of Health Services • consistent support of the clinical audit of individual care What will they (we) do? What did they (we) decide? Did it do any good?

25. Information for Commissioning • Understanding need and demand • Comparative performance • Capacity generation – generating a market? • Understanding the true cost base • Giving patients useful information • …

27. JOINED UP THINKING ! PCS Web - a groundbreaking new e-record system that gives everyone in the primary care team instant, online access to patients' records - is being piloted in two PCTs in England from next month. For the first time in the UK, health visitors and district nurses will have their own tailored e-nursing care records, based on the internationally recognised Omaha classification system. Staff will be able to draw up nursing care plans and make detailed assessments of social aspects such as patients’ living conditions, hygiene needs and ability to care for themselves; areas that a traditional GP system does not cover, but that are essential for other staff to plan care and measure outcomes.

29. Proposals are in hand to expand health services in the home. 'I don't like it. They're queuing for surgery on the kitchen table.

30. The public is in favour of shifting care

31. Key Challenges – what do you think • How do we specify community health services – particularly the “ethos”? • Who do we see as the possible providers? • How do we measure the volume of services? • What is the outcome? • How can we increase investment? • How do promote inter-practice collaboration? • How do we tie it together with Local Auhtority services? • What part should Non Execs play in commissioning?