SUPPORTING PAPER (FOR INFORMATION)BOARD OF DIRECTORS’ MEETING

Date of meeting: Thursday, 27 September 2012

Title of paper: A review of the publication ‘Our NHS Care Objectives: A draft Mandate to the NHS Commissioning Board’

Presented by: Associate Director of Strategy, Contracting and Performance

Executive Summary: This paper sets out in summary the content of the publication ‘Our NHS care objectives: A draft mandate to the NHS Commissioning Board’. The 22 proposed objectives in the mandate have been considered and assessed on how they may impact on NEAS/ambulance services. The assessment shows there are areas where we can have greater input to delivery/contribution to than others.

There has been a review of alignment of our own corporate objectives with those proposed and there is generally a good fit.

The document is currently for consultation/discussion and a draft response is being prepared with a view to submitting a collective ambulance response to the Department of Health by 26 September 2012.

Recommendations: The Board of Directors is asked to note the proposed content of the mandate, the close alignment of our own corporate objectives and the proposed draft response being prepared for the Department of Health.

CQC Essential Standards ofQuality & Safety:

Involvement and Information

Legal Issues: None identified

Author: Rachel Lonsdale, Strategic Business Planning and Performance Lead

Date: 21 September 2012

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NORTH EAST AMBULANCE SERVICE NHS FOUNDATION TRUST

REPORT: A REVIEW OF ‘OUR NHS CARE OBJECTIVES: A DRAFT MANDATE TO THE NHS COMMISSIONING BOARD’

REPORT BY: RACHEL LONSDALE, STRATEGIC BUSINESS PLANNING AND PERFORMANCE LEAD

EXECUTIVE SUMMARY

This paper provides a summary of the content of the recent publication ‘Our NHS care objectives: A draft mandate to the NHS Commissioning Board’, which is currently out for consultation with responses due by 26 September 2012.

The mandate’s purpose is to set the vision and commissioning objectives for the NHS Commissioning Board to deliver. There are 22 objectives for consideration. There are 12 consultation questions covering the objectives, aspects of the content, the structure, its’ future development etc.

The principles and objectives of the mandate are broadly supported by other documentation that we are supportive of, mainly the NHS Outcomes Framework, and there are some areas where we can explicitly contribute to delivery. Other areas, such as the ‘choice framework’ is difficult to align our service to, due to the nature of emergency care.

Our 12/13 corporate objectives appropriately align to the mandate objectives providing assurance that we are well aligned to emergent national directives and policy.

As part of the consultation process we are supportive of a collective ambulance response and the draft response is attached in Appendix 1. In summary, responses generally set out the need to shift emphasis from acute hospitals and for the mandate to provide details of scrutiny and accountability and for it to also set out clear transformational leadership expectations.

Due to the recent changes in Ministers since the release of the mandate it is not clear how much will change in the document therefore we will need to continually review and update as required.

A review of ‘Our NHS care objectives: A draft mandate to the NHS Commissioning Board

1. Introduction

1.1. The Health and Social Care Act 2012 received Royal Assent on 27 March 2012. The Act creates the legislation to support the Government’s vision for improving the NHS. In line with the changes in the Act, the Government are now consulting on their proposals for their first mandate to the NHS Commissioning Board, ‘Our NHS Care Objectives’. The mandate will be the method used by Government to state what it expects the NHS commissioning system to achieve with the funding made available.

1.2. Responses to the consultation questions (included at section 10) are due by 26 September 2012. The final mandate will be published in autumn 2012 and will come into force in April 2013.

1.3. A review has been undertaken of the draft mandate to assess the implications for the Trust, and to ensure alignment of our corporate objectives with the objectives in the mandate. The findings are outlined in this report.

2. The Draft Mandate

2.1 The NHS Commissioning Board will be set objectives by the Government every year in the form of a mandate to ensure that it effectively oversees the spending of funding available to the NHS and is supporting Clinical Commissioning Groups to commission high-quality care for patients. The Government has now published a draft of the first mandate, a draft ‘choice framework’ illustrating the Government’s intended approach to explaining the choices that will be available for people using NHS services and a consultation document, explaining the approach taken to developing the mandate. The mandate sets out the expectations for the health service and marks the move to a more patient centred, independent, transparent and outcomes focused NHS.

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2.2 The Commissioning Board will publish a report at the end of each year detailing its performance. The mandate is a multi-year document which sets objectives for the period April 2013 to March 2015.

