Guidance & Advice for Hospital Doctors

Posts Tagged ‘Darzi review’

Understanding NHS finance, budgets and commissioning

By Mike Broad - 23rd July 2009 3:24 pm

Political expectations are growing that hospital doctors will get to grips with NHS finances and get more involved in budget management and commissioning.

With the NHS facing a funding shortfall of up to £10bn for the three years after 2011, there’s increasing political pressure on doctors to help identify areas where savings can be made.

Lord Darzi also called for hospital doctors to be more involved in commissioning and budget management to help drive the quality agenda. In High Quality Care For All: Our Journey So Far, which charts the progress of the Darzi Review (July 2009), he calls for the extension of practice-based commissioning from GPs to hospital doctors and nurses.

To this end, the Academy of Medical Royal Colleges has teamed up with the Audit Commission to produce a guide on NHS finance for doctors. The guide says: “This is not about turning doctors into accountants; it is about enabling doctors properly to engage with finance colleagues so as to make the best use of NHS resources for patients.”

Commissioning - the background

Commissioning is the process of determining the health needs of the population, the resources available and how to organise service provision. Commissioning currently occurs mainly at PCT level and they’re responsible for buying services from local providers. This can be from NHS trusts, foundation trusts, themselves (or other PCTs) or from the independent sector.

The first step in this process is a Joint Strategic Needs Assessment. This is a process conducted in partnership by local government, PCTs and the local community to identify areas of priority for action to improve local health and wellbeing. It informs the Local Area Agreements, helping commissioners to specify outcomes that will help providers design local services and it’s been a statutory requirement since 1 April 2008.

Practice-based commissioning

Commissioning at PCT level can be seen as relatively remote from patients and clinicians. So, GPs have been given more say in how they deliver services to their patients because they’re closer to them. Theoretically, under practice-based commissioning, services better represent patients’ preferences.

PBC has also been developed with the aim of making the NHS more patient-centred by extending choice in elective care.

GPs can take on the commissioning and financial responsibility for large parts of PCT budgets and change the patterns of service provision. Practices can group together but the PCT retains legal responsibility. Practices can use 70% of the savings made for reinvestment for new services or more equipment.

While benefits have been seen in primary care, there’s little evidence so far that any form commissioning has greatly affected hospital services in the past 20 years.

Despite PBC being introduced in 2004, most GPs are really only now developing formal commissioning relationships with PCTs.

World Class Commissioning

World Class Commissioning is a government programme to improve commissioning and thus the quality of care. It strives to secure maximum improvement in locally prioritised health and wellbeing outcomes from existing resources.

There are 11 competencies for a PCT to become a World Class Commissioner. They include locally leading the NHS, working with community partners, collaborating with clinicians, engaging with public and patients, prioritising investment and promoting innovation. Commissioners will be assessed against them by an annual commissioning assurance process.

Understanding Payment by Results

If hospital doctors are to get more involved in finance, they need to understand Payment by Results. PBR was introduced in 2003 and is a rules-based approach for paying for hospital services in the NHS. It is a key part of the current reform programme in the NHS and was designed to directly link the payments that healthcare providers receive to the activity they undertake. PBR underpins patient choice by enabling the money to follow the patient.

A national rate, or tariff, is set annually for each type of service, with services classified by health resource groups. Commissioners are then required to pay for healthcare provided to their patients at this tariff.

PBR has significant implications for NHS organisations. Both hospital providers, and particularly PCT commissioners, face greater financial risk and reduced financial control.

With the price set nationally, contract negotiations focus on the volume of activity to be provided. Without the protection of fixed value block contracts, providers need to maintain a certain level of activity and ensure that costs do not exceed the national tariff in order to remain financially viable.

Budget management

Once an organisation has set its overall strategy and its service and financial plans, these need to be translated into a budget. Setting a budget in this way will ensure that resources are allocated in line with the organisation’s aims and objectives.

Good budget management is achieved where budget holders are held to account for managing their budgets; reports monitoring performance against budgets are accurate and provided regularly to budget holders; monitoring reports do not just contain financial data but are linked to information about performance and service improvements; and, variations against budget are identified and investigated, and corrective action is taken.

Financial management is about explaining and accounting for what has happened in the past and forecasting income and expenditure in the future. Using budget statements, budget holders should be able to identify the areas where they have spent less and spent more than their budget.

