Sian Davies, Nuffield Trust & Suzanne Robinson HMSC

Functions and mechanisms of priority setting: the national and

local picture Functions and mechanisms of

priority setting: the national

and local picture

Describe the proposed structure for the NHS Describe who will be commissioners and what they

will commission Analyse some emerging policy themes, post Future’s

Forum

Over to you:

What will priority setting look like in five years time What can be done now to increase our chances of

success?

Outline

The NHS is obsessed with structure…

http://www.guardian.co.uk/politics/2011/aug/05/labour-ridicules-cameron-nhs-structure#zoomed-picture

Commissioners – National level

National Commissioning

Board

•GP services

•Community pharmacy

•Dental services

•Prison & military

•Specialised services

•Public Health: Child

health, immunisations,

screening

NICE

•TAs, quality standards

Clinical senates

•Expertise, leadership,

advise

Clinical networks

Monitor

Healthwatch

Commissioners – local level

Clinical Commissioning Groups

•Hospital services, community services

Local authorities

•Social care

•Sexual health services, alcohol &

substance misuse, community

behaviour change programmes, NHS

health checks

NHSCB Outposts

•Some CCG responsibilities if

partially authorised

•CCGs responsibilities where not

authorised

LA Public Health Depts

•Advice to CCGs

Health Watch

•Info to support pt choice

•?complaints advocacy

NHSCB

outposts/clusters

•Commissioning

support

HWBs

•JSNA

•JHWS

• “It is a National Health Service – but it must be a locally delivered service. And that is where the power should lie. That is what the evidence tells us, that is how we’ll improve outcomes, and that is how we’ll achieve real transparency and accountability.” Andrew Lansley Speech to the NHS confederation. 24th June 2010

• 'But the bill retains extensive reserve powers of intervention for the secretary of state, and it is likely that the political dynamics nationally and locally will be so strong that the Department ofHealth will be drawn in to intervene—for example, at times of financial or clinical crisis. Walshe K. Can the government's proposals for NHS reform be made to work?' BMJ 2011;342:d2038

• 'The moment he [Andrew Lansley], as a national politician, started to reopen services that clinicians had agreed needed to close, he undermined the whole strategic argument for his reforms. Given his actions how could he claim that he wanted to limit political interference in day-to-day NHS activities?' Corrigan P. Securing the Secretary of State’s responsibility for ensuring the provision of health services for all NHS patients without political interference in every aspect of patient care. Blog post 06/09/2011

Localism v’s centralism

The Nicholson challenge

Quality innovation productivity and innovation

CB has wide ranging duties

Oversee the commissioning budget

Oversee system of CCGs

Develop commissioning guidance

Develop a medium term strategy for the NHS

Authorisation and CCG functions Explicit duty to deliver the QIPP challenge

Risk assessment led by SHA clusters

Localism v’s centralism

Department of Health. Developing the NHS Commissioning Board. July 2011

Department of Health. Developing clinical commissioning groups. Towards authorisation. August 2011

Monitor: Objectives revised to include the promotion of integrated care as well as prevent anti-competitive behaviour

Monitor and CB have discretion to include variations in rules for the

tariff (e.g. bundling). Move towards commissioning based on outcomes

Expansion of patient choice central to H&SC Bill. Choice Mandate –

recommended by the Future’s Forum – may offer choice where is has not been offered before

Competition, collaboration & choice

Thanks to Frank Sodeen of the Nuffield Trust for summarising the key changes

to the H&SC Bill

Providing care for a population v’s individual patient Ethical duty to advocate for the individual patient Legal duty under GMS regulations to ‘order drugs & medicines which

are needed for treatment’ Provider and commissioner

Conflicts of interest

At worst, the negative impact for GPs could be patients

lobbying outside their front door, saying, 'You've got a nice

BMW car but you will not allow me to have this cytotoxic

drug that will give me three more months of life,'"

Claire Gerada. Doctors warned to expect unrest over NHS reforms. The Guardian. 19th November 2010

Involvement of outside stakeholders in CCG decision making CCGs will have a duty to 'act with a view to enabling patients to make choices on

the health services that are provided to them' CCGs must describe their PPI arrangements in their constitution and have

credible plans for public engagement CCGs must have specific arrangements in their constitutions for ensuring

transparency in the decisions of the group and the manner in which made Inclusion of other clinicians on CCG boards Explicit duties with regard to accountability to Health & Wellbeing Boards CCGs will have to share their plans with the HWB boards to check their

compatibility with the strategy and explain how those views have been taken into account

CCGs must involve HWBs when they are preparing or significantly revising their commissioning plans for the year

Governance and accountability

And what of the future….

What does successful priority setting

look like?

Process concepts

•Stakeholder engagement

•Use of explicit process

•Information management

•Considerations of values

and context

•Revision or appeal

mechanism

Outcome concepts

•Improved stakeholder

understanding

•Shifted resources and/or

reallocated resources

•Improved decision

making quality

•Stakeholder acceptance

and satisfaction

•Positive externalities

Sibbald SL, Singer PA, Upshur R, Martin DK (2009) Priority setting: what constitutes success? A conceptual framework for

successful priority setting. BMC Health Services Research 9 (43)

Use of explicit process & information

management

In five years time CCGs will:

1. Recognise the importance of priority setting internally rather than

responding to external drivers

2. Will have sufficient resources (time, money, technical expertise) to

successfully implement priority setting

3. Will have sufficient access to public health expertise to successfully

implement priority setting

4. Have strong clinical leadership in priority setting

5. Have transparent robust processes in place for exceptional treatment

requests and broader health system decision making

Please score on a scale of 1 to 5: 1=very unlikely, 5= very likely

Stakeholder engagement

In five years time CCGs will:

1. Have stakeholders (e.g. hospitals) involved in their decision making

processes

2. Are seen as legitimate decision makers by their constituent clinicians

3. Have patient and public involvement integral to their priority setting

processes

4. Have been able to lead the implementation of disinvestment decisions

5. Have to listen to Health and Wellbeing Boards; they have considerable

influence

Please score on a scale of 1 to 5: 1=very unlikely, 5= very likely

Shifted priorities / reallocated resources

In five years time CCGs will:

1. Base their priority setting activities more on internal recognition of the

value of an explicit process, than on external drivers

2. Have experienced less political interference when trying to implement

difficult decisions

3. Have made significant disinvestment decisions and implemented them

4. Have more local autonomy in deciding what treatments and services to

provide

5. Have been able to make changes in the whole health economy

(especially acute trusts) as a result of priority setting decisions

6. Be less likely to make short-term end of year rationing decisions that

their PCT predecessors

What would you do?

3 scenarios…

You are a consultant brought in to advise clinical commissioning groups on

developing priority setting around major disease care pathways. What 5

things do they need to do now to maximise their chances of success?

You are a consultant brought in to advise the Department of Health on

developing priority setting in the NHS. What 5 key national policies will

assist the development of priority setting in CCGs?

You are a consultant brought in to advise David Nicholson on how the

NHSCB can support local commissioners in priority setting. What 5 key

actions can he do now?