2.3 The mandate includes objectives under five core sections:

Improving our health and our healthcare: this sets objectives for improving outcomes and reducing inequalities under the NHS Outcomes Framework

Putting patients first: this sets objectives to extend shared decision-making and choice, improve information, make services more integrated around the needs of individuals, and improve the support the NHS gives to carers.

The broader contribution of the NHS: this sets objectives about how the NHS can work better with other public services, and how it can contribute to economic growth, including through its support for research and innovation.

Effective commissioning: this sets objectives about getting the full benefits from the new system of commissioning, while at the same time managing the transition in a way that safeguards service performance and finances.

Finance and financial management: this will set the Board’s resources and expectations of increased efficiency.

2.4 There are 22 objectives contained within the mandate with a limited descriptor and indicator of measurement. Based upon the information available, a review has been undertaken to assess which of the objectives the Trust currently contributes to. Where possible, the Trust should look to align internal objectives with the objectives set out in the mandate, to ensure the Trust is operating in line with the direction of the wider NHS.

2.5 Some ‘levels of ambition’ have been created which take into account recent and likely future trends with targets for the Commissioning Board which are considered achievable within current resources. These targets will be developed over the consultation period and published in the final mandate: the technical annex to the mandate includes example of what these levels may be.

2.6 The five core sections provide details of the objectives within the draft mandate and a review has been undertaken below as to how they may impact upon the Trust should they be included in the final mandate.

3. Improving our health and our healthcare

3.1. This section of the mandate explains how the Government intends to set ambitions for improving healthcare outcomes and reducing inequalities through the NHS Outcomes Framework whilst upholding core performance standards such as ambulance response times. It also details how the NHS will seek to prevent illness and support people in improving their health. Performance of the Commissioning Board will be measured based on an aggregated measure of performance for each of the five domains within the Outcomes Framework. The five domains are as follows;

1. Prevent people dying prematurely2. Help people recover after ill health3. Enhance quality of life for people with long term conditions4. Protect people from harm when being cared for5. Ensure people have a positive experience of care

3.2. The objectives contained within ‘Improving our health and our healthcare’ are as follows:

Objective Impact on TrustDomain 1: Prevent people dying prematurelyObjective 1: Secure an additional x life years for the people of England, through the reduction of avoidable mortality, by 2015; x life years by 2018 and x life years by 2023.

The Trust A&E and Contact Centre service lines work to save lives through the delivery of effective clinical care and providing timely emergency responses.

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Clinical staff are trained in the latest clinical practices which are reviewed in line with JRCALC and NICE guidelines.The Trust continues to meet our local trajectories and on average between May 2011 and April 2012 we successfully resuscitated 23% of patients who were in cardiac arrest, which is in line with the national average. The Trust is consistently in the top three trusts for successfully resuscitating all patients in cardiac arrest nationally.The Trust provides a quality patient transport service to ensure patients attend hospital appointment to increase life expectancy e.g. renal dialysis, oncology

Domain 2: Help people recover after ill healthObjective 2: Increase the number of Quality Adjusted Life Years for people in England with long term conditions to X by 2015; X by 2018; and X by 2023

The Trust positively contributes to the management of patients with long term conditions through our acceptance of advance care plans, which inform our call takers and crews of a patient’s condition, thus providing them with the latest information on a patient’s condition to enable them to provide an appropriate response where possible.The Trust provides a quality patient transport service with appropriately skilled staff that can administer oxygen and who are trained in caring for immobile patients, lifting and handling etc., in order that they may receive care to support treatment of their long term condition.

Domain 3: Enhance quality of life for people with long term conditionsObjective 3: Improve recovery from illness or injury through increasing the number of Quality Adjusted Life Years for NHS patients in England by X by 2015; X by 2018; and X by 2023.

The Trust provides a quality patient transport service with appropriately skilled staff that can administer oxygen and who are trained in caring for immobile patients, lifting and handling etc. to help patients recover from illness or injury.

Domain 4: Protect people from harm when being cared forObjective 4: i) Increase the proportion of NHS patients in England who would rate their experience as “good” (an additional X patients by 2015); ii) increase the proportion 4 of patients who would recommend their hospital to a family member or friend as a high-quality place to receive treatment and care; iii) increase the proportion of doctors, nurses and other staff who would recommend their place of work to a family member or friend as a high-quality place to receive treatment and care; and iv) provide evidence that poor performance is being tackled where patients and/or staff say they would not recommend their hospital to family members or friends as a high-quality place to receive treatment and care.

