The new landscape of care: implications and challenges for the academic community

1. The new landscape of care: implications and challenges for the academic community Paul Stanton Adviser on Standards Department of Health Paul.stanton@ncgst.nhs.uk

2. Aims • Review the national policy drivers for system reform • Consider the implications and challenges for the health and social care academic communities • Does the NHS £1.3billion education and training spend deliver ‘value for money’ from the perspective of patients, local communities and the tax payer? • Does Qualifying training deliver a workforce that is ‘fit for current purpose’? • Does CME and CPD expenditure deliver evidenced value for money in improved patient experience or outcomes? • Would current expenditure stand up to NAO scrutiny? • Has professional education and training stayed abreast of fundamental and on going system reform? • What challenges and opportunities are posed by this agenda? • ‘Chatham House Rules’

3. Market forces Faculty of the Status Quo

4. Public Sector Priorities • “The imperative for reform is urgent and growing.… • Now is not the time to rest on our laurels; now is the time to step up the pace of reform” Hewitt:Introduction Health Reform In England: Update and Next Steps 2005 • “We start from a very low base … the system has suffered from a combination of monopoly statism and professional power”Corrigan 2006 • “The time has come for audacious and deep seated reform …..It’s absolutely ludicrous that for as long as most of us can remember, public sector managers have spent their lives staring up at Whitehall targets instead of looking to their customers in the street…”Sir Sandy Bruce-Lockhart Chair of LGA 2006 • Customers?

5. The Policy Imperative • Major NHS structural change • Forthcoming Local Government White Paper • From re-active deficit based provision, to pro-active promotion of ‘health and well being” • Our Health, Our Care, Our Say • Shift in emphasis from organisational performance to ‘system performance’ and ‘integration’…

6. Aligned Inspection Aligned Performance Management Aligned Budget Cycle Strategic Care Needs Analysis Joint Outcomes Local Area Agreements Joint Commissioning Framework Practice Based Commissioning Direct Payments & Individual Budgets Unbundled Tariff Joint Teams Joint Infrastructure Year of Care Tariff Personal Health & SocialCare Plan Integrated Capital Market Joint Electronic Records Integration Architecture Liam Byrne [former] Minister for Care Services

7. Aligned Inspection Aligned Performance Management Aligned Budget Cycle Strategic Care Needs Analysis Joint Outcomes Local Area Agreements Joint Commissioning Framework Practice Based Commissioning Direct Payments & Individual Budgets Integrated Workforce Unbundled Tariff Joint Teams Joint Infrastructure Year of Care Tariff Personal Health & SocialCare Plan Integrated Capital Market Joint Electronic Records Integration Architecture Liam Byrne [former] Minister for Care Services

8. The PM’s Four Principles of Public Sector Reform National Standards

9. National Standards • Defined by Government • “Social Care Standards” – 2002 • Independent Health Care National Minimum Standards Regulations - 2002 • “Standards for better health” (S4BH) - 2004 • “Standards for Better Health sit at the heart of the new relationship between central Government and the NHS, under which it is the role of the Department of Health to set broad, overarching standards defining the Government’s high level expectations of the health service” Standards for Better Health July 2004 • Independently audited and inspected by CSCI or Healthcare Commission • Factored into performance management

10. National Standards • Shelf-life • Merger of CSCI & HCC (2008) – “Offcare” • “Revised and converged standards” - 2009

11. The PM’s Four Principles of Public Sector Reform National Standards Devolution to the ‘front line’

12. Devolution • “More freedom for all NHS organisations as emphasis shifts from Whitehall-led to patient-led improvements” Corrigan 2006 • “Double devolution” (Milliband) • A more active voice for the public via LINks • For Local Strategic Partnerships in establishing priorities • More active Local Scrutiny of NHS performance via LA OSCs

13. Devolution • Renewed impetus for Foundation Trust status – Foundation Communities? • Supported growth of the ‘third sector’ • Greater clinical involvement in ‘commissioning’ via Practice Based Commissioning • Fostering innovation and change

14. The PM’s Four Principles of Public Sector Reform National Standards Devolution to the ‘front line’ Competition

15. The case for competition • “The interests of the providers of services came to take precedence over the interests of the users of services. • The NHS’s monopoly over the provision of services compounded these problems … • [and] meant that the system lacked both alternative sources of capacity, and the inbuilt challenge and spur to innovation and efficiency that a plurality of providers can bring”Hewitt 2005

