Operating Framework

11 December 2008 the operating framework for the NHS in England 2009/10 High Quality Care For All was published. Download here. It outlines how the NHS Plan will now move to phase 3.

Phase 1 – NHS Plan and increasing capacity and investment
Phase 2 – introducing levers to enable reform: choice, contestablity, freedom for providers and better financial systems
Phase 3 – using these to deliver high quality care and value for money as set out in the Next Stage (Darzi) Review High Quality Care For all spanning safety, effectiveness and patient experience.

It also published PCT Allocations: There’s been a change in the formula (page 34 of the Operating Framework)
There’s an average 5.5% uplift to PCTs with a floor of 5.2%. The formula has been changed:

"a separate, transparent formula targeting funds at the places with the worst health outcomes;
a new needs formula which enables need according to age and other factors to be assessed together for the first time; and
a new market forces factor (MFF), which reduces the variation in the MFF for neighbouring PCTs and secondary care providers."

You can download the allocations here.

There will still be at least a 3% cash-releasing efficiency expected. Two areas of inefficiency highlighted are pre-op bed days and reducing outpatient DNAs.

The Commissioning for Quality and Innovation (CQUIN) framework is also published. See Jargon Buster Commissioning for higher quality and innovation.

The standard NHS contracts for acute, ambulance and community services are all published . To go to the page from where you can download the contracts click here.

Commentary from IMPRESS, with a focus on elements that affect the delivery of respiratory care

Finances
Given the economic climate there is a claw back of some of the surplus from 2008/09, but £800 million of the surplus is to be reinvested over the next two years. The average uplift to PCTs is 5.5% with a floor of 5.2%. However, there is an even stronger emphasis not just on better care, but also better value for money. There is also a restatement of the shift from better care to better health outcomes supported by better education and support for smoking cessation, obesity and alcohol misuse.

Levers
Choice and contestability remain as levers for change.

Policy and priorities
The shift to primary care remains.

The national priorities set in the 2008/09 framework have been set for 2009/10 but there are expected to be systematic quality improvements across the NHS.

The role of the national NHS is clearly stated as setting standards (note the language is now more about standards than targets and this is described as “once national targets are achieved these will become national minimum standards”), and strategy, and the role of PCTs is to commission and manage local NHS services that meet local needs.

The five priorities, highlighting issues for respiratory care
• Improving cleanliness and reducing HCAIs
• 18 weeks referral targets and improved access to primary medical care services (including weekends and evenings) – this now includes the breathlessness and sleep pathways
• Improving the health of the population and reducing health inequalities this includes the vascular check, and the prevention package for older people (personalised care plans, and carers’ support as well as priorities for stroke, maternity, cancer and children as before. Note: there is the possibility that the vascular check will include some lung function testing too.
• Improving patient experience and staff satisfaction
• Preparing to respond in a state of emergency such as pandemic flu outbreak

Improving health and reducing health inequalities in more detail
Para 34 Prevention Package for Older People “will initially improve falls and fracture services, foot care,intermediate care, telecare and audiology services, with the aim of enabling older people to live longer, healthier and more independent lives. The package will evolve with new enhancements added over time. “

“Para 36: Over the next two years, to ensure that those living with a long-term condition receive a high quality service and help to manage their condition, everyone with a long-term condition should be offered a personalised care plan.”

“Para 37 The Carers’ Strategy sets out how we can ensure that we support carers. One key requirement is that PCTs should work with their local authority partners and publish joint plans on how their combined funding will support breaks for carers, including short breaks, in a personalised way. “ Carers at the heart of 21st century families and communities: a caring system on your side, a life of your own. Click here.

Priorities determined and set locally

These highlight the issues raised in the Next Stage Review. Of the list, one is particularly relevant:

•    alcohol;
•    dementia;
•    end of life care;
•    mental health;
•    military personnel, their dependants and veterans;
•    mixed-sex accommodation;
•     people living in vulnerable circumstances;
•    people with learning disabilities.

Para 63   To deliver the End of Life Care Strategy – promoting High Quality Care For All Adults At The End Of Life and the local SHA visions, PCTs will want to consider delivering extended and improved service provision with their partners.

Defining and delivering quality
Three domains: “ it is these three things together that make a quality service – not one, not even two, but all three.”
• Safety
• Effectiveness
• Patient experience

Clinical ownership and leadership is given a greater prominence.   It was seen as crucial to the success of the Next Stage Review process, and must be maintained during implementation. “ If we get it right, the quality agenda has great potential to mobilise and empower clinicians across the system. And, conversely, we will get nowhere without clinicians on board. So clinical leadership needs to be part of everything we do. “

High Quality Care for All says “quality is the organizing principle of the NHS”.

So it also set out a framework for systematically improving quality, based on seven components. Progress is expected in each and will underlie the COPD Clinical Strategy:

• bring clarity to quality (Nice review of the evidence, standard setting)
• measure quality (metrics and clinical dashboards, clinical indicators out to consultation til 12 Dec 2008)
• publish quality performance (quality accounts – annual publication of performance against the metrics. Starting in    April 2010 for acute providers)
• recognise and reward quality (local incentives schemes, CQUIN)
• raise standards (role of SHA Medical Directors and the Clinical Advisory Board, and NHS Medical Board which comprises the SHA Medical Directors and Sue Hill, Clinical Strategy lead for COPD)
• safeguard quality (Care Quality Commission – whose role extends to primary care too)
• stay ahead (innovation)

The paragraph on CQUINs; “All PCTs will need to agree with NHS providers how to link payment to quality in their 2009/10 contracts. In the first year, organisations may choose to link the 0.5 per cent of contract value to measurement of quality. Acute contracts should include a CQUIN scheme linking payment to specific locally determined goals that cover the domains of quality and innovation. For community, mental health and ambulance service providers, payment may be linked to a quality improvement plan. In future years, the proportion will increase and will start to reflect quality improvements. The new Care Quality Commission will also recognise where quality has been achieved through high-profile publication of trusts’ results.”