The Trust is capturing patient experience utilising two external companies, who will provide touchscreen tablet computers and bespoke survey software to collect patients’ views of their ambulance care in real-time and who will support the Trust in an analysis of the results. From these surveys the Trust is developing a Net Promoter Score (NPS) which will fulfil the Department of Health’s Friends & Family Test which is being introduced for Acute Trusts in 2013. The NPS responses in our latest survey provided the Trust with an indicative score of 45, which is ‘good’.We will utilise the results of our surveys to plan improvements based upon the feedback received and to improve any areas of poor performance.

Domain 5: Ensure people have a positive experience of careObjective 5: Improve patient safety, reducing Quality Adjusted Life Years lost to NHS patients in England through avoidable harm by X% by 2015; X% by 2018; and X% by 2023.

The Trust provides a quality patient transport service with appropriately skilled staff that can administer oxygen and who are trained in caring for immobile patients, lifting and handling etc.The Trust has many safety procedures in place to improve patient safety, including a robust safeguarding referrals process and progress towards the NHSLA level 2.

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Objective 6: Ensure continued improvement of health outcomes, as measured by the indicators in the NHS Outcomes Framework, in relation to baselines set out in the technical annex.

The Trust must demonstrate that performance is being upheld and where possible improved on:

- Category A calls resulting in an emergency response arriving within 8 minutes 75% of the time (standard to be met for both Red 1 and Red 2 calls separately).

- Category A calls resulting in an ambulance arriving at the scene within 19 minutes 95% of the time.

- Ambulance Quality IndicatorsObjective 7: Provide an assessment of progress in narrowing inequalities for all domains of the NHS Outcomes Framework, and work towards a greater understanding of effective interventions to narrow health inequalities.

The Trust has considered, measured and graded our performance against the Equality Delivery System (EDS) by consulting with patients and staff. Following the EDS assessment and grading, the Trust has identified three equality objectives for 2012/13. The Trust is currently updating the Equality Objectives Action plan for 2012 to 2015.The Trust provides transport based on application of eligibility criteria thereby removing a barrier to accessing healthcare

Objective 8: Ensure continuous improvement in reducing inequalities in life expectancy at birth (as measured by the Slope Index of Inequality through greater improvement in more disadvantaged communities.

Not Applicable

Objective 9: Develop a collaborative programme of action to achieve the ambition that mental health should be on a par with physical health.

The Trust currently faces challenges when referring patients to a mental health crisis team. The Trust is working with Northumberland Tyne and Wear Mental Health Trust to support the development of a clinical service redesign to the ‘crisis’ pathway.Training is delivered to staff as part of their Statutory and Mandatory training on mental health awareness, dementia awareness and access for people with learning disabilities.

Objective 10: Uphold, and where possible, improve performance on the rights and pledges for patients in the NHS Constitution and on the service performance standards set out in Annex B.

The Trust must demonstrate that performance is being upheld and where possible improved on:

- Category A calls resulting in an emergency response arriving within 8 minutes 75% of the time (standard to be met for both Red 1 and Red 2 calls separately).

- Category A calls (red incidents) resulting in an ambulance arriving at the scene within 19 minutes 95% of the time.

The treatment that we provide is line with the NHS Constitution and we strive to deliver equality of access and free at the point of access etc.

Objective 11: Develop a collaborative programme of action (to commence by April 2014 to further the ambition that healthcare professionals throughout the NHS should take all appropriate opportunities to support people to improve their health.

The Commissioning Board will have important public health responsibilities with regard to emergency preparedness and health protection. It has a power to facilitate a coordinated response to an emergency by CCGs and providers of NHS services, and a duty to take steps to ensure that CCGs and providers of NHS services are properly prepared for such events.

Part of the Trust’s strategic direction is to be a key partner in urgent care reform and promote staff and patients to look after their own health. The Trust takes all opportunities to train our frontline staff to signpost to appropriate services and we are actively pursuing this via our NHS 111 service and our see and treat strategy.

The Commissioning Board and commissioning consortia have a duty in relation to assuring NHS emergency preparedness. The Trust has already highlighted this as a potential business development opportunity should there be a need for sub-national co-ordinated provision.

