NHS Standard Contracts Implementation Workshops 20082009

1
NHS Standard ContractsImplementation Workshops
2008/2009
2
NHS Standard ContractsWelcome to your
Implementation Workshop

• Eamon Kelly
• Director of Commissioning, NHS West Midlands

3
The SHA perspective on Commissioning
Requirements processes

4
West Midlands SHA Productivity Improvement and
Yorkshire Care Pathway Programmes November
2008 Judy Hall Productivity Improvement
Lawrence Moulin MH Modernisation
5

• Aims of to-days presentation
• Set the context of the of the Productivity
  Improvement Programme (PIP)
• Describe the outputs of the pilot and development
  phase of the PIP Community Services programme
• Provide feedback on the testing of the Yorkshire
  Care Pathways (YcP) project
• Describe the roll-out plan for the PIP (MH/LD)
  and YcP programmes

6

• The 7 Big Challenges
• Inequalities widening
• Variable quality and safety of services
• Lack of upstream investment
• Buying things that dont work
• Costs increasing faster than income
• Lack of public confidence in services
• Complex systems difficult to navigate

Our Priorities Full Engagement Improving the
Quality and Safety of Services Care Closer to
Home Sustainable Services Organisations Fit for
Purpose

• 10 WM Projects
• Market Development for Lifestyle Risk Management
  Service
• Commissioner Collaboration on Upstream
  Intervention
• Towards Consumer Directed Care
• Real Time Patient Experience Feedback
• Safest and Highest Quality Services in the
  Country
• Systematic Provision of Information on Quality of
  Primary Care Service
• Development of Care Pathways
• A Clear Vision for each health economy
• Workforce Transformation
• 10. Productivity Improvement Project

7
Productivity Improvement Programme
Safety Quality Workforce Transformation
Safety Quality Workforce Transformation
NHS Institute Productive Ward Programme (Beginnin
g Roll out 2008)
Community Services Project (Roll Out Commenced
March 2008)
Mental Health Services Project (End of pilot
stage 2008)
8

• To develop and pilot a bespoke methodology that
• achieves the following outcomes in the stated
  time frame

• Provides a rigorous and insightful analysis
  including benchmarking of workforce productivity
  of
• Community Services
• Mental Health and Learning Disabilities
• Assesses current levels of productivity and
  identified areas for improving productivity and
  reducing costs while maintaining standards in key
  quality and performance indicators
• Focuses on developing organisational capacity to
  manage and improve service line economics
• Utilises outputs and best practice from the work
  undertaken in the acute sector as part of the
  West Midlands Productivity and Improvement
  Programme
• Delivers the methodology in electronic toolkit
  form, including data collection templates, for
  rollout to other West Midlands Community Services

9
Productivity Improvement Programme Community
Services
10
Twin Track Approach
Functional Level Analysis
Service Level Analysis
Nationally available data analysis Design and
implementation of benchmarking tool Deep Dive
areas identified Workforce Productivity Tool

• Directory of Services
• Service Prioritisation
• Service Line Economics
• Deep Dive areas identified
• Challenging Service Models

Synthesis and Recommendations
Development of electronic toolkit
11
(No Transcript)
12
Community Benchmarking Tool (CBMT)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
T2C outputs
17
Community Services Rollout Plan
18
(No Transcript)
19
What was the brief?
To develop and pilot a bespoke methodology that
achieves the following outcomes in the stated
time frame

• Provides a rigorous and insightful analysis
  including benchmarking of workforce productivity
  of Community Services (including Community
  Hospitals) in two pilot sites
• Assesses current levels of productivity and
  identified areas for improving productivity and
  reducing costs while maintaining standards in key
  quality and performance indicators
• Focuses on developing PCT capacity to manage and
  improve service line economics
• Utilises outputs and best practice from the work
  undertaken in the acute sector as part of the
  West Midlands Productivity and Improvement
  Programme
• Delivers the methodology in electronic toolkit
  form, including data collection templates, for
  rollout to other West Midlands Community
  Services
• Utilises, where appropriate, the outputs of the
  NHS Institute for Innovation and Improvement
  Productive Community Hospital Project.

20
The Challenges in Understanding Productivity in
Mental Health

• We do not have a common way of describing the
  range of people who come through mental health
  services and their needs (a currency)
• Clinical diagnosis is a very poor predictor of
  the treatment people will receive or renounces
  they need
• Without this clarity there is no common language
  between service user, clinician, provider
  organisation and commissioner
• Therefore we can not compare how teams work in
  any meaningful way

21
Yorkshire Care Pathways/clusters What they are

• Set of 13 care pathways for all people who use
  adult mental health services (plus 3 for older
  peoples MH)
• All new referrals are assessed using a form of
  HoNOS (HoNOS Plus)
• Based on an algorithm a pathway is automatically
  suggested, clinicians can override this (97
  concordance)
• Viewed nationally as the only viable model for a
  currency with the possibility of developing into
  a tariff.

