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.
There is normally continuity between years, steered by the Spending Review period. Unusually in 2010 there were two - a June revision to the 2010/11 Framework, following the election of the Coalition Government, and the 2011/12 Framework, issued on 15 December 2010. This marks the first operating framework of the next four-year Spending Review period.
15 December 2010 - Operating Framework for 2011/12 was published by DH England. Click here for documents that include transitional commissioning arrangements from PCTs to GP consortia requiring PCTs to cluster into "single executive teams" by June 2011, confirmation that £20 billion to be found through quality and productivity but now over 4 years (to March 2015); hospital tariff to be set at an average 1 per cent below the cost to the average provider for the first time and providers will also be allowed to offer services at below tariff from April 2011.
Operating Framework 2011/12 Headlines for IMPRESS
There is a paragraph on respiratory disease
Respiratory disease
4.53 The 2010 public consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease (COPD) in England revealed strong consensus support for the 24 recommendations and PCTs are asked to continue the task of delivery. Diagnosis of COPD is a particular problem with individuals often presenting late with disabling disease. If these patients were identified and managed effectively, the burden of those who progress to severe or very severe disease would be significantly reduced for the NHS as well as for patients and their carers.
In addition there are many other relevant points:
POLICY
The framework builds on the 21 June 2010 Revisions to the Operating Framework , but now set in the context of the
Finance
The QIPP challenge has been slightly eased: the £20 billion savings are now to be realised by the end of March 2014/15 - an extra year.
Equality Act
This is described right at the beginning of the document and may turn out to be important for people with COPD and their carers. NHS organisations will have to comply with the Equality Act 2010, due to come into force April 2011: the important difference is that the definition of disability has been changed to apply to "a person who has a physical or mental impairment that has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities." A person no longer has to show their impairment affects a particular capacity such as mobility.
Direct discrimination in services has been extended to cover disability. It also applies to discrimination against a carer - a person is treated less favourably because they are associated with someone with a disability.
Discrimination by association, by perception and indirect discrimination are all new additions to the Act.
ACCOUNTABILITY
Centralising control during transition
To support the transition to the post white paper NHS, there will be a tight central grip on finances (SHAs will top slice 2% from PCTs that can only be accessed by PCTs on submission of a business case for non-recurrent funding, although it is not being called top slicing).
The new roles and structure
- David Nicholson, Chief Executive, remains the accountable officer, and will hold NHS to account for requirements in the Operating Framework, QIPP and a single integrated process of reform
- SHAs remain responsible for operational delivery and to lead transition across their regions for 2011/12
- PCTs accountable to SHAs, and remain statutory authorities until April 2013, but will increasingly discharge responsibilities in clusters with a single Executive Team in place by June 2011. They may remain "beyond that date if the NHSCB chooses."
- GP consortia will begin to take on devolved responsibility
- NHS Commissioning Board (NHSCB) will be established as shadow Special Health Authority in 2011/12, fully operational from 1 April 2012 led by Sir David Nicholson.
GP consortia
- Will be offered by PCT clusters a development fund of £2 per head to support development, this will be funded from management cost savings released by the MARS (the redundancy) scheme. (it is expected that they will receive a running costs allowance in the range £25- £35 per head by 2014/15).
- A qualified or accredited senior finance manager
- An organisational development expert/facilitator
- Expert in governance/corporate affairs
- A commissioning expert
Encouragingly, they will be supported to participate in the Joint Strategic Needs Assessment (JSNA) and to ensure a partnership approach to the commissioning cycle
They will have their own budgets from 2013/14.
Social care
PCTs will receive specific allocations totally £648 million in 2011/12 and £622 million in 2012/13 to support social care that they will transfer to local authorities, referring to the Vision for Adult Social Care and the Carers Strategy. This is in addition to the reablement funding (see below).
Reablement
PCTs received in their baseline £70 million in 2010/11. This increases to £150 million in 2011/12 and £300 million from 2012/13. There might be scope to use this to fund post-discharge support for people with COPD. All PCTs have an allocation for social care and reablement in their baseline. The Reablement 2010 allocation was published separately. See here for more information. PCTs should be able to tell clinicians what they have spent/are planning to spend it on by sharing a written plan that is due by 31 December 2010.
Health and Wellbeing boards
These will be statutory bodies from April 2012 to enable councils to lead on integrated working and commissioning across the NHS, public health and social care in collaboration with other agencies.
Foundation Trusts
All NHS trusts will become FTs by April 2013. Trusts will be supported by the Provider Development Authority led by the National Managing Director for Provider Development and SHAs.