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The Trust has a Major Incident Plan that is developed by our Emergency Planning Department (EPD. The EPD works at a national level and also with other agencies including the Home Office, Foreign and Commonwealth Office and the Environment Agency, to ensure the Plan is as up to date as possible and inclusive as possible.

The Plan details our command structure which is aligned to the national structure of Operational, Tactical and Strategic levels of command being adopted.

A cohort of Trust operational staff under-go comprehensive disaster management training by means of both an internationally recognised three day Advanced Major Incident Medical Management and Support (MIMMS) course. All on-call Officers and Team Leaders attend a one day MIMMS course and the Trust has recently introduced this training for all other operational staff. A number of staff also receive Chemical, Biological, Radiological and Nuclear (CBRN) training and are able to respond locally to any incident involving any of these agents.

4. Putting patients first

4.1. This section of the mandate intends to extend shared decision-making and choice, improve information, make services more integrated around the needs of individuals and improve the support the NHS gives to carers. A draft ‘choice framework’ has also been published explaining where and how patients can expect to be able to make choices.

4.2. The objectives contained within ‘Putting patients first’ are as follows:

Objective Impact on TrustObjective 12: Enable shared decision-making, and extend choice and control for NHS patients. This includes:

– ensuring that commissioners support people to be involved in decisions about their care and treatment;

– extending the availability of personal health budgets to anyone who might benefit; and

– subject to the outcome of pilots during 2012/13, ensuring that patients are able to choose from a range of alternative providers if they either have waited, or are likely to wait, for more than 18 weeks after referral to start consultant-led treatment for a non-urgent condition.

The Trust offers choices, where available and appropriate, for patients with an urgent care need via the Contact Centre. Information that is made available is relevant in an urgent care situation and we plan to increase the options available to patients through expansion of our Directory of Services.

Where appropriate patients are always involved in discussions and decisions about the emergency/urgent care and treatment. This is not always possible in an emergency situation whereby a patient may be unconscious.

Crews and Contact Centre staff consistently provide patients with information verbally regarding their care and involve them in the decision where appropriate e.g. advise patient of urgent care centre options available to them.

The Trust is also working with other partner agencies in campaigns such as “Choose Well” and “Deciding Right” which promote patient choice.

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Objective 13: Ensure that the new commissioning system promotes and supports the integration of care (including through joint commissioning) around individuals, particularly people with dementia or other complex long-term needs.

The Trust is involved in wide external engagement with Health and Wellbeing Boards, CCGs and local groups e.g. LINks.

Objective 14: Improve the quality and availability of information about NHS services, with the goal of having comprehensive, transparent, and integrated information and IT, to drive improved care and better healthcare outcomes.

Where relevant the Trust provides information to patients, e.g. Thrombolysis (which has now been superseded by PPCI). The Trust provides relevant information in different formats that helps consultation with patients, public and staff regarding the future planning and delivery of services. The Trust engages with local authority Overview & Scrutiny Committees across the North East in a continuous process of consideration of current and emerging issues.

Objective 15: Improve the support that carers receive from the NHS, in particular by:

– early identification of a greater proportion of carers, and signposting to information and sources of advice and support; and

– working collaboratively with local authorities and carers’ organisations to enable the provision of a range of support, including respite care.

The Trust provides advice and support to carers, where appropriate, when they call us on behalf of a patient and work closely with escorts on the Patient Transport Service to ensure they are supported as part of the patient journey.

5. The broader contribution of the NHS

5.1. This section emphasises that the NHS is in a unique position to work with other public services to help achieve broader social and economic objectives. It promotes partnership working within and beyond the public sector and going beyond the traditional boundaries of the healthcare system. The mandate highlights areas where partnerships can be improved. This also includes an objective about the role of NHS commissioners in supporting research and contributing to economic growth through the life sciences industry. Increasing patient participation in research is an important component of delivering this objective. The NHS, working in collaboration with UK Trade and Investment, seeks to work with commissioners and providers to build and grow the commercial value of the NHS’s skills technologies, products and knowledge internationally.

5.2. The objectives contained within ‘the broader contribution of the NHS’ are as follows:Objective Impact on Trust

Objective 16: Contribute to the work of other public services where there is a role for the NHS to play in delivering improved outcomes. This includes, in particular:

– ensuring that children and young people with special educational needs have access to the services identified in their agreed care plan;

– continuing to improve safeguarding practice in the NHS;

– contributing to multi-agency family support services for vulnerable and troubled families;

– upholding the Government’s obligations under the Armed Forces Covenant;

– contributing to reducing violence, in particular by improving the way the NHS shares information about violent assaults;

– developing better integrated healthcare services for offenders.