22
(No Transcript)
23

• Yorkshire Care Pathway Project
• Objectives of Phase 1 (May-September)
• Test the acceptability of the Yorkshire Care
  Pathway model to clinicians
• Test the effectiveness of the assessment tool in
  allocating service users to pathways
• Test the ability of IT systems to report activity
  information PAS by service user

24
Yorkshire Care Pathways Where we are up to

• Pathways tested in two Trusts. Key questions
• Do the pathways make clinical sense?
• Do we have an effective assessment tool to
  allocate users to a pathway, allocating 95 plus?
• Are we able to download IT data by service user?
  (from 1 pilot site)
• Have the pathways the potential to be built into
  tariffs?
• A great deal of progress in the pilot sites
• Broadly the answer seems to be yes

25
Progress on allocation to clusters Pilot site
one
Total of 409 cases
26
Progress to staff input Pilot site 2
Average Time per Patient 185 mins
27
Benefits of using pathways

• For user
• Upfront information of what services will be
  provided by who and when
• For clinicians
• Allows analysis and comparison of clinical
  practice
• Will be part of developing outcomes measures
• Good practice pathways to work towards
• For provider organisations
• Detailed understanding of current model of
  service delivery
• Facilitates service redesign
• For commissioners
• Focus on pathways of cost and greater
  transparency of service model and improved
  dialogue for commissioners and providers

28
Caveats and warnings

• It is essential not to jump to conclusions based
  on early data
• It is probably two years work to get a robust
  system running, and IT will be a major challenge
• Commissioners and providers must work
  collaboratively
• To date clinical buy in has been very positive,
  we must maintain that
• There must be quality measure attached to every
  pathway
• We need to ensure this delivers for People with a
  Learning Disability and Older People with a
  Mental Health problem
• We need to make sure with Social Care is at the
  heart of this development

29
Current view

• There is clear evidence that the Yorkshire Care
  Pathways offer significant benefits of themselves
  to help to understand activity
• They are the basis for the development of a
  currency and potentially the basis for a tariff
  system
• There is a national commitment to have a MH
  currency using pathways with local prices by
  March 2010, but centrally there is a lack of
  clarity about how.
• We need to move on in the West Midlands, the new
  national contract offers a strong framework to
  support this

30
Twin Track Approach
Provider/Commissioner Focus
Provider Focus
Productivity and Improvement Programme
Yorkshire Care Pathway Programme
Directory of Services MH/LD Benchmarking
Tool Rostering Assessment Reference Cost
Benchmarking Tool Time to Care Diary Card
completion

• Yorkshire Care Pathway Launch and Training
• Assessment and allocation to pathways
• Collection and Analysis of PAS data in pathways

Cost Activity Workforce
Synthesis Recommendations Action Plans
Local Cost Shadow tariff
Tariff
Service Level Economics Tool
31
(No Transcript)
32
(No Transcript)
33
The NHS Contract for 2009

• The Policy in Context
• Bruce Potter
• Morgan Cole / DOH

34
The NHS is changing because the world is changing
The cost of new drugs is increasing
Quarter more over 85s by 2015

• Lucentis and Macugen
• NICE will rule this year on two treatments to
  prevent blindness in people with AMD
• These new drugs could cost the NHS between 60m
  and 180m a year.

Rising consumer expectations
Diseases of modern lifestyles
35
There has been unprecedented investment
By 2008 NHS investment will have trebled, but
36
Weve established a comprehensive reform
programme
Better care Better patient experience Better
value for money
Choice Commissioning (demand-side reforms)
37
History of Commissioning

• NHS has commissioned for over a decade, but
• Command control delivery model has
  consistently reinforced the provider line
• Commissioners have lacked robust levers
• Not all available levers have been used
• Inadequate regulatory regime bail out
• Low investment in developing commissioners
• Highly variable fragmented practice
• Lack of legitimacy (linked to voice patient
  /public engagement)
• Very limited range of providers

38
Re-launching Commissioning

• Commissioning Framework (July 06)
• Practice-Based Commissioning Guidance (November
  06)
• Interim New NHS Contract (December 06)
• Care and Resource Utilisation demand management
  (December 06)
• Commissioning Framework for Health, Care
  Well-being (March 07)
• A Vision for World Class Commissioning (Planned
  for December 07)

39
Approach to Contracting

• The need for a NHS contract was introduced with
  in the Commissioning Framework, July 2006
• It has the main tool for achieving accountability
  and improving performance in a system with more
  autonomous providers
• It is legally-binding for NHSFTs, the IS and
  Third Sector
• Recognises need for greater focus on services
  provided away from acute hospitals

40
Learning from the Acute Contract

• The interim contract was generally well-received
• Co-ordinating commissioner arrangements are
  broadly right
• The contract is a useful as a framework across
  the NHS to support consistent behaviours
• Each set of parties felt that the risk was
  unfairly weighted against them
• Very few participants were able to describe
  accurately the levers and sanctions in the
  interim contract
• In a number of cases mandatory elements of the
  contract were deleted during negotiations

41
Learning from the Acute Contract

• There was not enough time to prepare and
  implement properly
• Greater clarity is need on what is mandatory and
  what is negotiable
• The roles of the SHA, PCT, Co-ordinating
  Commissioner and associates need to be clearly
  described
• The Co-ordinator / Associate role needs to be
  developed around a binding standard consortium
  agreement, supported by clear and consistent
  guidance
• The legal language needs to be simplified and
  explained
• The implementation arrangements and guidance need
  to be significantly improved

