The Operating Framework is the NHS's planning and priorities document issued by the Department of Health annually in December for the year ahead to enable the NHS to begin its planning for the financial year starting in April.
21 June 2010 The DH has issued a revised operating framework for the NHS in England for the remainder of 2010/11. It heralds more substantive changes to the Framework for 2011/12 where indicators will be removed that have "little or no clinical relevance."
Points of relevance to the IMPRESS audience
The NHS is still expected to deliver on the December 2009 NHS Operating Framework 2011/11, and PCTs will still be accountable to their SHA for the delivery of their operational plans submitted in March 2010 and well as their QIPP plans with the exception of these changes. What is changing is what will be "performance managed" - that is, require regular returns to PCTs and onwards to SHAs and to the DH. Some "process" targets will be dropped, others changed, and others the subject of local negotiation.
A standard deed of variation will be issued to PCTs to pass on to contractors with which they have an NHS contract.
Revisions to the Vital Signs and Existing Commitments
- Guaranteed access to a primary care professional within 24 hours and to a primary care doctor within 48 hours target removed
- Vital sign Tier 1 Patient experience of access to primary care (and supporting measures) target removed
- 4 hour A&E wait target remains but threshold shifted from 98% to 95% with median times in A&E to be performance managed.
- Vital sign Tier 1 Percentage of patients seen within 18 weeks for admitted and non-admitted pathways (and supporting measures) target removed
New rules on reconfiguration
Moratorium on all reconfiguration except for trauma care and the review of paediatric cardiac surgery. All four tests to be satisfied before any other reconfigurations go ahead:
1. Support from GP commissioners for the change
2. Strengthened public and patient engagement
3. Clarity of clinical evidence base,
4. Consistent with patient choice
SHAs have to go back and check that these four tests have been demonstrated in any planned, ongoing or completed consultations.
Transforming community services
Deadline remains to achieve separation of PCT provider arm by April 2011 (or at least substantial progress) even if interim transfer to another organisation necessary. Plans now have to demonstrate that they have
- Been tested with GP commissioners and local authorities
- Are consistent with the forthcoming NHS Strategy to strengthen delivery of public health services and services for children
- Considered implications for choice and competition (there will be a phased move to an Any Willing Provider" model for community services); a wide range of options, including the development and early delivery of Community Foundation Trusts and Social Enterprises, providing employee leadership and ownership;
- Engaged staff and their representatives
There are no changes to Vital signs Tier 2 and 3, which are already locally determined.
Finance and efficiencies
The figure still quoted for efficiency savings over the next 4 years is £15-20 billion, although growth (assume just above zero) will continue to be made in NHS budgets.
Accelerating development of the payment system and tariff changes
The tariff guidance in the autumn 2011 will include more best practice tariffs and also pathway (year of care) tariffs will be introduced - COPD and end of life care could be included, supported by commissioning packs.
From 1 Dec 2010, hospitals will be responsible for patients for the 30 days after discharge and cannot claim tariff for a patient readmitted within 30 days. Some PCTs are already doing this for avoidable readmissions due to poor quality care. This is now mandatory for all admissions with the aim of creating more integrated working between secondary, primary and community care. The method of non-payment is for local discretion, with GP and local authority involvement.
Conclusion
The NHS will not suffer the cuts faced by other public services but the amount of growth will be minimal. Given the estimated rise in demand and healthcare inflation, this equates to the £15-20 billion efficiency challenge by 2014 which remains. It is expected roughly 50% will be delivered by efficiencies in pay, management costs, procurement, estates and so on, and 50% through transformation of services. In some regions there are PCT management cuts of up to 50% being decided upon, as well as decisions on revising expenditure on services, so life in many PCTs is very uncertain and it will be hard to find the right person to speak to. This is at the same time as a renewed policy emphasis on GP commissioning, where PCTs are expected to support its growth, as well as separation of community services, and re-looking at any major reconfiguration plans.
It will also be interesting to see the impact on trends in performance because it is acknowledged that there have been significant benefits to patients in the reduction in waiting times.
The NHS operating framework for England for 2010/11
PCT Allocations
The DH England has now (December 2009) issued policy and planning guidance for 2010/11 called the Operating Framework (for the last 2 years' frameworks see below), PCT allocations and the 2010 Payment by Results Road Test package. This year is the third and final year of a three-year settlement that increased public spending on health. However, whilst the last Pre-Budget Report of 2009 still says the NHS remains a top priority, commentators all agree that “the NHS will have to save “a relentless 5 per cent a year (presuming a pay freeze), each year, for three years to meet Wanless’s vision for the NHS” (John Appleby, King’s Fund and manage “the biggest financial challenge it has faced in a generation” (NHS Confederation). So, the 2010/11 Operating Framework signals that a start should be made now on finding the £15bn-20bn savings that will be required. “…need to view future decisions in the context of delivering cash-releasing strategies while sustaining and improving the quality of services.”
One of the issues that has attracted most attention from commentators is the need for PCTs and SHAs to reduce their management costs by 30 per cent over the next four years. Options include reducing procurement and “back office” costs and merging management functions with other organisations, including local authorities. The Health Service Journal (HSJ) calculated this could be as over 5,000 administration and commissioning redundancies but there is no figure in the policy document. However, the HSJ quotes Chief Executive of the NHS in England David Nicholson:
‘I don’t want to hide it: it’s true. You can’t take a third out without affecting the workforce’
It is also the first Operating Framework to be published since the new medium term NHS Plan: NHS 2010-15...from good to great, Preventative, people-centred, productive, and provides the detail about its implementation.