Following the Munro review, the Trust has identified a number of actions from the recommendations made and the Safeguarding Team are currently working to implement these.

The Trust scans the horizon for potential for tenders and business opportunities which we may peruse to contribute to the work of other public services to improve patient outcomes for example with special education transport, community transport and taxi provision.

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Objective 17: Ensure that the new commissioning system promotes and supports participation by NHS organisations and NHS patients in research funded by both commercial and non-commercial organisations, to improve patient outcomes and to contribute to economic growth through the life science industries:

– Ensure payment of treatment costs for NHS patients who are taking part in research funded by Government and Research Charity partner organisations; and

– Promote access to clinically appropriate drugs and technologies recommended by NICE, in line with the NHS Constitution.

The Trust adheres to protocols and seeks to review the use of drugs and treatments, established by the Joint Royal College of Ambulance Liaison Committee (JRCALC). All NICE guidelines and recommendations are endorsed for Paramedic use through JRCALC.

There may be financial implications of these recommendations.

The Trust actively participates in research following an internal approval process.

6. Effective commissioning

6.1. A number of objectives have been set to help achieve the benefits planned for clinically-led commissioning, while at the same time managing the transition in a way that safeguards service performance and finances. The Government expects the Commissioning Board to publish a procurement framework to enable CCGs to procure support from a wide range of providers. As statutory bodies, CCGs will be able to choose commissioning support from whatever organisations in whatever sectors are best able to meet their needs.

6.2. The Commissioning Board will therefore need to operate a transparent system, based on clear principles, in which its approach to issues such as pooling financial risks, and interventions in the event of poor performance, distress and failure, is clearly set out for CCGs.

6.3. The objectives contained within ‘effective commissioning’ are as follows:

Objective Impact on TrustObjective 18: Transfer power to local organisations and enable the new commissioning system to flourish, so that:

– CCGs are established across England by 1 April 2013;

– as many CCGs as are willing and able are fully authorised by April 2013;

– CCGs are in full control over where they source their commissioning support;

– clinical networks and senates are highly-valued sources of advice and insight to commissioners;

– there is a transparent, principle-based system for the Board’s interactions with CCGs, including the effective management of poor performance and financial risk; and

– there is effective partnership working between CCGs and Health and Wellbeing Boards.

The NHS structural changes to the commissioning function and bodies for all health services will affect the Trust in how it deals with all future commissioning and contracting arrangements and negotiations. It is still not clear whether the Trust will have to deal with all commissioning consortia in the region, the NHS Commissioning Board or whether the consortia will use the provision within the Bill to appoint a lead consortium to discharge the commissioning function for ambulance services. The Trust is acting to establish working relationships with the emerging CCGs in the region and to influence where possible commissioning of ambulance services on a region wide basis.

The Trust attends Health and Wellbeing Boards across the region to influence their agendas where possible. The Trust will have to develop closer working relationships with local authorities and the newly established Health and Well-being Boards and ensure its own strategic plans are aligned to the health and well-being strategies that they will jointly develop.

The Trust will engage with clinical senates which are intended to bring together a range of experts, professionals from across different areas of health and social care to offer access to independent advice about improvements in quality of care.

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Objective 19: Ensure that financial incentives for commissioners and providers support better outcomes and value for money; extend and improve NHS pricing systems so that money follows patients in a fair and transparent way that enables commissioners to secure improved outcomes.

The Trust is being paid on a PBR basis for services within the A&E SLA. Whilst activity is increasing the Trust will gain and if activity falls we will re-pay Commissioners. Currently, tariffs are agreed locally between the Trust and commissioners and we are contracted on this basis. The DH has set out a proposal to move to a national tariff, based on average currency prices from April 2013 – though this has not been ratified and may be ‘phased in’ through transitional arrangements. Any move to a national tariff would benefit the Trust as we are currently 11% below average cost, in reference cost terms. If this were to happen there is a risk that the Trust could expect Commissioners to insert tougher performance penalties.PTS will not move to PBR within the next two years – at least until CCGs are embedded, but the principle could be applied. If the Trust was to move to PBR on PTS then it may negatively impact on our income if recent annual decreases in PTS activity continued.111 services are currently contracted on a block basis based on a set level of calls received.