42
Current Status

• Contracts for Mental Health and Learning
  Disabilities, Ambulance Services, Community
  Services are due for publication in the autumn.
• Some elements remain to be concluded and we are
  continuing to seek stakeholder views
• Todays presentations on the contracts structure
  and controls represent current thinking and
  proposals
• Further implementation support events will be
  scheduled after the publication

43
NHS Standard Contract

• Operating Framework

44
Context

• CSR07 average 4 real terms growth over three
  years, compared to 1.9 for total public
  expenditure
• Three Departmental Strategic Objectives
  Promoting Better Health Well-Being For All
  (PSA) Ensuring Better Care For All (PSA) Better
  Value For All
• Contribution on six PSAs led by other Departments

45
Four Strands

• Priorities Freeing up the front line while
  maintaining a focus on the issues of most concern
  to the public.
• Enablers Developing world class commissioning
  and using reform levers to help transform
  services.
• Financial regime A framework that fully
  supports reform goals and incentivises
  improvements in services and choice.
• Business processes A business-like and
  transparent approach to planning and management
  of risk

46
Process and Stakeholders

• DH process up and running, led by David Flory and
  overseen by the NHS Management Board
• Stakeholders will be fully engaged Monitor,
  Healthcare Commission, NHS Confederation etc
• Important links with Department of Communities
  and Local Government (LAAs)

47
Priorities

• Will need to take account of
• PSAs
• Existing commitments
• LAAs
• Direction of travel

48
Priorities

• Aim will remain the creation of greater local
  freedom for PCTs to respond to local need and
  expectations, coupled with clear accountability
  and continued focus on national priorities.
• Increasing focus on outcomes
• Better Health For All Life expectancy,
  inequalities, smoking, mental health, independent
  living
• Better Care For All 18 weeks, HAIs, access,
  LTCs, maternity choice, patient satisfaction

49
Enablers

• Incentives and levers
• Compliance and assurance programme
• Public and patient empowerment
• Workforce
• New models of care/NHS Next Stage Review
• IMT
• CQUIN

50
Financial Regime

• Confirmation of PCT allocations
• Expectations on efficiency drivers Better Value
  Strategic Objective
• Clarification of other planning assumptions

51
Business Processes

• Need for increasingly business-like and
  transparent approach to planning.
• Better alignment of NHS and LA planning
  processes.
• Clarification of the roles and responsibilities
  of each part of the system.
• Timetable for local plans to be agreed and
  confirmed.

52
CQUIN

• Update on Commissioning for Quality and
  Innovation

53
We want to make quality and innovation part of
the commissioner-provider discussion everywhere

• The Next Stage Review set out visions for high
  quality services and new measures to enable and
  support the NHS to increase quality
• There are many good local and regional quality
  improvement initiatives in the NHS
• In some places, these already bring quality
  improvement and innovation into commissioning
  discussions. However, we know this good practice
  is inconsistent
• Several places in UK and internationally are
  successfully using incentives to improve quality
  we want to make it easier it do this in the NHS

• A new national framework aims to support and
  embed a cultural shift by making quality and
  innovation part of the commissioner-provider
  discussion everywhere
• This will be a developmental process which will
  embed quality as a priority for organisations and
  their Boards, so there are real improvements in
  quality of care for patients in the long term

54
Development of the CQUIN payment framework has
been based on the four principles of NSR
implementation

• The emerging principles of CQUIN have been
  developed through discussions with NHS colleagues
  on their experience
• The development and agreement of local CQUIN
  schemes will depend on commissioners and
  providers working together to drive quality
  improvement and innovation, supported by SHAs
• This is a developmental journey. Nationally and
  locally we should learn lessons from the first
  year to inform future development

CO-PRODUCTION

• Local CQUIN schemes will need to be developed
  with clinicians and use clinically meaningful
  indicators as demonstrated by similar schemes
  already running successfully eg in the North West

LOCAL CLINICAL ENGAGEMENT

• The framework has explicitly been designed to
  allow good existing work to continue and develop,
  and with as much flexibility as possible, within
  a few broad national parameters, where NHS
  colleagues have advised they are needed

SUBSIDIARITY

• The CQUIN payment framework will help embed
  quality as the organising principle, bringing it
  into commissioning and contracts
• It aims to reinforce the Quality Framework and
  will help PCTs demonstrate their World Class
  Commissioning competencies

ALIGNING SYSTEM ARCHITECTURE
55
A CQUIN payment framework will be just one part
of a comprehensive approach to quality and
innovation
Approach to deliver high quality care throughout
the NHS
Define
Measure
Publish
Reward
Improve
Regulate
Innovate
Changing the way standards are created and set by
expanding NICE so it selects the best standards
available, or fills the gaps, and runs a new NHS
Evidence service

• Quality Metrics across service line (Patient
  experience and patient related outcomes)
• Clinical dashboards for teams
• Initial metrics being developed for the 2009/10
  NHS Operating Framework

• All providers of NHS services will publish
  Quality Accounts from April 2010
• Comparat-ive information on NHS choice

• New Commission-ing for Quality and Innovation
  (CQUIN) payment framework
• Multi-year tariff projections, tariff for mental
  health