Principles of High Quality Care for All are restated:
• clinical ownership and leadership
• co-production
• subsidiarity
• system alignment
Quality and productivity challenge
All the areas that IMPRESS has considered are endorsed as the ways to achieve the “challenge”
• More care closer to home;
• Fewer acute beds;
• Reduced unit costs;
• Reduced variation;
• More standardisation of pathways;
• Early and more upstream intervention; and
• Greater co-production, with people taking greater ownership of their health.
Note: NHS Evidence has a number of entries about improving quality and productivity in respiratory care such as oxygen assessment, hospital at home and access to psychological therapies (as well as some generic long term conditions examples).
Vital signs
The Vital Signs appendix has the same categorisation of Tier 1: national must dos; Tier 2: national must dos for local delivery and Tier 3: options for local negotiation and agreement.
For the third year in a row, the 5 national must dos remain the same: "
• Improving cleanliness and reducing healthcare associated infections;
• 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; and
• Preparing to respond in a state of emergency such as an outbreak of pandemic flu, learning from our experience of swine flu.
During 2010/11, the NHS must also continue its work to reduce local variation and eliminate poor performance.“
Standard NHS contracts for 2010/11 published January 2010.
In his covering letter to NHS chief executives, David Nicholson, highlighted:
Quality - changes to the payment system for rewarding quality
Sharing risk - the need to share risk across the system and re-balance risk between commissioners and providers
System characteristics - seeking a reforming system where changes continue to be shaped locally by cooperation, competition and patient choice
Integration - transforming patient pathways leading to integration of services and, in some cases, organisations.
Key financial points (from HSJ and NHS Confederation)
For PCTs
• 2010-11 allocations remain: average increase of 5.5 per cent
• 0.5 per cent extra efficiency needed for new responsibilities for ophthalmic, dentistry and pharmacy services
• 2 per cent set aside for non-recurrent, one-off costs of change (eg redundancies) to avoid long term commitment: aggregated at SHA level til 2013/14 then by PCT
• £400m surplus spent by April 2011
• Assume inflation-only increases from 2011-12 onwards
• Savings from tariff will be used to create a regional pool for system risk management and transformation
• Management cost reductions in PCTs of 30% by 2013/14 (front-loaded into early years)
• A requirement to make a £1b surplus from PCTs and SHAs by the end of 2010/11 to be indicatively deployed during 2011/12 to 2013/14.
For providers
• No inflationary uplift to tariff: assumes 3.5% efficiency saving from providers
• Rising proportion of income from CQUIN - up to 1.5 per cent of contract income
• Unplanned activity over 2008-09 levels at 30 per cent of tariff
• Changes due to specialist top-up values
• A signal to move towards tariff as maximum price not guaranteed price
• PCTs will have rights to withhold a proportion of the contract payment up to 10% over time if providers do not met agreed patient satisfaction goals
NHS Alliance commentary
Welcomes the changes to tariff and CQINs, and that any emergency activity that occurs above the value of the contracted baseline at the aggregate level will only attract 30% of the relevant emergency tariff.
Dr David Jenner, Practice Based Federation Lead for the NHS Alliance, said: “This move will be much welcomed by commissioners as it gives clear incentives for PCTs and acute trusts to work together to avoid unnecessary hospital admissions.”
Management costs – reduction over 4 years
As well as the leadership challenge, the Health Service Journal focuses on this element. It says the DH wants to “front load” the management savings in the first year, to give the maximum chance of releasing savings of about £420m from PCT and SHA management costs a year. To avoid redundancies it is likely that employers will start by reducing the wage bill, not head count (eg part time, sabbaticals, unpaid leave, early retirement). Management consultancy services are to be used only when no other option is available
The NHS Confederation also picks up that:
• There is a strong emphasis on working more effectively with local government. Nothing specifically on integration of health and social care budgets
• There is a set timetable for plans for community services to be in place by March 2010 and for non-foundation trusts to have plans in place for achieving foundation status by March 2010 and to have achieved foundation trust status by 2013/14. There is a need to focus on delivery not merger.
• There is another £500m PCTs and strategic health authorities should contribute to DH £2.3b savings. How? For providers this is already incorporated into the tariff as part of their efficiency savings
The Kings Fund commentary focuses on transactions: the need for co-operation and the need to focus on quality and value for money during negotiations:
'Success will depend on whether the changes to the financial incentives proposed in the Operating Framework have the desired impact. The tariff is being adapted to give incentives to hospitals to reduce admissions and pay more attention to quality. It is unlikely that financial incentives alone can drive the level of co-operation within the NHS that is needed to make the transformation.
'The proposal to abandon the fixed-price tariff system after 2011 in favour of maximum prices has significant implications for the NHS. Although this may open up opportunities for commissioners to secure better value, it is likely to lead to higher transaction costs as PCTs return to bargaining with hospitals over prices. Commissioners will need to stay focused on quality and value for money when negotiating prices.'
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
- Access to personalised and effective care including 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. Have a look at the NHS in England End of LIfe care website for more information.
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 of the five priorities will be conducted using the Vital Signs framework, which provides three sets of indicators (download poster here) :
• 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.
As a reminder, the 5 priorities are:
- Improving cleanliness and reducing HCAIs
- Access to personalised and effective care
- Improving the health of the population and reducing health inequalities
- Reputation, and Improving patient experience and staff satisfaction
- Finance
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
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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.