Objective 20: Support changes in services that lead to improved outcomes for patients. Priority should be given to changes to services which improve outcomes whilst also maintaining access, and changes must meet the Secretary of State’s four tests that there is

– support for proposals from clinical commissioners;

– strong public and patient engagement;– a clear clinical evidence base; and– consistency with current and prospective

need for patient choice.

The introduction of NHS 111 facilitates more appropriate outcomes for patients and also helps to satisfy unmet patient need whilst also improving access to more suitable dispositions for patients with urgent care needs.

The Trust is committed to improving patient outcomes and routinely monitors the new Ambulance Quality Indicators, setting action plans for improvement where required.

Objective 21: As part of the work to improve healthcare outcomes, put in place arrangements to demonstrate transparently that the services commissioned by the Commissioning Board are of high quality and represent value for money.

The Trust consistently delivers against operational performance targets and is a continual high performer in delivery of the AQIs. The Trust has the lowest reference costs in the country demonstrating value for money.

7. Finance and financial management

7.1. Objectives have been set for the Commissioning Board to make efficiency savings through the Quality, Innovation, Productivity and Prevention (QIPP) programme and to allocate resources in a fair and transparent way. In the future, the Commissioning Board will be responsible for allocating the budget for commissioning NHS services.

7.2. The objectives contained within ‘finance and financial management’ are as follows:

Objective Impact on TrustObjective 22: Ensure the delivery of efficiency (QIPP) savings in a sustainable manner, to maintain or improve quality in the current Spending Review period and beyond.

There are a total of 74 identified projects which will contribute to the overall CIP in 2012/13. This includes 56 continued projects from 2011/12 and 18 initiated in year.Reporting mechanisms have been established for CIP schemes in relation to quality measurement to ensure the quality of service to patients is not impacted through the efficiency savings identified. Annual targets for delivery of cost improvements have been set on the assumption of 4.5% efficiency gains in 2012/13, 5% in 2013/14 and 4.20% in 2015/16.

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8. Measures for assessing progress of the mandate

8.1. The objectives outlined in the mandate will be assessed using evidence gathered showing progress towards delivery of the NHS Outcomes Framework. Progress will also be assessed using standardised data collected across all acute and A&E services from April 2013 (where applicable). Local feedback data will be measured to ensure it is acted upon to improve local services and eradicate poor care. Performance will be monitored against the baselines set in the technical annex when published and expectations for performance will be set for indicators which are worsening or staying the same.

9. Alignment to NEAS Corporate Objectives

9.1. The 12 Corporate Objectives that have been agreed for the Trust for 2012/13 have been reviewed in conjunction with the objectives outlined in the draft mandate for the Commissioning Board and the Trust’s direction of travel is aligned with that of the wider NHS, as has been evidenced below:

Corporate Objective Alignment with Mandate Objectives

1To commence delivery of the components of the refreshed PTS Strategy that will secure its long term financial viability and improve its commercial competitiveness

Objective 2 / 3 / 5

2To implement the A&E Review to achieve the most efficient use our resources, achieving locally commissioned response targets and our two national targets on a quarterly basis throughout 2012/13

Objective 6 / 10 /21

3To continuously improve the safety and quality of care we provide through evidencing clinical quality improvements and adoption of the latest advances in clinical effectiveness and patient safety

Objective 17

4 To maintain a Financial Risk Rating (FRR) of 4 or above Objective 19

5 To deliver efficiency savings to preserve our strong financial position, whilst protecting and improving the quality of our services Objective 22

6 To implement ‘NHS 111 North East’ to the contract standards and performance requirements Objective 20

7To join up the emergency and urgent care systems developing streamlined care pathways, scoping out a programme of action to address pathway gaps for patients with long term conditions and our vulnerable patients

Objective 2 / 13 / 20

8 To extend the roll out of e-PRF into our communities gaining the support and commitment from our commissioners and community/primary care providers Objective 14

9To further develop and implement a programme of engagement with our local Clinical Commissioning Groups and clinical leaders ahead of 2013/14 contract negotiations

Objective 13 / 18

10 To develop the foundations to build effective Trust-wide clinical and quality leadership that will position us well for the future Objective 10

11 To develop and maintain reliable information systems to support internal and external customers Objective 14

12To improve the health and well-being of our staff through effective support mechanisms and utilising the new Equality and Delivery System and results of the recent staff survey to target improvement activity

Objective 4 / 11

10. Response to consultation

10.1. There are 12 consultation questions in the draft mandate. A response has been drafted and is to be discussed nationally prior to agreeing a collective response to the Department of Health. The draft response is attached at Appendix 1.

