Health and care system
The health and care system has undergone substantial change and a summary of the key changes are as follows.
Clinical Commissioning Groups
Clinical commissioning groups (CCGs) are the bedrock of the new health system. They consist of GP practices, hospital doctors and nursing representatives. There should also be public representatives on a CCG. They are responsible for commissioning the majority of health services and the government expects CCG’s to understand the health needs of their population and commission services accordingly. This includes emergency care, elective hospital care and maternity services. They will also commission community and mental health services.
Services will be commissioned from an increasingly diverse competitive market place which includes NHS Trusts, community health services and private and voluntary sector provision. There are 211 CCGs in total and in 2013/ 14 they are responsible for a budget of £65 billion which equates to approx. 60% of the total NHS budget.
All commissioned services will be regulated by the following agencies:
- Care Quality Commission
CCG’s will be supported by Commissioning Support Units and Clinical Senates:
Commissioning Support Units
Commissioning Support Units provide support through business intelligence, procurement services, back-office administration and some contract management. Commissioning Support Units comprise of the NHS Commissioning Board, which employ their staff to carry out the tasks required. It is envisaged that by 2016 these will operate in a competitive market and be independent organisations.
Clinical Senates provide hospital expertise and cross speciality collaboration so informed decisions are made about the populations CCGs represent. Clinical Senates provide advice and leadership at a strategic level. They consist of a range of clinicians and professionals from health, public health and social care and patient and public representatives. Clinical Senates will also advise Health and Wellbeing Boards (HWBBs)
NHS England formerly established as the NHS Commissioning Board on 1 October 2012, will be responsible for direct commissioning that is not in the remit of CCGs. This includes primary care, public health, offender health, military and veteran health and other specialised services. They are also responsible for CCG authorisation, quality improvement, commissioning support, IT strategies and patient safety.
Health and Wellbeing Boards
Responsibilities for local public health are now firmly placed with local government. Local authorities are in charge of driving health improvement, collating evidence on public health and public health interventions and ensuring the right mix of arrangements and services are in place to meet population health and well-being outcomes. This means that local government has to ensure good partnerships with and between key players such as NHS, social care, housing, environment of health and leisure and transport.
Health and Wellbeing Boards are the forum where key leaders from the health and care system work together to improve the health and wellbeing outcomes of their local population and reduce health inequalities. They will undertake a Joint Strategic Needs Assessment (JSNA) and develop a Joint Health and Wellbeing Strategy for their population which will inform planning and consequent commissioning. They also liaise and work with CCGS and the electorate.
Public Health England is an executive agency of the Department of Health and promotes public health at a national level publishing policy, guidance and consultations.
Healthwatch is an independent consumer champion for health and social care. It operates at a local level, Local Healthwatch and national level, National Healthwatch. It has been set up to represent patients’ rights and enable people to influence how services are planned. Local Healthwatch has a seat on the Health and Wellbeing board and contributes towards Health and Wellbeing strategies and JSNAs.
Integration is crucial to realise the new NHS system. It is expected that integrated services will be person centred, designed to improve outcomes and to reduce health inequalities. The NHS Commissioning Board (NHS England), CCGs, Monitor and health and wellbeing boards have a duty imposed upon them to promote and enable integration as enacted by the Health and Social Care Act 2012. The draft Social Care and Support Bill also sets out a similar duty on the local authority to promote the integration of services.
Sources of further information
Developing Collective Leadership for Health Care May 2014 The King’s Fund. An insightful paper that argues for collective leadership within the NHS. Collective leadership involves effectively distributing and allocating leadership power to whoever is best placed to carry out necessary functions. This involves making the best use of expertise, talent, capability and motivation within organisations. NHS Boards are the key steer and the paper goes into some depth in to how collective leadership can be envisaged and implemented.
All in this together? An analysis of spending on integrated care by commissioners in the new health and social care system 2014 An mph Health publication which offers an interesting analysis of spending on integrated care. It includes a case study of the North West and some potentially useful tables and information on specific authorities. The report shows how a lot of spending has been used to support existing services rather than transforming them; that funding is not sufficient and that plans for integration are often based on limited evidence and that there is lack of robust data on impacts and outcomes of integrated arrangements.
Transforming primary care: safe, proactive, personalised care for those who need it the most 2014. Department of Health guidance setting out plans for better quality care through a personalised focus and joined up approach. It describes in depth the Proactive Care Programme which provides 800,000 patients with complex health and care needs with a personal care and support plan; a named accountable GP; a professional to coordinate their care and same-day telephone consultations. The plan builds on the role of primary care in keeping patients well and independent. It explains how professionals across the healthcare system can work together to transform care to become more proactive and tailored to patients’ individual need.
An alternative guide to the urgent and emergency care system in England 2014. The King’s Fund has developed a new animation which gives a quick tour of how the A&E system fits together and unravels some myths about what’s really occurring.