Transforming Community Services
By 1 April 2011 all PCT directly provided community services must be separated from PCT commissioning.
Commissioners should use the Any Willing Provider model to stimulate the market for community services. This could be one of the biggest areas of change over the next few years - the stimulation of the market of community services. See here.
A Right to Provide
This creates the opportunity for NHS staff to set up and lead new social enterprises. We could see the establishment, for example, of nurses and AHPs setting up services.
CONTRACTS AND TARIFFS
Contracts
All contracts will use the standard NHS contracts and be signed by the start of the financial year. They will allow "providers to take responsibility for managing demand" eg follow up OP ratios in defined specialties. Also may use sanctions for incomplete data or poor data quality.
Care homes
There is a bespoke contract for the care homes sector - it will be reviewed during 2011/12.
Tariffs
There is an overall tariff price reduction from 2010/11 and 2011/12 of 1.5%. All tariffs are set 1 per cent below the national average level (recognising that the average might be skewed by poor performance). A five-day trim point floor is introduced, so that relatively short stays do not attract a long stay payment. All tariffs are set 1 per cent below the average. There are also best practice tariffs (list not included in the Operating Framework).
No reimbursement for emergency readmissions within 30 days
In 2011/12 the responsibility of PCTs to secure post-discharge support and hospitals for the first 30 days of discharge will come into play. As acute trusts know, "In 2011/12 hospitals will not be reimbursed for emergency readmissions within 30 days of discharge following an elective admission, and all other readmissions within 30 days of discharge will be subject to locally agreed thresholds, set to deliver a 25% reduction, where possible. This is to ensure that, wherever possible, hospitals have good discharge arrangements in place to avoid readmissions. PCTs should work with providers, GPs and local authorities to manage the savings arising from non-payment of emergency readmissions to fund reablement and post discharge support."
"currency" for smoking cessation
This is described as one of the new outpatient attendance tariffs and will be introduced in 2011/12. We are finding out more information.
Year of Care tariff for Cystic Fibrosis
In 201/12 the DH will mandate a "national currency for cystic fibrosis services to reflect the care that patients receive over the course of a year."
The HRG4 for A&E services will be introduced.
New cut price tariff opportunity
Providers who have the confidence in their efficiency will have the flexibility to undercut the tariff and offer commissioners a price lower than the published tariff to win new business. This is likely to work best in surgical interventions in the first instance, until different sorts of tariff exist for respiratory services.
CQUINs
Most of these will be organised at regional level but there are two mandated goals: VTE risk assessment again, and responsiveness to personal needs of patients. These must equal one fifth of the CQUIN value. Some regions are included CQUINs that would benefit respiratory services eg in London a COPD discharge bundle has been accepted onto the NHS London CQUIN pick list.
Education and training
See the consultation document
Pay
Two year pay freeze from April 2011 for those earning more than £21,000.
Outcomes Framework
Is now out. For IMPRESS summary go here. It has an encouraging number of respiratory-related outcomes. In the future, each domain will be supported by NICE Quality Standards. The NHS Commissioning Board will also use these NICE Quality Standards to develop an outcomes framework for GP consortia.
NHS Life Sciences Delivery Board
A new partnership with industry to support QIPP. The remit includes increasing access to cost effective innovative medicines and medical technologies. No further information yet.
Patient experience
PROMs guidance will be revised in 2011 to extend their use.
Duty to Involve
PCTs' statutory obligation is confirmed, during transition to GP consortia.
Better Information
The Quality Information Strategy and the Information Strategy will be available in 2011, but PCTs should publish plans for 2011/12 including:
- PROMs
- Real-time patient feedback
- Use of the NHS number
- Use of digital technology eg telehealth, telecare and online services - so IMPRESS has a role to clarify the evidence base for this in respiratory care
- Informatics use across health and social care - we should watch for good examples
- Supporting GP consortia's information needs
Choice - consultant-led team
By April 2011 all patients should be able to choose a named consultant-led team for outpatient appointments
Choice and diagnosis
During 2011 patients should be offered greater choice in diagnostic testing and post-diagnostic care - and note that chest x-ray gets a particular mention under the cancer requirements 4.35 : "patients should have timely access to diagnosis and treatment and be seen by the right person with the appropriate expertise in particular......four priority areas for diagnostics: chest x-ray to support diagnosis of lung cancer" Compare this to the more general statement about diagnosis for COPD: "4.53 "Diagnosis of COPD is a particular problem....If these patients were identified and managed effectively the burden...would be significantly reduced..."