• Strong role for regulation by the Care Quality
  Commission. Annual report to Parliament
• Regulation to be extended to primary care for
  first time, in time extended to dental practices

• Stronger clinical engagement in commissioning
• Medical Director Clinical Advisory Board at
  every SHA
• Quality Observatory in every region
• National Quality Board

• Best Practice Tariffs programme from 2010/11
• SHAs to promote innovation, new fund, and prizes
• Health Innovation Education Clusters
• Academic Health Science Centres

56
The Darzi review said a proportion of provider
income will be made conditional on quality and
innovation
Health communities will develop local schemes
within broad parameters set out in a national
Commissioning for Quality and Innovation (CQUIN)
payment framework
LOCAL ROLE
REGIONAL ROLE

• Given their market management and assurance role,
  SHAs may have a role in supporting PCTs in
  setting fair and transparent goals.
• When established, Quality Observatories may help
  support PCTs in developing local schemes.
• Any disputes between PCTs and providers would be
  resolved through existing resolution processes in
  place for contracts.

• Local CQUIN schemes will be developed by the lead
  PCT for each provider taking into account views
  of Associate PCTs.
• Lead PCTs will identify local priorities and
  agree with the provider appropriate goals as part
  of contract negotiations.
• The lead PCT will need to clarify the roles and
  responsibilities locally, and consider who they
  may wish to involve in developing their local
  scheme e.g. patients.

NATIONAL ROLE

• DH sets the framework for local flexibility to
  ensure transparent mechanisms
• Support learning on a developmental journey eg
  optional exemplar scheme(s)

57
PCTs should choose the indicators for CQUIN in
discussion with providers

• AREAS OF QUALITY
• The national CQUIN framework will align with the
  Quality Framework, focusing on three elements of
  quality
• safety,
• effectiveness (including clinical outcomes and
  PROMs),
• user experience
• Local CQUIN schemes should reflect these three
  areas and also recognise innovation.

Innovation

• CHOOSING INDICATORS AND GOALS LOCALLY
• Where nationally standardised definitions exist
  PCTs should use these (levels 1-3).
• If national definitions do not exist, PCTs may
  choose to experiment and develop new indicators
  in agreement with providers (level 4).
• Goals should be stretching but realistic

1
58
Income will depend on quality - rather than
paying more for quality. The amount affected is
likely to grow

• Uplifts in contract value will be calculated to
  create funds for CQUIN at PCT level improvement
  will be integral to what PCTs pay for
• The size of the incentive will be decided
  nationally - probably around 1-4 of contract
  value, based on the limited international
  evidence
• We expect it will start small perhaps 0.5 or 1
  in the first year. As people become familiar with
  the scheme, the percentage will increase,
  building on the feedback from experience and the
  evaluation

SIZE OF INCENTIVE
OPTION OF ADDITIONAL MONEY

• Allowing provision for additional money could
  help make CQUIN a stronger incentive and allow
  reward for very challenging goals
• PCTs would decide whether to offer additional
  money, and how much

• A payment schedule will need to be agreed
  locally.
• PCTs could pay some or all of the CQUIN money in
  anticipation of most goals being met, as they
  should be realistic as well as challenging. This
  will ease cash flow and support good
  relationships. If goals are not achieved, later
  payments could be stopped or adjusted later. The
  timing of final adjustments will be affected by
  how fast reliable data is available

FREQUENCY OF PAYMENT
59
How will local CQUIN schemes work in practice?
There will be a number of steps in developing the
local schemes. Several of these will take place
simultaneously, as part of the contract
negotiations.

• Develop a local scheme
• Agree local roles, responsibilities and who to
  involve
• Commissioner and provider agree priority areas to
  improve, indicators and realistic improvement
  goals
• Agree overall scheme and how payment will reflect
  the indicators

• Monitor and manage scheme
• Make payments
• Review progress against goals
• Make sensible assessment of performance and
  reconcile payment
• Review the scheme

Publish scheme
60
We have engaged with a range of NHS and
independent sector colleagues. Clear principles
are emerging
The Commissioning for Quality and Innovation
(CQUIN) payment framework will make a proportion
of a providers contract value conditional on
local quality improvement and innovation goals

• PCTs should agree local schemes with all
  providers on national contracts. Goals in local
  CQUIN schemes should be stretching but realistic
  and draw from established indicators
• Initially, PCTs may wish to focus more on
  incentivising improvement in data collection on
  quality. From the second year, PCTs should start
  to consider including quality goals in their
  local scheme, focusing on improvement over time
• Local CQUIN schemes can be used to support
  existing quality improvement initiatives and
  innovation, and show World Class Commissioning
  competencies
• Local CQUIN schemes should be published showing
  both the achievement against previous goals, and
  the promised goals for the forthcoming year
• It should apply to all service types covered by
  national contracts
• High Quality Care for All made clear this would
  begin from 2009/10

61
The CQUIN framework should apply to all service
types covered by national contracts

• The principle that a providers income should
  reflect quality should not be limited to just one
  sector. The CQUIN payment framework will apply
  to services covered by national contract i.e.
  acute, community, mental health and ambulance
  services.
• Following feedback from the NHS, we now think
  that introducing CQUIN in all sectors at the same
  time may stretch PCT commissioning capability and
  capacity too far. Therefore, we suggest that
  CQUIN is mandatory for acute in 2009/10, and
  optional for community, mental health and
  ambulance services.
• In primary care, there are existing incentive
  schemes, in particular the Quality and Outcomes
  Framework for GPs, which we do not want to
  duplicate.