11. Recommendations

11.1. The Board of Directors is asked to note the proposed content of the mandate, the close alignment of our own corporate objectives and the proposed draft response being prepared for the Department of Health.

Rachel LonsdaleStrategic Business Planning and Performance Lead21 September 2012

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APPENDIX 1

Draft responses to consultation questions

1. Will the mandate drive a culture which puts patients at the heart of everything the NHS does?

The Trust supports the engagement process underpinning the development of the mandate which will support the drive for an open and accountable culture. In particular we support the move to an outcomes based approach that builds on the themes of alignment, affordability and focus on core priorities, putting patients at the heart.

The mandate could go further in ensuring the NHS CB plays a part in driving all organisations to work collaboratively across the health and social care system for improvement and in addressing cultural issues partially created by organisational, functional and political boundaries. There needs to be increased emphasis on transformational whole system leadership.

The essence of patient centred care needs to be reflected in the reward and incentive structures underpinning national contractual arrangements.

Whilst the drive to use the mandate as a positive lever for change, provider organisations must also be able to input into the mandate in a way that reflects their roles in delivering patient care and supporting QIPP delivery. Such organisations like ourselves, are closer to different patient experiences from the forefront of emergency and urgent care and treatments that could influence system design.

2. Do you agree with the overall approach to the draft mandate and the way the mandate is structured?

The structure of the mandate could be improved to clearly set out the vision and how the duties of the Board map to the vision and also what the key underpinning strategies are for ensuring delivery of each duty.

The use of the NHS Outcomes Framework is welcomed for alignment, but some overarching goals for NHS commissioning should be set out that would be expected to drive delivery of the Outcomes Framework.

3. Are the objectives right? Could they be simplified and/or reduced in number; are there objectives missing? Do they reflect the over-arching goals of NHS commissioning?

Whilst we support the domains of the outcomes framework, there could be better use of aims to promote developing pathways, supporting system change and promoting the use of certain types of provider to facilitate change such as the Ambulance Service in the emergency and urgent care system. Again, putting patients first and working as a health system to develop benefits in terms of quality, does not come through the objectives in a way that is meaningful to the different parts of the health and social care system, there is too much acute focus. The outcomes identified do provide a system for objective measurement, but have a feeling of measuring numbers not outcomes. Further alignment should be made to the other existing levers and incentives to measure progress.

The levels of ambition need to be focused locally and through local commissioning arrangements to ensure that we are delivering national imperatives with a local flavour at a CCG level.

Levels of ambition should include both health system indicators and organisational ones with incentives following the contribution of the organisation to health community efficiency and reflect local priorities. It would be helpful to set more structure regarding medium to long term goals and also application of scrutiny by the Board and levers to be used to ensure delivery.

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4. What is the best way of assessing progress against the mandate, and how can other people or organisations best contribute to this?

Progress must be measured against the principles of putting patients first, improving our health and our healthcare and supporting working to change the culture of the system through incentivisation and appropriate levers to encourage system and pathway change.

Scrutiny and accountability needs to be clearly set out for the Board and for contributors to delivery ie to be measured against the baseline of each provider organisation, normalised by funding activity growth and service/system change. National contact penalties should not be applied in a black and white way and should take account of organisational baseline, service and activity growth, contribution to the wider QIPP agenda in health communities and on the basis of offering services that put patients first by doing the right thing for patients without perverse funding streams.

Cultural issues can only be addressed if assessment is dual between commissioners and providers who should be able to demonstrate a commitment to joint planning and problem solving whilst maintaining organisational accountability to delivery of priorities.

Clinical outcomes from the outcomes framework should be central to the progress assessment and triangulated with Patient Survey Feedback, to ensure the principle of putting patients first is maintained.

There is little in the way of counter measures to mitigate risk of delivery caused by transition to new architecture.

5. Do you have views now about how the mandate should develop in future years?

The mandate will need to develop as CCG’s, Local Area Teams and the National Commissioning Board develop. Both commissioning and provider organisations should be involved in the review process to ensure that areas that should be locally commissioned remain so and those that have failed to thrive at a local level can be reconsidered in the national brief.

Learning from others across the 16 Areas and across each health sector should be encouraged and built into the review process as should feedback from Health and Well-being Boards and other parts of the new architecture as it develops.

