Policy reference Policy product type LGiU essential policy briefing Published date 09/08/2010 Christine Heron This covers England.

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1 1 of 5 23/03/ :07 Liberating the NHS consultations: Transparency in outcomes: a framework for the NHS, and Regulating healthcare providers Policy reference Policy product type LGiU essential policy briefing Published date 09/08/2010 Author Christine Heron This covers England Overview This briefing should be read in the context of the general briefing on the White Paper Equity and excellence: liberating the NHS which describes all the key NHS reforms. LGIU briefings on other consultations stemming from the White Paper commissioning for patients, local democratic legitimacy in health, and the review of arms-length bodies will be issued shortly. The NHS outcomes framework is an important element in the government s reform of the NHS. The aim of the framework is to motivate service improvements and to ensure there is accountability for performance at the most senior levels. The Secretary of State for Health (SoS) will hold the new NHS Commissioning Board to account for progress on NHS outcomes, and ultimately Parliament will be able to hold the SoS to account. The framework is divided into five domains which are intended to cover the full scope of NHS work: preventing people from dying prematurely enhancing the quality of life for people with long-term conditions helping people to recover from episodes of ill health or following injury ensuring people have a positive experience of care treating and caring for people in a safe environment and protecting them from avoidable harm. Each domain will contain a set of outcome indicators, improvement areas and standards by which the performance of the NHS can be judged. This framework is for the NHS separate frameworks will be produced for public health and social care. However the NHS framework is likely to include many outcomes that require the NHS to work with adult social care, children s services and other local services. The consultation report indicates that the social care framework will based on the principles of the NHS framework, thus making it of particular interest to local authorities. The consultation on regulating healthcare providers describes an expanded role for Monitor as the independent economic regulator for health and social care, taking over some of the functions currently delivered by the Department of Health (DH). Monitor would be responsible for regulating prices, promoting competition and supporting service continuity. The consultation also describes freedoms for foundation trusts including removing the private income cap which restricted the amount of private healthcare that could be provided. While Monitor is the regulator for health and adult social care, there are no specific examples of how it would apply its functions beyond the NHS. Its role in relation to adult social care is as yet unclear. Both consultations are seeking views on all aspects of their proposals. A series of regional events to discuss the white paper will be announced on the DH website. The consultations run until 11 October and responses should be submitted to The government intends to respond to the consultation prior to the introduction of a health bill later this year. The first outcome framework should be published at the end of 2010 or the beginning of 2011 alongside the NHS Operating Framework for

2 2 of 5 23/03/ :07 Briefing in full The outcomes framework Each of the five domains identified above would have the following elements. An overarching outcome indicator or set of indicators to measure overall progress. Approximately five or more specific improvements areas, such as topics of particular importance to patients, with corresponding outcome indicators. Quality standards with supporting good practice guidance developed by the National Institute for Health and Clinical Excellence (NICE). 150 standards will be developed over the next five years; three, including stroke treatment and dementia care, were published this June. Section three of the document explores the possible content for each of the domains. For example, in domain two Enhancing the quality of life for people with long term conditions, suggestions for the overall outcome include percentage of people with long term conditions where day to day activity is affected or percentage of people feeling supported to manage their condition in primary care. There would be improvement areas for children and young people, working age adults and older people for older people the outcome could be ability to live independently or be physically active. Quality standards would relate to the care and treatment of long term conditions. The document states that existing or proxy indicators will be used in the short term as others are developed. Annex A presents a list of potential indicators for each domain. The delivery of outcomes is likely to vary according to geographical area and across different population groups. The framework should not be considered as a performance management tool for NHS providers the Care Quality Commission will continue to be responsible for ensuring that providers meet minimum standards and essential levels of quality and safety. Implications for local authorities The consultation document indicates that the framework will be focused on outcomes that the NHS alone can influence. Some outcomes will require partnership working, and in order to ensure clear accountability the framework should identify the extent to which the NHS is accountable for these outcomes, as distinct from the role of public health, adult social care or children s services. The Department of Health will be constructing and consulting on outcomes frameworks for public health and social care in the coming months, as part of an integrated cross service approach to the spending review. The intention is to enable organisations to provide complementary and integrated services. The framework for adult social care will be developed using the same principles and designed to align outcomes across the NHS and its local partners as far as possible (2.3). Regulating healthcare providers The government intends to augment the role of Monitor as the independent economic regulator in order to exert control over NHS providers through regulatory licensing rather than hierarchical management. (Another control mechanism is contracting with commissioners). Monitor will work along side the Care Quality Commission which is responsible for quality assurance, inspection and enforcement. Monitor s tasks include: regulating prices including setting national tariffs in the payment by results system, currently set by the DH promoting competition on a level playing field of providers