• Concerns raised
• This will be hard for PCTs to do
• Phase changes dont require people to do
  everything at once and first, get new contracts
  right
• Large number of providers if do for all sectors
  simultaneously do PCTs have capacity to agree
  schemes with all from scratch?
• For many areas of quality, data and information
  systems are less developed than in acute

2009/10 Mandatory Acute Optional Ambulance,
Community Mental health
2010/11 Mandatory Acute, Ambulance, Community
Mental health
DO YOU AGREE?
62
We want your help answering some practical
questions about how the CQUIN payment framework
will work

• Who will drive the scheme locally?
• How do you encourage discussions on quality
  improvement now? How will you use CQUIN to
  complement this
• What do you see as the SHA role?
• What would you want DH to do to support the use
  of CQUIN?
• What benefits do you think CQUIN will bring?
• What risks and barriers do you foresee? How can
  they be managed?
• Who will be involved in PCTs in developing and
  implementing local CQUIN schemes?
• Should CQUIN be optional or mandatory for mental
  health services in 2009/10?
• Please tell us if you already have local
  financial incentives on quality

63
Coffee Break in the Stephenson Foyer

64
NHS Standard Contract

• Aims and Principles of Contracting

65
What is the Contract?

• The NHS Standard Contract, will cover agreements
  between PCTs and providers for the delivery of
  NHS Funded Care
• Is legally binding
• It has a default duration of 3 years. Guidance
  will be issued to enable shorter or longer
  contract periods.
• The contract will recognise and allow for
  Partnership Commissioning (under S75 NHS Act 2006
  and S10 Children Act 2004
• Providers can be Foundation Trusts, NHS Trusts,
  Care Trusts, Independent Sector and Third Sector.

66
Key Principles of a legal contract in the NHS

• Legally Binding
• Fair and equitable
• Encourage a partnership
• Practical Future-proof
• Embrace policy
• Provide for remedy before penalty
• Mandate in order to maintain NHS principles
• Allow as much local agreement as is practical
• Keep as simple as possible

67
Why stand-alone standard NHS TCs?

• To supports NHS principles, values and standards
  and the NHS Constitution
• To provide a consistent minimum fair playing
  field and prevent some contracts being unfair
  compared with others
• To simplify and focus the contract negotiation
• To avoid nationally-required generic changes
  having to be executed through multiple contract
  changes
• To remove the bulky legal and boiler plate
  elements from the procurement

68
Who will use the new Contract

• The Contract will apply to agreements from
  2009-10 as follows
• All NHS Trusts and Care Trusts
• Foundation Trusts
• New FTs and existing FTs whose contracts expire
  in March 09, are required to adopt the new
  Contract for 2009/10 onwards.
• FTs with contracts which extend beyond March 09
  may adopt the new Contract or retain their
  existing contracts until the required notice
  period passes.
• Independent Sector and Third Sector Providers
• The contract is designed for use by IS and Third
  Sector providers whose contracts expire at the
  end of 2008/09.

69
Contract RelationshipsStakeholder Principles

• The contract should
• Reflect vision, long term planning and change
• Recognise the community interest
• Provide clarity on commitments that need to made
  to stakeholders
• Clarify and define respective roles and
  responsibilities
• Recognise that open information is required from
  both parties to manage the contract
• Underpin a relationship between equals
• Understand mutual dependency and benefit of the
  parties in aiming for a partnership approach
• Support co-operation and collaborative behaviours
  that benefit both parties and cement the positive
  relationship between them.
• Be based on terms that are deliverable in practice

70
Contract RelationshipsExpected behaviours

• Find and support win-win solutions
• Achieve appropriate risk sharing, and sharing of
  any benefits that are realised by mutual effort
• Maintain mature, regular dialogue within a
  professional code of conduct
• Ensure flexibility where there are genuine
  problems in delivery
• Provide incentives as well as penalties
• Recognise investment required to achieve
  requirements over a reasonable time period
• Support providers to change their service offer
  over time in relation to changes brought about
  through patient choices
• Maintain honesty and transparency across both
  parties and with patients and the public

71
Main Features Heads of Terms

• Standard terms and clauses the boiler plate
• Activity planning and review
• National v Locally-agreed quality standards
• Local Developmental Quality Standards
• Requirements on information flows and provision /
  Data Quality Improvement Plans
• Bi lateral and Multi Lateral Contracts will be
  available to Commissioners
• Dispute resolution arrangements
• Contractual Control mechanisms

72
Structure of the Contract
73
Draft Standard NHS Terms and Conditions

• Definitions and Interpretation
• NHS Principles and Values and Constitution
• Services Environment, Vehicles and Equipment
• Emergency preparedness, Business Continuity Plan,
  Duty of Partnership
• Prices where PbR applies and Payment
• Representatives
• Consent
• Complaints
• Staffing and Employment issues
• Emergencies Urgent Care
• Death of a Patient
• Reporting, Analysing Learning from Patient
  Safety Incidents
• Quality
• Transfer and Discharge Obligations
• Governance and Transaction Audit
• Patient Health Records
• Confidential Information
• NHS Branding and Promotion
• Pastoral and Spiritual care