Service-line reporting provides a framework that enables NHS bodies to understand the combined view of resources, costs and income, and hence profit and loss, by service-line or specialty rather than at trust level. Managing at this level allows managers and clinicians to make more effective decisions about, for example, growing or reducing services on the basis of efficiency and profitability, where cross-subsidisation is occurring, or where services might be better provided in the community. PBR has encouraged more trusts to adopt a more comprehensive approach.

There is also a growing impetus for trusts to introduce patient-level information and costing systems. It involves a bottom-up approach to costing, using information about individual patients’ resource consumption. The costs of individual patients are aggregated to generate costs for differing groupings, for example by HRG, by procedure or by consultant.

This provides a much better understanding of what drives costs and how to make efficiencies.

Making changes and efficiencies in NHS services

Efficiency savings can either be cash releasing or non-cash releasing. Cash-releasing efficiency savings result in the cost of the service provided being reduced. Non-cash releasing efficiency savings occur when more activity is provided but the cost of delivering the service remains the same. An example of this could be a reduction in average lengths of stay, which resulted in more patients being treated.

Improvements in quality and efficiencies are expected to be secured through better procurement, commissioning, organisation and management, with any additional savings being reinvested in new or better local services.

There are a variety of reasons why changes to service delivery might be made; for example, to improve the patient experience, the need to meet efficiency targets or to move services from secondary to primary care.

The financial consequences of such changes should have been determined and set out in a business case.

Developing a business case

A business case is a document developed to support decision making for new investments or to change or develop a new service. It sets out the case for undertaking a project, weighing up the objectives and benefits against the estimated costs and risks. Business cases should include: measurable objectives; an appraisal of all the options available (including the ‘do nothing’ approach, an indication of the preferred option and an explanation setting out why it is favoured); demonstrate the affordability and value for money; provide a timetable reflecting the life of the project; and define the roles and responsibilities of those involved.

It should make a compelling case to the audience that is going to judge its merits and should be subject to a robust appraisal process which evaluates its relative costs and benefits, both financial and non-financial.

Financial training for doctors

The report, A Guide to Finance for Hospital Doctors, by AMRC and the Audit Commission also suggests that clinicians should receive financial training to help them understand budgets, commissioning and their monitoring.

Related stories

PBR needs overhaul

Tags: Commissioning, Darzi review, Funding, PBR, Practice-based commissioning
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How do we build teams without walls?

Dr WR Burnham, registrar of the Royal College of Physicians - 22nd July 2009 10:06 am

Reconfiguration and its associated drive towards providing care closer to home throws up a number of challenges.

Specifically, as patients with long-term conditions make increasingly complex moves between primary and secondary care, demand management may occasionally disrupt the close working between generalist and specialist practitioners necessary for effective care.

As the chronic disease burden rises, specialists and generalists will need to work together more closely to better meet the needs of patients with long-term conditions throughout the time of their illness.

Unsurprisingly, many of the royal colleges are now looking at ways to erode the artificial boundaries between NHS organisations in order to restore the close working relationships that used to exist. In 2008, the RCP, RCGP and RCPCH, together with representation from the NHS Alliance Specialist Network, published its own concept paper Teams without Walls.

This argues for an integrated model of care in which multi-professional teams are designed by local clinicians and patients and cut across traditional interfaces.

The anecdotal UK evidence in favour of integrated working practices between primary and secondary care of this kind is considerable. There is also much evidence from the USA. However, an efficient mechanism to facilitate this integration has up until now been elusive.

While by no means perfect, practice-based and world class commissioning may offer new levers to initiate clinical integration, provided this involves patients, generalists and specialists working together to design patient pathways. The working party responsible for Teams Without Walls collected numerous examples which illustrate that, with imagination, integrated services can be achieved.

The common features of these services were clinical leadership and involvement; high quality partnership with professional management; primary and secondary care partnerships; committed and flexible commissioners; clear patient focus; clear governance arrangements; and agreed measures and standards to ensure continuous improvement.

Consequently the college is now working with the RCGP, the Patient and Carer Network and the specialties we represent to develop tailored models in order to define a high quality service. Such services could then be used by commissioners, in cooperation with local doctors (generalists and specialists) and patients with long term conditions, to plan pathways of care that put into practice these principles.

Linked intimately to the future success of this approach is the ability of both the generalist and specialist to learn to work in different ways in the future. Current and future trainees should be trained in integrated care and, during training, they should be supported outside hospital in the same way as in hospital.

