The joys of policy analysis mean the NHS Operating Framework is obligatory reading. 'Grip' is its message, no surprises there. But tucked in amongst the pages four things caught my eye.
Para 3.29 requires commissioners to link patient NHS numbers to contractual payments by March 2013. By then, it should be possible to identify routinely how much NHS expenditure goes on each individual – a crucial milestone to identify efficiencies. My bet is on information to give the NHS the biggest lift over the coming decade.
The second was para 4.24 – in response to concerns about "cherry picking" commissioners will be allowed to adjust the tariff price if the type of patients that a provider treats results in lower costs than the average for the tariff category. Perhaps this para was designed with Independent Sector Treatment Centres (ISTCs) in mind who are accepting less complex cases than the NHS (although offering at least as good care).
My bet is on information to give the NHS the biggest lift over the coming decade
But my mind wandered to the current opaque area of NHS policy on price flexibility. Could not commissioners use the presumed innocent para 4.24 to start negotiating price reductions? And what of David Nicholson's suggestion to one of the House Committees last year that price flexibilities should be accompanied by trusts supplying greater information on quality of care (to help reduce skimping)? No mention of that in the Operating Framework.
The third thing to catch my eye was mention of integrated care in the very first paragraph, which is some triumph after its absence in the original Equity and Excellence White Paper. We've been tracking progress in Trafford which shows you the long haul in store, even with committed staff and £2m investment. That is, without more radical freedoms and incentives – which make for tricky partners with 'grip'. More on this in early 2012.
The fourth was the stated value of risk stratification in helping identify patients at high risk of hospitalisation. Our analysis: Choosing a predictive risk model: a guide for commissioners in England may help here.
I note the size of populations covered by the shadow clinical commissioning groups (CCGs) – a healthy 93k to 1.3m. All then a reasonable size to manage most unpredictable financial risks. Our analysis on developing a needs-based predictive formula for allocating resources to commissioning practices shows that practices are too small to take on much risk – clearly a job for the NHS Commissioning Board to advise CCGs in this area, if practices are to hold budgets.
The hunt is on for any intervention to reduce avoidable emergency hospitalisations. Answers on a postcard would help. We will report later on telehealth/telecare and virtual wards. But in the meantime read more about the lessons from the virtual ward model deployed in Toronto.
Finally, is anyone else bothered by all the changes proposed for public health? I have in mind the third tribe: the first being those in health protection/communicable disease control and moving to Public Health England; the second being those interested in the wider determinants of health and moving to local authorities; and the third being the minority interested in health services research and quality of NHS care.
The latter were championed by Sir Donald Acheson in his landmark report in 1991. But what home for them?
Comments (2)
Yes, lots of people bothered on public health! See the latest poll from the Faculty on this, the profession seems now dead set against the reforms (though on a third turn-out for their poll). The Health Committee is seriously worried and many commentators including ourselves (the King's Fund) are concerned. In our case there are three core issues: there has been far too little said about accountability, no clear plans to translate the public health outcomes framework into anything meaningful locally (unlike on the NHS side), and its unclear how this put together with the NHS reforms will "increase the health of the poorest fastest," government code for reducing health inequalities. On the latter the Future Forum's workstream on the NHS contribution to public health is critical, the NHS has a massive role in reducing inequality - all the analytical evidence-based work undertaken under the last government is in grave danger of being forgotten - it needs to be refreshed and implemented. The debate on public health reform has been dominated by workforce issues in the transition from PCTs to local authorities, very important, but too little said about the pros and cons of the reforms themselves. In summary, it seems the government has managed to turn a minor triumph into a developing crisis - at least of perception - in the year since Healthy Lives, Healthy People was first released. We urgently need a clear narrative from the Department on how all this fits together, let's hope the imminent suite of papers being released before Christmas (as far as we know) start to do that.
One thing you did not touch on is involvement and engagement with service users, carers and the community in the Operating Framework. At a time when the local NHS needs to stay close to its public and lead change with their understanding and support, the new Operating Framework won’t deliver involvement, quite the opposite in fact. The engagement “model” contained in Appendix B “Developing a communications and engagement commissioning support service” sets out a hard line centralist approach with “do once” messages devised centrally and then delivered locally. This boils down to a bromide: 1) Tell your audience what you’re going to tell them. 2) Tell them. 3) Then tell them what you told them. 4) Job done. 5) Engagement box ticked. That’s what PPI in the new order will come down to, it appears. There is nothing here about bottom up involvement or community development or leadership from patients, carers and members of the public. Or 3rd sector user led organisations. And there are phrases about what the service will cost -“best price possible” etc, – which raises the real possibility that CCGs as “customers” are going to have to pay for this “support”. If I was a GP with a stake in local commissioning I’d be pretty hacked off about being handcuffed like this. They need to communicate and involve now if they are going to make the kind of changes that QIPP savings demand, not a year from now. This OF is supposed to get us well into 2013 when CCGs take over; I wonder if we will make it that far? As Harold Macmillan was wont to say “events, dear boy, events” are always the greatest challenge. And you can be certain that during 2012/13 the NHS will have its share of “events”.
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