• Discrimination
• Dispute Resolution Procedure
• Monitoring
• Performance mechanisms (including mechanisms for
  retention of payments)
• Suspension and Termination (including partial)
  and Consequences
• Remedies
• Inducements to Purchase
• Variations
• Representations and Warranties
• Notices
• Force Majeure and Major Incidents
• NHS Counter Fraud and Security Management
• Third Party Rights
• Waiver
• Assignment and Sub Contracting
• Exclusion of Partnership
• Non-solicitation
• Costs and Expenses
• Governing Law and Jurisdiction

Click to edit Master title style
Click to edit Master title style
Click to edit Master subtitle style
Click to edit Master subtitle style
74
Structure of the Contract
75
Draft must-have elements for local negotiation

• Consortium agreement between Co-ordinating
  Commissioner and Associates
• Pricing local agreement of non PbR
• Activity Plan and Review,
• Care pathways and Capacity review
• Commencement and Duration, and Contract Review
• Information flows and reporting provisions
• Service specifications and requirements
• Service Improvement/Development
• Clinical Networks and Screening Programmes
• Serious Untoward Incident and Patient Safety
  Incident Reporting
• Service Targets/indicators
• Information Audit
• Demand Management requirements including prior
  approval and utilisation management
• Termination clauses local elements
• Quality Standards Nationally required and
  consortium level
• Retention of payments thresholds / ranges
• Performance - indicators, thresholds / ranges

76
Structure of the Contract
77
Elements Entirely for local agreement

• Examples might include
• Additions to specific service care pathways
• Local care/treatment protocols
• Performance and quality incentive schemes
• Locally agreed additional Quality Standards
• Locally identified additional information
  requirements

78
NHS Standard Contract

• Key Areas an outline

79
Key Clauses

• Clause 2
• Commencement, Duration, Transition
• Sets the contract term
• 3 years is default
• DH will provide guidance where longer or shorter
  contracts may be appropriate
• SHA will approve all contract lengths that are
  not 3 years
• Clause 4 Schedule 2 (Service Specification)
• Services
• Obliges the Provider to supply Services
• Service Specifications (Sch2,Pt1 for local
  definition)
• Activity Plans (Sch3,Pt1, annex1 standard
  format, locally completed)
• Quality Standards (Sch3,Pt4A Pt4B some
  mandated, some local)
• The Law

80
Key Clauses

• Clause 7
• Prices Payment
• Obliges the Commissioners to pay for the Services
  provided
• At the agreed price at tariff and non-tariff
  items
• Details payment terms
• 1/12th of the Annual Contract Value on 15th each
  month
• (This is only obligatory if the Provider has
  issued a valid statement of account)
• Within 30 calendar days of receipt of invoice for
  NCA
• Within the terms of the Compact (applies in the
  main to small third sector organisations)
• Reconciliation of payment rules.
• What to do in the event of a dispute

81
Key Clauses

• Clause 8
• Review
• Obliges the Commissioner and Provider to review
  the contract including
• The Activity Plan
• The Annual Contract Value
• Operating Framework requirements
• The locally agreed Schedules
• Performance (including notices)
• Compliance with Quality, Clinical Governance
  Demand Management
• Complaints, incidents and SUIs
• Information
• Sets out the requirement to plan the following
  years activity together

82
Key Clauses

• Clause 16
• Quality
• Specifies the standards to which Services must be
  performed
• The Law
• Good Clinical Practice
• Good Healthcare Practice
• Clinical quality development plans
• Standards and recommendations of other bodies and
  reports (Standards for Health/National Minimum
  Standards, SUI reports, NICE)
• Obliges the Provider to have regard for any DH
  guidance
• Requires the publication of an annual clinical
  quality review (this will become this Quality
  Accounts)

83
Key Clauses

• Clause 28
• Dispute Resolution
• Describes the Parties rights and obligations
  when in dispute
• The obligation to try and resolve internally
• Escalation to the SHA / Monitor if agreed
• Escalation to CEDR
• CEDR mediates the dispute in line with Schedule 9
  Dispute Resolution Procedure
• If after 20 operational days agreement is not
  reached, agreement will be by Independent Binding
  Pendulum Adjudication
• The Parties still retain their rights to
  terminate the contract with 12 months notice
  (subject to Mandated and Essential Service
  obligations)
• NOTE Disputes between PCTs and NHS Trusts will
  be arbitrated by the SHA, not CEDR

84
Key Clauses

• Clause 29
• Information Requirements
• Describes the Data Quality Improvement Plan
• Links to Schedule 5 which details the
  Information requirements
• Sets out the consequences of not supplying
  information
• The commissioner must demand the information
  formally, in writing and stating that retention
  will occur if information is not supplied
• The Provider will have 5 days to comply
• If the Commissioner(s) actions have caused the
  failure the Provider cannot be held accountable