Coding
HRG4 will be used.
See here and the Guide to Respiratory coding.

Performance management – vital signs
Performance management will be conducted using the Vital Signs framework, which provides three sets of indicators:

• Tier one or "must do" indicators apply to all PCTs and provide national standards and performance measurement. The most important tier one targets are for access to primary care and capacity.   Monitored by the Care Quality Commission.
• Tier two national priorities for local delivery must do’s but with more flexibility about how it is done locally. Monitored by the Care Quality Commission.
• Tier three is a range of indicators which PCTs can use in consultation with partners and local communities to set targets for improvement. Performance management is left to the PCT.

Annex A: Planning Process
Timetable
The timetable below sets out the main stages and decision-making points for commissioners to be
aware of during the planning discussions.

Planning and technical guidance issued January 2008
PCT strategic plans developed October 2008
SHA talent and leadership plans developed Autumn 2008
PCT allocations 2009/10 December 2008
Tariff 2009/10 December 2008
Standard contract 2009/10 December 2008
Pandemic influenza and other major incident plans to be completed December 2008
Initial SHA plans submitted for 2009/10–2010/11 for finance, workforce,
Vital Signs and informatics 30 January 2009
Contracts to be agreed 28 February 2009
Local Area Agreements submitted to Government offices 2 March 2009
Final SHA plans submitted for 2009/10–2010/11
for finance, workforce, Vital Signs and informatics 20 March 2009
PCTs and provider units to publish joint plans on eliminating
mixed-sex accommodation 31 March 2009
NHS providers register with the Care Quality Commission 1 April 2009
Quality framework for community services to be piloted June 2009
PCTs to have developed plans for the future provision of
community services October 2009
Providers delivering services on behalf
of the NHS to publish ‘quality accounts’ June 2010

-----------------

The Operating Framework for 2008/09: priorities haven't changed.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081094

This explicitly moves to a more hands-off approach allowing more local discretion. So there will a small number of national priorities, and then areas for local PCT prioritisation and flexibility. However, when you look at it, it still seems like a lot of national direction (given all the previous must-dos don't go away). It is a step in the right direction though.
There will be a "vital signs" document soon, or indicators to encourage joint working with local authorities.

A. The must dos:

improving cleanliness and reducing HCAIs;
improving access through achievement of the 18-week referral to treatment pledge, and
improving access (including at evenings and weekends) to GP services;
keeping adults and children well, improving their health and reducing health inequalities;
improving patient experience, staff satisfaction, and engagement;
preparing to respond in a state of emergency, such as an outbreak of pandemic flu.

B. The issues that PCTs need to consider whether local recovery action is required:

equality
mixed-sex accommodation
learning disabilities
diabetic retinopathy
Mental health crisis resolution

C. Issues that are on the horizon that need to be considered by PCTs

mental health - improving access to psychological therapies (IAPT)
older people - dementia - earlier intervention
end of life care (new strategy mid 2008)
disabled children

D. Then there are the existing targets

Existing commitments
" Whilst there is a need to focus on new priorities, it is essential that the levels of service set through previous commitments, which should have been achieved by April 2008, are maintained. We will ask the Healthcare Commission to feed the following specific commitments into its performance assessment of NHS bodies, alongside its performance assessment of other issues: "

four-hour maximum wait in A&E from arrival to admission, transfer or discharge;

guaranteed access to a primary care professional within 24 hours and to a primary care doctor within 48 hrs € a maximum wait of 13 weeks for an outpatient appointment;

a maximum wait of 26 weeks for an inpatient appointment;

a three-month maximum wait for revascularisation;

a maximum two-week wait standard for Rapid Access Chest Pain Clinics;

thrombolysis 'call to needle' of at least 68 per cent within 60 minutes, where thrombolysis is the preferred local treatment for heart attack;

guaranteed access to a genito-urinary medicine clinic within 48 hours of contacting a service;

all patients who have operations cancelled for non-clinical reasons to be offered another binding date within 28 days, or the patient's treatment to be funded at the time and hospital of the patient's choice;

delayed transfers of care to be maintained at a minimal level;

all ambulance trusts to respond to 75 per cent of Category A calls within 8 minutes;

all ambulance trusts to respond to 95 per cent of Category B calls within 19 minutes;

a two-week maximum wait from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals;

a maximum waiting time of one month from diagnosis to treatment for all cancers;

a maximum waiting time of two months from urgent referral to treatment for all cancers;
100 per cent of people with diabetes to be offered screening for the early detection (and treatment if needed) of diabetic retinopathy;

deliver 7,500 new cases of psychosis served by early intervention teams per year;

all patients who need them to have access to crisis services, with delivery of 100,000 new crisis resolution home treatment episodes each year;

all patients who need it to have access to a comprehensive child and adolescent mental health service, including 24-hour cover/appropriate services for 16- and 17-year-olds and appropriate services for children
and young people with learning disabilities;

chlamydia screening programme to be rolled out nationally .

E. There's the new 0809 tariff

F. There is guidance on the duty of PCTs and local authorities to produce a Joint Strategic Needs Assessment (the key local needs assessment document)

G. And finally, Annex D has Principles and rules for co-operation and competition . This is an important - if slow - acknowledgement that managing the market needs some transparency and principles.