3 3 of 5 23/03/ :07 supporting service continuity helping to ensure that alternative arrangements are in place in the event of failing services licensing providers of NHS services and imposing conditions such as collecting information to aid price-setting raising fees from the industry to support its operation, rather than the current government grant. The consultation also proposes that all NHS trusts must become foundation trusts in three years. The legislative framework for foundation trusts which ensures that any surplus or proceeds from sales of assets is reinvested in healthcare will be retained. The aim is to create the largest and most vibrant social enterprise sector in the world. Foundation trusts would have a number of freedoms such as removal of the private income cap to allow an expansion of private healthcare provision, and some trusts, such as community services, would be able to operate with staff-only membership (e.g. not requiring patient and public members). Much of the remainder of this consultation is concerned with technical aspects of economic regulation such as loans, mergers, anti-competitive practice and insolvency. Implications for local authorities At various stages the document specifically refers to Monitor s role in relation to both health and social care. For instance, providing equitable access to essential health and adult social care services and making best use of limited NHS and adult social care resources (3.2). Its strategic remit will be confined to health and adult social care, e.g. it will not cover supply of pharmaceuticals. However, the document does not give any examples of how it will exercise its functions over social care, and, in relation to licensing, social care is specifically excluded. The reason given is that there are already mature markets and choice in social care. Comment The outcomes framework is intended to provide a coherent and comprehensive mechanism by which to judge progress in the NHS. It has been welcomed in principle by many NHS organisations, such as the NHS Confederation. However, there is also a view that that the proof of effectiveness will be in transparent development and implementation. One of the most positive aspects of the framework is the prominence of the patient experience as a domain in its own right, and the emphasis on involving patients, public and clinicians. Bringing together outcomes, indicators and standards within one framework should also help promote a coherent and consistent approach. However, some caution is needed about how this framework relates to the work of local authorities and the aims of service integration and health improvement. While it is perfectly appropriate for the NHS, public health and social care to have separate outcomes frameworks covering their core business, without shared outcomes there is a danger of fragmentation. The single Health and Social Care Outcomes and Accountability Framework was a positive development in that it encouraged organisations to jointly own performance outcomes. The consultation on the new framework is extremely NHS focused. While it indicates that many of the outcomes likely to feature in the final framework will require joint work, the potential indicators set out in Annex A are almost exclusively NHS. A further factor is the role of Communities and Local Government, from where it seems that almost every new announcement signals the demise of red tape and bureaucracy. The abolition of the Comprehensive Area Assessment in June also calls into question the future of crosspublic service performance assessment. Therefore, while a strong commitment to integrated working and exploring the benefits of place-based budgets can be found in the White Paper and the consultation on local democratic legitimacy, it would be helpful if the outcomes framework were more focused on joint work. One

4 4 of 5 23/03/ :07 of the consultation questions is how the framework can support partnership working between the NHS, public health and social care, and local authorities may wish to consider and respond to this question in particular. NHS targets were criticised by the Conservative party before the election, although some health organisations, including the Kings Fund, pointed out that targets have played an important role in improving the quality of patient care. The revised NHS Operating Framework removed the 18-week referral to treatment target, but largely maintained the 4-hour maximum wait in A&E. The Outcomes Framework does not contain targets, however, it will have specific improvement areas and national outcome goals leading to the question when is a national outcome goal not a target. Changes to regulation have received more cautious support from health commentators although the organisation representing foundation trusts is understandably enthusiastic. The changes will resolve some of the ongoing issues of recent years. The overlap, and apparent rivalry, between Monitor and the CQC should be improved by clearly defined responsibilities. The lack of clarity over competition between NHS and independent providers appears to have been resolved by the proposal for a level playing field. However, previous opposition to the removal of the private income cap was generally due to a concern that expanding foundation trusts private income might mean they paid less attention to their NHS duties. The role of Monitor will be crucial in ensuring that the NHS work remains the key priority. It will also need to be vigilant on issues such as maintaining access for rural areas in the face of the need to improve efficiency. Finally, on social care, the main body of this briefing described how the consultation document gives no details on how Monitor might regulate social care in practice. The English Community Care Association has expressed concern that Monitor has little or no experience of adult social care. None of the consultation questions mention adult social care, and the conclusion could be drawn that the DH has not yet considered how these measures might apply. Clarification on this issue could be sought as part of the consultation.

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