85
Key Clauses

• Clause 32
• Performance
• Describes the performance management
  system/process
• Provides for remedy before penalty
• Exception Report (to Board, Regulators, SHA) may
  be the biggest consequence

86
Key Clauses

• Clause 33
• Clinical Quality Review
• Describes the clinical review process
• Links to Schedule 3 Part 4A
• Clinical Quality Performance Indicators sets out
• The indicators (some mandated, some for local
  agreement)
• Thresholds
• Consequences and
• measurement methodology for Nationally mandated
  and locally agreed
• Aims to expose, investigate and rectify
• Penalties are only for failure to implement a
  rectification plan (regardless of whether it
  rectifies the breach)
• Is a closed-loop control system for continuous
  improvement

87
Key Clauses

• Clauses 34 35
• Suspension Termination
• Allow the Co-ordinating Commissioner to suspend,
  terminate or partially suspend of terminate.
• The partial element is of a Service or a part
  of a Service
• Allows for restoration of suspended services
• Allows for parties to terminate just because they
  want to (only after year one and with 12 months
  notice)
• If a Provider is in breach of contract it has 60
  days from notification to remedy before it is a
  termination event
• The Provider will be obliged to continue
  Mandatory Goods and Services and Essential
  Services

88
Partnership Arrangements

• Key new section in the contracts
• Arises from S75 NHS Act 2006 and S10 Children Act
  2004
• Trigger clauses will be put in place to cover
  the commissioning partnerships and separate
  trigger will be put in to cover provider
  partnerships. These will act as a sign post to
  the Partnerships Schedule
• New Schedule (written but under review) drives
  the process
• Both Provider and Commissioner S75/S10 agreements
  to be documented within the contract (Sch 11)
• If there is not a commissioner or provider
  partnership the provisions of the contract
  referencing the arrangement will not apply

89
Controls and levers in the contract

• A contract enables parties to agree rules and
  sets out the methods for dealing with and the
  consequences of failure.
• Parties can resolve issues without resorting to
  the contract but the contract sets the boundaries
  in a clear and agreed form.
• If a party breaches a contract where there are no
  levers then the other party has only two choices
  ignore the breach or terminate.
• Where services, especially clinical services, are
  concerned there are contract targets which
  dictate the level of service that is to be
  provided. The contract levers allow this to be
  monitored and for appropriate corrective measures
  to be agreed.
• Where failure occurs defined consequences act as
  a reasonable deterrent where termination my be
  unreasonable or impossible.

90
Purpose of Controls

• Clinical
• To improve performance
• To engender continuous improvement
• To mitigate failure to implement agreed change
  (not failure to hit targets)
• Non-Clinical
• To mitigate poor performance
• To provide risk, not certainty of penalty
• To increase commissioner control over spend
• Performance priority
• To underpin delivery of key national policies and
  targets
• To ensure consistency and fairness
• Termination
• To ensure Patients and the NHS is protected from
  poor contractors

91
Summary

• Contract controls provide a framework for
  improvement
• Consequences are based on a failure to act or
  implement agreed action plans and not the breach
  itself
• Most indicators (clinical or otherwise) will be
  for local agreement
• Some consequences will be for local agreement
  DH will provide guidance
• The control mechanisms protect both parties
• Risk to organisational reputation may be a
  significant consequence both to the organisation
  (in the eyes of the patients/service users) and
  the individual officers (professionally)
• The regimes are constructed in a spirit of
  co-operation not penalisation
• Termination remains the ultimate sanction

92
Preparatory Steps (within the contract)

• There are a number of things that you can do now,
  in advance of the publication of the full
  contract
• Governance
• Quality requirements
• Pricing structure
• Service Specification
• Activity and Volumes
• Information requirements (want, need, actually
  get)

93
Preparatory Steps (outside the contract)

• There are a number of things that you may need to
  address out side the strict confines of the
  contract which will help
• Partnership arrangements
• Organisational fitness/competencies
• Information requirements (want, need, actually
  get)
• Forthcoming plans (service developments or
  commissioning needs
• Build on your relationships

94

• Session QA

95
NHS Standard Contract

• Afternoon Breakout Groups

96
SHA Contract workshopsNHS Standard Contract for
Community Services
97
Primary and community care strategykey themes

• Not a national blueprint
• Setting a clear vision
• and creating the right environment for leading
  local change

Shaping services around individuals
Promoting healthy lives
Continuously improvingquality of care
Clinical leadership
World class commissioning
Patient power and choice
98
Primary Community Strategy clinical service
improvement areas

• Services for Staying Healthy
• Services for Children and families
• Acute care Services in the community
• Services for Long Term Conditions
• Services for Rehabilitation
• End of Life Care

99
(No Transcript)
100
Working Group Membership

• NHS Confederation Primary Care/FT Network/IS
  Network
• 3rd sector umbrella organisations
• SHAs
• PCT Commissioners Providers
• DH reps
• Social Enterprise providers