16. Competition led efficiency • Broad political consensus • “Hospitals like other organisations need to be paid for the work they do not get an annual grant … we need incentives to hospitals to improve services - cost control and productivity are the roads to thriving organisations” Corrigan 2006 • Payment by ‘results’ • In the region of 15% of care delivered by the private sector by 2008 (Priorities & Planning Framework 2005/2008) DH 2004 • Currently £4 billion (5.5%) of clinical services budget

17. Competition led efficiency • Rationalisation of historical basis of hospital provision & transfer of point of care • Major workforce implications • “Allowing different providers to compete for services” Our health, our care, our say & fostering development of the capacity and capability of the independent sector to compete for contracts alongside the public and private sector • “If there are barriers that prevent collaboration, we will remove them. If there are rules that prevent private and third sector bodies bidding against the public sector, we will change them”PM June 2006 • Market pluralism

18. The PM’s Four Principles of Public Sector Reform National Standards Devolution to the ‘front line’ Competition Choice

19. Choice • Giving consumers (some) customer leverage • Promoting choice from a diverse provider market • Extension of direct payments? • "The idea would be to give such patients a choice between receiving a package of care from the NHS, as they do now, or instead having their own budget - an NHS credit - which they could control directly." Alan Milburn Former Secretary of State for Health • To improve the flexible responsiveness of provision

20. Patient Voices • This was where Andrew’s stroke story was inserted • All of the digital stories that were used in this presentation can be found at www.patientvoices.org.uk • They are available free of charge and can be used in education, training and organisational development

21. Choice • ‘Choosing health’ • Promoting health and well being • Illness awareness • Disease prevention • The management of long term conditions

22. Choice • Co-production of services (cf Degeling & Sang) • “must extend far beyond hospitals. … it means involving residents in the development of local services and the regeneration of their own neighbourhoods – all helping to create a virtuous circle of healthier people in safer communities supported by responsive public services ”Hewitt 2005 • Reform as process – not event

23. The reform agenda

24. Health Reform In England: Update & Next Steps DH December 2005 Nine further policy initiatives by December 2006 Health Reform In England: Update & Next Steps DH December 2005 Eight further policy initiatives by December 2006

25. The primary focus for 2006/7 £ Assuring short term financial balance

26. Cost & Value • Financial stringency + broader engagement with resource and ‘value’ • “Currently, an estimated 80 per cent of costs and over two thirds of NHS activity relates to the one third of the population with the highest need. People with longer-term health and social care needs want services that will help them maintain their independence and well-being and lead as fulfilling a life as possible” DH 2006

27. Cost & Value • “Because the patients and users of the NHS are also its taxpayers and contributors, we must ensure that we are seen to provide value for money”Treasury 2005 • “To secure the future of the NHS as a publicly funded service free at the point of use, there is a need for an honest and realistic debate about what the NHS can and cannot deliver in a cost-constrained system” ipsos/MORI 2006 • The education and training budget

28. Is Public Sector Reform On The University & Professional Education and Training Agenda? To what extent is the public sector reform agenda a key topic of debate for the University: 0 1 2 3 4 5 6 7 8 9 10

29. Is Public Sector Reform On The Faculty/School Professional Education and Training Agenda? To what extent is the public sector reform agenda a key topic of debate for the faculty/school: 0 1 2 3 4 5 6 7 8 9 10 [Faculty] [Centre for Medical Education] [Faculty of Health & Social Care] [School] [Depends upon individuals, rather than schools/faculties] = Joint score for Faculty and/or School

30. Is Public Sector Reform On The Pre and Post Registration Education and Training Agenda? To what extent is the public sector reform agenda a key topic of debate within the curriculum for professional pre and post registration students? 0 1 2 3 4 5 6 7 8 9 10 [Higher Level Medicine] [Basic Medicine] [Higher Level Nursing& SW] [Level I Nursing & SW] [Post-reg] [Post-reg] [Pre-reg] [Pre-reg] [Depends upon individuals, rather than curriculum]

31. Is Public Sector Reform On The Agenda? Additional comments and scores: 0 1 2 3 4 5 6 7 8 9 10 [Students/customers] [Statutory bodies] Professional bodies [e.g. BMA etc] playing ostrich