Personal health budgets
There is a commitment for wider roll-out in 2012 to allow greater integration between health and social care at the individual level. IMPRESS could work with the DH during 2011 to publicise findings from the national pilots including some with people who have COPD.
KEY NEW COMMITMENTS
There are 21. Of relevance to respiratory services:
- Increase the number of Health Visitors by 4,200 by April 2015.
- Expand Family Nurse Partnership programme
- Establish the Cancer Drugs Fund of £200 million for 2011/12.
- SHAs responsible for ensuring the implementation of the Murrison Report into veterans' mental health
- Support for carers by:
- Financial support for breaks for carers in PCT baselines
- Agreeing policies, plans and budgets to support carers with local authorities informed by the Recognised, valued and supported: next steps for the Carers Strategy
- Maintaining referral to treatment times, in the NHS Constitution
- Improvement in the performance against A&E indicators
- Improvement in performance of clinical quality of ambulance services
- End of life care: ensure staff are trained, including using the e-learning modules (we would hope IMPRESS's Living and Dying educational package be used too)
- Commissioners need to ensure that adequate 24/7 community services are available to support the QIPP end of life workstream that wants people approaching the end of life to be asked their preferences for care.
- Cancer reform - see Diagnostics above
- Stroke Strategy - there is a particular mention of post hospital discharge, early supported discharge and community specialist stroke rehabilition with effective reablement support. An equivalent is not yet included for COPD.
- Increasing access to psychological therapies (the IAPT programme). Expansion will continue including training programmes for the workforce and a choice of NICE-approved therapies. The DH will extend access to people with comorbid mental and physical health long term conditions. IMPRESS will publish more on this.
AREAS FOR IMPROVEMENT
There are 7 of these, including
Respiratory Disease:
"4.53 The 2010 public consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease (COPD) in England revealed strong consensus support for the 24 recommendations and PCTs are asked to continue the task of delivery. Diagnosis of COPD is a particular problem with individuals often presenting late with disabling disease. If these patients were identified and managed effectively, the burden of those who progress to severe or very severe disease would be significantly reduced for the NHS as well as for patients and their carers. "
MAINTAINING QUALITY IN PUBLIC HEALTH
Optimising medicines
There is a specific mention of medicines: Optimising the use of medicines in people with newly diagnosed long term conditions, and targeting of Medicines Use Reviews are areas that SHAs and PCTs should actively engage in.
Pandemic flu
Pandemic influenza remains a serious threat and NHS organisations will wish to ensure that the ability to operationalise and coordinate their pandemic response plans across local areas is maintained and continues to be tested with their local partners. All local plans should be able to deal with a range of potential levels of pressure, from the relatively mild, such as swine flu, through to much more severe pandemics.
Headline performance measures reported at national level
Quality
- HCAI measure (MRSA & CDI)
- Patient experience survey
- Referral to Treatment waits (95th percentile measures)
- MSA breaches
- A&E Quality Indicators (5 measures)
- Ambulance quality (Cat A response times)
- Cancer 2 week, 62 day waits (2 aggregate measures)
- Emergency Readmissions
Resources
- Financial forecast outturn & performance against plan
- Financial performance score for NHS Trusts
- Delivery of running cost targets
- Progress on delivery of QIPP savings
- Acute Bed Capacity
- Non elective FFCEs
- Numbers waiting on an incomplete Referral to Treatment pathway
- Health visitor numbers
- Workforce productivity
Reform
- FT pipeline
- Transforming Community Services (TCS) successfully achieved
- GP Consortia progress and transfer of relevant functions NHS CB/LAs
- Establishment of PCT clusters
- Choice
- Information to Patients
- Competition
"Supporting measures" - none for respiratory but emergency admissions and care plans and smoking quitters and carers breaks all relevant
Quality
- MRSA – delivery of objective
- CDI – delivery of objective
- VTE Risk assessment
- % deaths at home (inc care homes)
- Ambulance quality indicators (all other measures)
- A&E quality indicators (all other measures)
- Cancer waits (all 9 measures)
- Stroke indicator
- Community services
- Carers breaks
- Access to NHS dentistry
- Staff engagement
- PROMS scores
- Maternity 12 weeks
- Mental health measures (EI, CR/HT, CPA, IAPT)
- Low value procedures
- Smoking Quitters
- Breastfeeding at 68 weeks
- Breast screening
- Bowel screening
- Cervical screening test results
- Diabetic retinopathy screening
- Referral to Treatment waits (median wait measures)
- Coverage of NHS Health Checks
- People with Long Term Conditions feeling independent and in control of their condition
- Emergency admissions for Long Term Conditions
- Safeguarding
Timetable