Financial mechanisms for integrating funds for health and social care: an evidence review March 2014. This evidence review from the University of York pulls together evidence of evaluations of integrated care arrangements. It demonstrates that although integration is often perceived as a solution for some of the major challenges faced by health and social care systems it should not be considered a panacea that will lead to the successful delivery of integrated care. Empirical studies of integrated care systems suggest that the reality falls short of these high expectations. While some evaluations have identified cost savings or improved outcomes, most find no significant benefits, and in those that do identify improvements, the effects are small.
Making our health and care systems fit for an ageing population 2014 A new report from the King’s Fund that sets out a framework and tools to help service leaders improve the care they provide for older people across nine key elements; Healthy, active ageing and supporting independence; Living well with simple or stable long-term conditions; Living well with complex co-morbidities, dementia and frailty; Rapid support close to home in times of crisis; Good acute hospital care when needed; Good discharge planning and post-discharge support; Good rehabilitation and re-ablement after acute illness or injury; High-quality nursing and residential care for those who need it and Choice, control and support towards the end of life.
Providing integrated care for older people with complex needs, lessons from seven international case studies January 2014 A Kings Fund report that brings together evidence on integrated care approaches for older people with chronic and multiple conditions. It synthesises evidence from other countries including Australia, Canada, The Netherlands, New Zealand, United Kingdom and the United States.
NHS Citizen a new social website created to enable people to take part in discussing the design, structure, function and governance of the NHS England’s Citizens’ Assembly
Networks that Work: partnerships for integrated care and services 2013 (NESTA) A useful report which looks at successful integrated care and networks. The report provides definitions of partnerships and networks, looks at the benefits and risks of different arrangements and provides a checklist for successful partnerships and networks. It also draws on case study sites which focus on commissioning and providing services and core actions for partnership working.
Principles for Health and Social Care Reform – Policy Report Number One. September 2013 (Solace) A short and concise document that sets out the new principles of health and social care reform. It provides a background to reform, looks at the main areas of change from a medical model of illness to a system of health and wellbeing and states the need for system leadership across the health and care system.
An alternative guide to the new NHS. The Kings Fund. A concise animation setting out the new NHS in England.
The Kings Fund has launched a learning resource called Learnist which sets out resources that cover the key elements of the new NHS system. This is very useful for all commissioners of health and public care.
The Kings Fund also has useful slides that demonstrate the new structures of the NHS
Health and Wellbeing Board member development toolkit April 2013 (The Institute of Public Care (IPC)) The toolkit is the result of a development programme for councillors in London with an interest in Health & Wellbeing Boards (HWBs) delivered by the Institute of Public Care in 2012/2013. The programme comprised of facilitated workshops, action learning and a toolkit. There were sessions for Chairs of the Board, members of the board and ward (backbench) councillors interested in learning more. There are six modules which can be worked through in any order; Introduction to HWBs for ward councillors; Role of the councillor on the HWB, Leading and chairing the HWB; Focussing on HWB priorities in your area; Managing relationships and responding to crises and Working with health.
Stronger Together: How Health and Wellbeing Boards Can Work Effectively With Local Providers. January 2013 (The NHS Confederation). This report outlines the benefits of involving and engaging local providers – many of which already have strong relationships with service users – as allies in producing a comprehensive Joint Strategic Needs Assessment (JSNA) or successfully delivering a Joint Health and Wellbeing Strategy (JHWS). The report also explains the significant contribution which provider engagement can make to service integration.
Frequently asked questions on integrated care. Monitor have published FAQs to assist commissioners, providers and health and wellbeing boards to comply with their obligations relating to integrated care and to explain the relationship between these obligations and the other rules that Monitor enforces.
Guidance Funding transfer from the NHS to social care 2013: directions (GOV.UK). Guidance for funding transfer from NHS to social care 2013 directions.
The government has launched a new care comparison website that gives easily accessible information about care homes and home care services. This is to help older people and their families to choose, compare and comment on residential care homes and home care services. The comparison website is on the NHS Choices website
Quality in the new health system - Maintaining and improving quality from April 2013 (The National Quality Board). The National Quality Board (NQB) brings together the leaders of national statutory organisations across the health and care system, alongside expert and lay members. Its role has been to provide leadership and system alignment for quality and to provide a forum for developing collective, cross-system advice to the Department of Health and Ministers on quality. Over the next few years, the structures in the NHS will change, both as a result of the Health and Social Care Act 2012 and in response to the NHS rising to the challenge of delivering better quality care in a tighter financial environment. This report looks at how quality will be improved and maintained in the new NHS system from April 2013 and represents a collective commitment to preventing, identifying and responding to serious failures in quality.
