Equity and Excellence: Liberating the NHS. White Paper outline An NHS that puts patients and the public first… …which focuses on improving healthcare

Equity and Excellence:

Liberating the NHS

White Paper outline

An NHS that puts patients and the

public first…

…which focuses on

improving healthcare

outcomes…

…with more autonomy for

professionals, and more accountability

to patients …

…with reduced bureaucracy and improved efficiency…

…leading to an NHS that achieves healthcare outcomes that are among the best in the world

White Paper outline


public first…

…which focuses onimproving healthcare

outcomes…

…with more autonomy for professionals, and

more accountability to patients and the public…



•Shared decision-making

•An “information revolution”

•Greater patient choice

•Public/consumer voice through HealthWatch

White Paper outline


public first…





•NHS Outcomes Framework

•Backed by clinically-evidenced NICE

quality standards

•Money to follow the patient, with incentives for quality


outcomes…

White Paper outline


public first…





•GP-led commissioning, supported by newNHS Commissioning Board

•More autonomy for providers; all providers regulated on a consistent basis

•Stronger role for local authorities, to boost local democratic legitimacy


outcomes…

White Paper outline


public first…





•Major cut in management costs, to reinvest in front-line services

•Abolition of Strategic Health Authorities, Primary Care Trusts and some arm’s-length bodies


outcomes…

Before

Policy:

Implementation:

NHS

Public health Social care

Department of Health

Public health NHS Social care

After

The new system

Department of Health

Public health service

NHS Social care

NHS Commissioning

Board

Monitor (economic regulator)

Care Quality

Commission

ProvidersGP commissioning consortia

Local authorities

Policy Context

• Equity and Excellence White Paper - towards GP- led commissioning and outcomes

• The Outcomes Framework• The Public Health White Paper• Quality Innovation Productivity & Prevention

(QIPP) agenda• Mental Health Strategy – 2010• IAPT and talking therapies

GP Commissioning

What we know:• Its going to happen• No (very little) central guidance• Variable size of groups• Every practice will be involved in a consortium• 80% of NHS expenditure will be devolved for

commissioning• Consortia can use private commissioners to commission

on their own behalf• Consortia will commission mental health services

GP Commissioning

What we don’t know:• Will there be a similar governance structure for all

consortia?• What levers will there be to influence the commissioning

plans?• What role will the public and users of services have in

commissioning plans?• What role will the Local Authority have in commissioning

plans?• What role will third sector organisations have?• …..

GP Commissioning…

…is not PCT commissioning

writ small

Doctor to Doctor contact

Mental Health

• Adult services– IAPT– CMHTs– In-patient services– Specialist Teams

• Older people services• Children’s services• Forensic Services• Links to Social Services

What should MH Trusts be doing now?

Identify local GP leaders

Support the development of local networks

Encourage the clinician to clinician contact

Embark on a charm offensive

Mental Health

• Emphasis on Outcomes• Traditionally difficult to measure outcomes in mental

health• How to annoy a chief executive of a mental health trust

“How many patients did you make better in the last quarter?”

Why outcomes?

• From a commissioner perspective:– It is outcomes that matter– Don’t need to get involved with process or clinical

detail• From a provider perspective:

– Less intrusion from commissioners in day to day running of services

– Greater focus on outcome, less on process– Greater opportunity for innovation

Outcomes should…

be simple to administer,

the data underpinning the currency should be easily obtainable

not provide perverse incentives

reflect the needs of the individual (the individual receives a high quality service)

reflect the needs of the population (the currency does not discriminate against hard to reach populations)

acknowledge the range of complexity of particular disorders, from the very mild disorder, to those with much more complex and severe disorder.

include outcomes which reflect best clinical practice

include outcomes which reflect the views and experiences of the person receiving the care

ensure outcomes are not be limited to just clinical/medical outcomes but where appropriate, social, employment or vocational outcomes

17

Four Domains

• Access– Population based block payment

• Recovery/improvement– Individually based payment

• Employment/vocation– Individually based payment

• Choice and satisfaction– Individually based payment

• Balance to be determined locally

18

Access

• Population access – proportion of at risk population attending IAPT services

• Disorder specific – allows payment to reflect that all common mental health disorders are treated

• Vulnerable groups – age, sex, ethnicity, gender specific etc

• To be determined locally

19

Improvement/recovery

• Designing a tariff that is just based on recovery has problems:

A large number of patients that showed improvement (but not recovery) would not merit an outcome based payment

The quantity of care and level of training of staff to deliver improvement/recovery for somebody with a longer term more severe disorder is much greater than for somebody with a mild short lived disorder

A solely recovery based tariff would encourage the provider to concentrate on those with mild and short lived disorder, at the expense of those with more complex, and longer lasting disorders. This is a perverse incentive that any tariff should seek to avoid

20

A Tiered Approach

We propose a tiered approach to outcomes, • Built on the PHQ-9 and GAD-7• Both questionnaires are completed by all patients• Includes the ADSMs score

Improvement/Recovery

Recovery Tier 1 Tier 2 Tier 3

PHQ-9 0 – 9 10 – 14 15 – 19 20 - 27

GAD-7 0 – 7 8 – 10 11 – 15 15 - 21

Current definitions of recovery

Proposed tiers for currency use ONLY



PHQ-9 0 1 2 3

GAD-7 0 1 2 3


PHQ-9 0 1 2 3

GAD-7 0 1 2 3

Total 0 2 4 6

Tariff Allocation

Tariff Points


Change in tariff points (between first assessment and last

assessment)

Tariff units earned by provider, per patient

2 or 1 1

4 or 3 2

6 or 5 3

Employment/Vocation

• Based on change of employment or vocation status, between beginning and end of contact with services

• Includes subjective (patient reported) opinion on change in intention in relation to work/vocation

• Developed into a unit calculation

Patient Choice and Satisfaction

Yes NO

Were you given the option to choose from the range of therapies and treatment approaches offered by the service*?

Were you offered information in a way that enabled you to make an informed decision about your treatment?

Were you satisfied with the overall experience of using this service?

Were you given the opportunity to feel involved in decisions about your treatment?

Do you feel that your therapist considered and valued your background, beliefs and lifestyle

* NICE recommends only CBT for some anxiety disorders; this question applies to people with other mental health problems

Outcomes

• Based on the balance between 4 domains• Data for the 4 domains already being collected• Balance between the 4 domains decided by local

stakeholders – This is how people who use the services and the

general public get involved in commissioning

Summary

• There is lots that we don’t know – (and others don’t know as well)

• Which provides the opportunity to design in, what we think is important

• How can we influence GP commissioners?• What impact will outcome led commissioning have?

Thank you

Documents

Equity and Excellence: Liberating the NHS. White Paper outline An NHS that puts patients and the public first… …which focuses on improving healthcare