32. LG White Paper + NHS Reconfiguration • ‘New’ and ‘distinctive’ organisations with ‘new’ functions • “Counterfeits of the past, under new names, can easily be mistaken for the future… We must be wary of the trap” Victor Hugo: 1872 Les Miserables

33. The new landscape of care • SHAs from DH ‘enforcers’ to ‘system reform leaders’ • With key workforce development, education and training responsibilities • Though not mentioned in SHA Model Corporate Governance Framework • Focussed on financial balance … • and PCT commissioning performance

34. Primary Care Trusts – the story so far • “Well kids, you tried your best… • and you failed miserably… • and the moral is • never try”

35. Primary Care Trusts – the story so far • “Well kids, you tried your best… • and you failed miserably… • and the moral is • never try”

36. The ‘new’ PCT • New Governance and Standing Orders • The role of the PEC? • New focus on collaborative governance • Local Strategic Partnerships • From a hierarchy of focus upon • Provided Services • Independently Contracted Services • Commissioned care • To … • Commissioning for financial balance and system reform • PBC alignment & Independent Contractor quality assurance • Transition from provision to outsourcing provided services

37. The primary foci of ‘new’ PCT functions A comprehensive LSP assessment of community health need & opportunity

38. The primary foci of ‘new’ PCT functions A comprehensive LSP assessment of community health need & opportunity A comprehensive PCT/SHA analysis of patterns, models, locations and cost effectiveness of inherited provision

39. The primary foci of ‘new’ PCT functions A comprehensive LSP assessment of community health need & opportunity GAP ANALYSIS A comprehensive PCT/SHA analysis of patterns, models, locations and cost effectiveness of inherited provision

40. Strategic priorities for system reform Medium term strategy for managed transition & benefit realisation Short term strategy for minimising dislocation while fostering choice & reform

41. Primary Accountability Strategic priorities for system reform LSP SHA PCT Medium term strategy for managed transition & benefit realisation Short term strategy for minimising dislocation while fostering choice & reform

42. Primary Accountability Strategic priorities for system reform LSP SHA PCT SHA PCT Medium term strategy for managed transition & benefit realisation Short term strategy for minimising dislocation while fostering choice & reform

43. Primary Accountability Strategic priorities for system reform LSP SHA PCT SHA PCT Medium term strategy for managed transition & benefit realisation PCT PbC Short term strategy for minimising dislocation while fostering choice & reform

44. Investment Implications PCT investment in health promotion and disease prevention % PCT total commissioning budget % PCT total commissioning budget Transitional investment in sustainable supply chain Delegation of % total budget to PbCs Short term strategy for minimising dislocation while fostering choice & reform

45. Strategic priorities for system reform Changes to patterns, models and locations of care Medium term strategy for managed transition & benefit realisation = Tactical adjustments to minimise dislocation while fostering choice & reform

46. Whole system thinking • From ‘episode of care’ to ‘care journey’ • Care is delivered by ‘systems’ not by ‘organisations • engaging carers • “Improved health outcomes usually lie outside the scope or control of any single practitioner {or organisation}. Real improvements are likely to occur if the range of professionals {and patients and their own carers}.. are brought together to share their different knowledge and experiences agree what improvements they would like to see, test these in practice and jointly learn from their results” Headrick, Wilcock, Bataldan BMJ 2005

47. Patient Voices • This was where the late Ian Kramer’s introduction and ‘Working In Partnership’ story was inserted • All of the digital stories that were used in this presentation can be found at www.patientvoices.org.uk • They are available free of charge and can be used in education, training and organisational development

48. Key challenges for the academic community • “What are the major threats and the opportunities that are likely to arise as a result of the system reform agenda” • Pink hexagons = key threats • Blue hexagons = key opportunities

49. Key Opportunities I Reshape/ redefine the nature of the HEI Focus on learning in & for the workplace Agree common priorities with public sector Work collaboratively With other HEIs Educate whole systems of care delivery Develop new forms of partnership Maximise opportunities for IPE Develop new types of healthcare worker With local LSPs, LAs SHAs & NHS providers With patients & carers Focus on new PCT & primary care priorities With private & ‘third’ sector Develop new management competences Develop primary care placements Develop private & ‘third’ sector placements

50. Key Opportunities II Exploit Bologna declaration Maximise use of simulations, blended & open learning Maximise flexible credit and credit recognition Invest in innovative ways of working/ learning Invest in development of academic staff & associates Develop & support communities of practice learning Promote IPE across medicine, health & social care