Working together to deliver the Mandate: strengthening partnerships between the NHS and the voluntary sector. The Kings Fund (2013). A report, commissioned by the Foundation Trust Network (FTN) and the Association of Chief Executives of Voluntary Organisations (ACEVO). This report brings together a range of innovative partnerships and projects between health trusts and voluntary sector providers from across the country and considers how barriers to effective partnership working can be overcome. The King’s Fund hosted a roundtable event to present recommendations addressed to different parts of the health and care system so they can work together more effectively to deliver the mandate.
Incentivising integrated care. Eurohealth Volume 19, number 2, 2013. This report analyses innovative integrated care. It looks at integrated care schemes, payment models and financial incentives that are being implemented in several countries. It provides eight in-depth case studies on incentive mechanisms in their respective contexts.
Evaluating integrated and community-based care: how do we know what works? Research Summary June 2013 (Nuffield Trust). This report presents a research summary of evaluations of over 30 community-based interventions that are designed to reduce emergency hospital admissions. It identifies nine learning points that may help professionals in designing, implementing and evaluating such interventions in future. It is particularly aimed for the new health and social care integration ‘pioneer’ sites that will be appointed by the Department of Health by September 2013.
Person Centred Leadership – Rediscovering our purpose May 2013 (The King Fund). This report summarises the main findings of the Francis Inquiry into the failings of care at Mid Staffordshire in relation to NHS leadership and culture. It sets out what can be done to prevent similar failures in the future. It focuses on the role of key ‘lines of defence’ against poor quality care for example frontline clinical teams, lead NHS boards and national organisations that oversee the commissioning, regulation and provision of care. The report also highlights the lessons that can be learnt from high-performing health care organisations from other countries. The report also presents findings from The Kings Fund 2013 leadership survey
Evaluation of the first year of the Inner North West London Integrated Care Pilot May 2013 (Nuffield Trust and Imperial College London). This report sets out the findings of an evaluation of the Inner North West London Integrated Care Pilot. The pilot aimed to develop new models of care for older people and for people with diabetes. The project objectives were to improve outcomes for patients; create better and more integrated care in the community; reduce unnecessary hospital admissions; and improve working practices and relationships across professional and provider boundaries. The pilot began in July 2011 with staff sharing information using an IT tool which identifies patients needing intensive case management. Multi- disciplinary groups of local care providers met on a regular basis to review and plan people’s care. The evaluation, carried out by Imperial College London and the Nuffield Trust, ran from September 2011 – July 2012.
Integrated Care: Our Shared Commitment May 2013 (Department of Health DH). Developed from a collaborative project, this report sets out a cross sector commitment to integrated care and support. The report states that local and national organisations need to take urgent and sustained action to forge integration forward. It sets out a definition of integrated care and support to ensure shared language, ethos and goals. The individual should be at the centre and around whom services should be co-ordinated. Localities are expected to adopt what ‘good’ looks like and to develop local initiatives as appropriate. The report sets out five areas of shared commitment looking at both the national and local level and what each is to do to realise these commitments.
Making integrated care happen at scale and pace: Lessons from experience March 2013 (The Kings Fund) is a guide to support integrated approaches. The document follows 16 steps that have been identified to make integrated care a reality and draws upon work by The King’s Fund and others to provide examples of good practice. However the report explains that there are no blanket solutions or approaches to integrated care and that good integrated care is also about discovery rather than just design and good practice. The report makes recommendations to improve national policy in regard to integration particularly around regulatory and financial frameworks.
The Prevention Revolution: transforming health and social care. The report of the ACEVO taskforce on prevention in health (2013). ACEVO Taskforce on Prevention in Health has published this report which calls for a radical shift away from reactive, hospital-based care towards preventative approaches such as health promotion, encouraging self-care and supporting people to manage their conditions at home and in the community. The report makes a number of recommendations to move this agenda forward.
Cardiovascular Disease Outcomes Strategy Improving outcomes for people with or at risk of cardiovascular disease. March 2013 (Department of Health). The strategy provides advice to local authority and NHS commissioners and providers about actions to improve cardiovascular disease outcomes. Improving outcomes is not just about reducing mortality - it is also about improving people’s quality of life, their experience of care and the safety of that care. There is also a theme of cost effectiveness within the strategy. The document sets out outcomes for people with or at risk of cardiovascular disease (CVD) in line with the NHS and public health outcomes frameworks.
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary. February 2013 (The Stationery Office). On 9 June 2010 the Secretary of State for Health, Andrew Lansley MP, announced a full public inquiry into the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire Foundation NHS Trust. The full exhaustive and comprehensive report examines the estimated 400 - 1,200 deaths that occurred between January 2005 and March 2009 at Stafford Hospital as a result of poor care provided. The report identifies numerous failures with the systems, culture and leadership within the NHS, which led to the voices of patients and those of staff being ignored. This Executive summary outlines a summary of findings and the table of recommendations. Click here to access the full report in 3 Volumes, the Chairman’s statement and key facts and figures.