A longer term review process will need to be developed to oversee the longer term delivery of strategic aims and assess the consistency in performance and commissioning intentions at a national level.

The mandate could also provide a clear indication of how the NHS CB will justify its activity in relation to carrying out its duties and how it will ensure early experiences are captured to assess how effective the new commissioning model is to drive future mandates.

The mandate may become more prescriptive to ensure identified innovation becomes wide-spread and collaboration and whole system working is embedded as routine or ‘the norm’.

Clarity regarding the timeline of the vision in this mandate may also influence future mandates.

6. Do you agree that the mandate should be based around the NHS Outcomes Framework, and therefore avoid setting separate objectives for individual clinical outcomes

Yes, although these are broad and not necessarily responsive to all health service contributions. In particular the Ambulance Service contribution to QIPP targets and the possibility of such services holding a mandate across the emergency and urgent care system should be considered.

Organisational levers, enablers and incentives (positively and negatively) should also be integrated with the outcomes framework to maintain consistency across the service.

Commissioning intentions at a local level should be developed from the mandate and the outcomes framework will need to be sufficiently detailed to give a sense of direction for all organisational types whilst maintaining a local commissioning feel but clearly derived from the mandate, the overarching vision and goals, rather than the mandate/vision being based around the outcomes framework as indicated by the question.

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7. Is this the right way to set objectives for improving outcomes and tackling inequalities?

The top down approach to developing the framework albeit with wide ranging engagement will not support the culture change in priority setting that the mandate aims at. This approach may not get the new commissioning architecture to buy into the priorities with this approach.

More could be done to pass responsibility to commissioners to commission across the wider system, working innovatively with other partners rather than at a purely organisational level to encourage contribution to the wider outcome domains.

The role of Health and Well-being Boards and Public Health does not come through enough to encourage integrated health and social care working.

8. How could this approach develop in future mandates?

Fuller involvement of CCG’s, Health and Well-being Boards and providers would allow local innovation, incentivisation and local demographics to be at the centre of commissioning decisions whilst encouraging innovative commissioning and better alignment across health and social care systems.

The design of the mandate review must encourage the cultural change promoted in organisations and with the public to make changes acceptable whilst reflecting the economic environment.

9. Is this the right way for the mandate to support shared decision making, integrated care and support for carers?

The mandate does encourage and support shared decision making and recognises the partnerships required with commissioners and providers, with the health system and social care and with Health and Well-being boards and patient groups.

It is less focused on how each part of the health sector can support pathway change and service transformation. In particular the document does not mention specific organisational types but many of the outcomes identified could not be applied in an easy way to Ambulance Services, it is very much focussed on acutes and not the whole care pathway.

There needs to be more thought given to some of the complexities of organisations such as ambulance trusts to avoid limiting developments, for example the role we can play in care planning and responding to care plans and the tailoring of services around the individuals.

10. Do you support the idea of publishing a ‘Choice Framework’ for patients alongside the mandate?

The Choice Framework is pertinent to many areas of the health and social care sector but not necessarily to the emergency service provided by Ambulance Service and patient expectations will need to be managed accordingly.

Choice across the urgent care sector as the structural change comes though would benefit from clarity and better system integration if we are also to control costs in this area..

The impact of a plethora of providers with different operating systems may have an impact on the Ambulance Service in terms of transport and travelling times that should be reflected in the performance regime and commissioning intentions.

11. Does the mandate properly reflect the role of the NHS in supporting broader social and economic objectives?

The mandate does support the principles of the NHS role in supporting broader objectives; however the mandate could be more explicit in articulating how operationally this should/could work ie referencing the types of organisations that commissioners should be engaging with to encourage broader working, looking at the wider determinants of health, whilst not being too prescriptive and by encouraging innovation in partnership development with aligned incentives taking into account the financial constraints placed on organisations that may reign back on such relationship development activity.

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12. Should the mandate include objectives about how the Board implements reforms and establishes the new commissioning system?

The mandate should not include prescriptive objectives relating to how reform and commissioning are established, but principles underpinning such an approach would be welcomed as well as a description of the approach to take.

The focus should not be on how the NHS CB will implement reforms but how it will provide the necessary whole system leadership.

Further guidance could be included, to more prescriptive about the commissioning of ambulance services given the challenge any local or disaggregated commissioning could have on the service.

Draft at 20.09.2012

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