101
Scope of community services contract
2
1
4
3
Out-Patient care
In-Patient Care
Community drop-in
Domiciliary Care
Includes Rehabilitative and palliative care in
community hospitals, hospices, nursing or
residential homes
Includes therapy services such as physiotherapy
and podiatry as well as district nurse clinics
diagnostics.
Includes specialist services such as family
planning health visiting
Includes home visits by district nursing,
occupational therapy, community midwifery and
health visiting.
Community Services
102
Aims, Strategic Links and Potential Barriers of
Community Services Contract
Strategic Links
Aims
Potential Barriers
Next Stage Review including Primary Community
Services Strategy System Management 3rd
sector SE Programme Wider programme re.
community services development Links to CQC re
standard setting, monitoring and response to
failure.
Wide scope of coverage Cross-departmental
approach for Section 75 agreements Joint
approach to be agreed with DCSF re. childrens
services, Legal agreements already in place with
non-NHS bodies may delay implementation Current
lack of standards/ targets in relation to quality
and activity Community MDS not in place, metrics
not yet available for majority of services
Flexibly support innovative commissioning
approaches Improve care outcomes, Catalyst to
maximise quality and productivity Support both
joint commissioning pathway based
care Develop benchmarking.
103
Potential Contract Routes for Community Services
(1 of 2)
Commissioner
Option 1
Benefit Reflects most common current practice
with commissioner contracting on an
organisational basis with each provider therefore
easy to implement
Option 2
Commissioner
Lead provider for geographical area
Benefit Could reflect PBC or local approach with
Local Authority with one provider accountable to
commissioner
104
Potential Contract Routes for Community Services
(2 of 2)
Option 3
Commissioner
Benefit Commissioner / provider split is
maintained, and commissioner retains full control
of commissioning care
Strong Commissioning
SINGLE CARE PATHWAY
Commissioner
Benefit One provider retains clinical and
financial responsibility for the patient, as well
as accountability to the commissioner
Option 4
Lead provider
SINGLE CARE PATHWAY
105
Structure of the Contract
106
Key Features

• Service specification template
• To be used for providers of all sectors
• 3 year duration as a norm
• Bi-lateral or multi-lateral basis
• Care pathways, lead providers
• Partnership arrangements
• Incorporates 18 weeks/PBR etc where applicable
• Flexible payment arrangements where appropriate

107
Testing

• At least 2 contractual relationships tested in
  each SHA
• 3 phase,10 week test period
• Flexible focus
• Section 75, Care Trusts, 3rd Sector, IS
• Open consultation

108
Learning from Testing

• Generally positive
• Grants or contracts?
• Which contract?
• Internal providers
• Capacity capability of both parties
• Maturity of relationships
• Surplus
• Terminology to embrace integrated health social
  care

109
Stakeholder Principles

• The contract should
• Reflect vision, long term planning and change
• Recognise the community interest
• Provide clarity on commitments that need to made
  to stakeholders
• Clarify and define respective roles and
  responsibilities
• Recognise that open information is required from
  both parties to manage the contract
• Underpin a relationship between equals
• Understand mutual dependency and benefit of the
  parties in aiming for a partnership approach
• Support co-operation and collaborative behaviours
  that benefit both parties and cement the positive
  relationship between them.
• Be based on terms that are deliverable in practice

110
Service Specification Template

• Aim provide shared understanding of contracted
  service
• NOT an operational policy
• Aims, population served, fit within whole
  system
• Local prices performance measures
• Additional specified measures for block contract
  prices
• Guidance via template re. service specific issues
  e.g. Children, end of life care, community
  hospitals

111
Quality Performance

• Applicable national targets
• Patient experience
• Unplanned admissions
• Reducing inequalities
• Improving productivity
• Waiting times
• Assessment care planning
• Care management
• Outcomes
• Activity monitoring
• Costs prices
• Continual service improvement

112
Moving to outcomes
113
What we mean by currency
Fee for individual service
Per period - eg year of care
Per patient pathway
Per case diagnostic/ procedure
Per day
Block budget/ grant
Per head - capitation
There are pros and cons to any point along this
spectrum
ENTIRELY ATOMISED
ENTIRELY AGGREGATED
What does it look like?
For what is it used?
114
How currencies are developed
115
Who does what by when?

• Department of Health
• Nov 08 currency and pricing framework published
• Dec 08 Core MDS identified for approval
• April 10 small number of national currencies
  developed ready for implementation
• April 09 Evaluation of PbR for community
  services begins
• NHS
• Dec 08 local currency and pricing development
  begins
• April 09 limited implementation of currencies
  and prices (PbR)
• April 10 adoption of nationally developed
  currencies (pricing local?)
• April 11 widespread implementation of locally
  developed currencies and prices

116
Contact Details

• Tracy.cannell_at_dh.gsi.gov.uk
• Craig.porter_at_dh.gsi.gov.uk
• Contract web page
• http//www.dh.gov.uk/en/Managingyourorganisation/C
  ommissioning/Systemmanagement/DH_085048

117
Workshop discussions some ideas

• Partnership arrangements
• Organisational fitness/competencies
• Build on your relationships
• Governance
• Quality requirements
• Pricing structure
• Service Specification
• Activity and Volumes
• Information requirements (want, need, actually
  get)

118

• Session QA

119
New NHS Contract For 2008 and beyond

• Closing remarks and
• Planning for the next workshop

120
New NHS Contract For 2008 and beyond

• Thank you for attending
• Please hand in your badge at the event desk for
  recycling