Thus, the doctors have to change and lead change, a theme of Lord Darzi’s Next Stage Review. If local commissioners respond to this challenge, then the future is bright.

Tags: Darzi review, Integrated care
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Darzi Review and NHS modernisation: at-a-glance guide

By Mike Broad - 17th July 2009 5:01 pm

The government’s plans to reform the NHS over the next 10 years were laid out in the Darzi Review.

In 2007, colorectal surgeon Lord Ara Darzi was asked to conduct the review on health services in England and consulted with strategic health authorities and clinical pathway working groups to set future priorities.

Darzi suggested that while the NHS was two thirds of the way through its modernisation programme - as set out in the NHS Plan in 2000 - further steps were needed. While the health service had increased capacity and driven down waiting times, quality and outcomes needed to be improved.

Other aims of the Darzi review included ensuring services were better joined up, care was more accessible and integrated, and services provided more patient control, choice and local accountability. There’s also been a drive to put clinical decision making at the centre of the reforms.

As the Darzi review took shape it echoed the themes of the white paper Our Health, Our Care, Our Say - particularly on choice, personalisation and community services - but there was a change in how it would be delivered. It was no longer about top down targets with a focus on outputs, but about quality and local determinism.

The key devices to achieving this are improved information on clinical performance, greater choice and control for patients and strengthened incentives for providers.

High Quality Care For All

The final report High Quality Care For All - NHS Next State Review Final Report was published in June 2008. It sets out how the NHS should move from centrally driven, target based management to one of empowered local services focused on quality as well as activity.

Darzi’s focus on raising quality

One of the key drivers of change will be a range of local quality indicators that will enable clinicians to benchmark and improve their performance. Areas measured will include mortality, complication and survival rates and patients’ views.

Financially, funding formulas and contract payments will increasingly be linked to quality outcomes. All providers - NHS, private and third sector - will be required from April 2010 to publish Quality Accounts explaining how they made a difference.

Clinical Excellence Awards will be more focused on quality improvement. New awards conditional on clinical activity and quality indicators, and encourage clinical leadership and innovation.

Patient rights

The review proposed the new NHS Constitution, which spells out its principles and values and enshrines patient rights.

Patients will have a greater choice of GP practice, and ‘choice’ is a tenet of the constitution.

Patients are now guaranteed access to the most clinically and cost effective drugs and treatments. All patients will receive drugs and treatments approved by NICE where the clinician recommends them. NICE’s appraisals process is to be speeded up. Some have criticised it for being toothless.

In his first major speech as health secretary Andy Burnham outlined the developing system of accountability in the NHS, initiated by Darzi, and founded on a smaller number of agreed patient outcomes and fundamental rights. The NHS Constitution will sit alongside service guarantees linked to a minimum set of standards - rather than lots of volumetric targets - that will need to be maintained.

Services closer to home

Darzi had just produced his 10-year plan for the reorganisation of the NHS in London when he started his review. The London plan proposed the creation of larger specialist centres for the treatment of conditions such as stroke and heart attacks. This was combined with a network of 150 GP-led health centres providing a combination of services traditionally offered by GPs and district general hospitals.

Many of these ideas were also reflected in the interim report Our NHS Our future: NHS Next Stage Review

published in Oct 2007. This report included recommendations to introduce MRSA screening for hospital admissions and create 100 new GP practices in deprived areas.

It also controversially proposed to create 150 new health centres around the country which would provide extended range of services and longer opening hours. Polyclinics are intended to improve access and better integrate primary care practitioners with diagnostic and specialist services.

They are intended to reflect local needs and priorities, and be open from 8am to 8pm every day to fit with people’s lifestyles. Any member of the public can walk into a polyclinic regardless of which local GP service they are registered with, and people will be offered the opportunity to register at these new facilities.

However there are concerns that, despite a lack of clarity over their purpose, they are being rolled without being piloted.

And that polyclinics will compromise the coordination of care, prompt staff shortages and end up primarily nurse-led.

It’s looking increasingly likely that polyclinics will only be established in London.

Personalised services in Darzi review

When consulting for the review, Darzi commented: “Patients have told me that they still sometimes feel like a number rather than a person…they lack ‘clout’ inside our health care system.”

Along with clarifying and strengthening patients rights, and giving them more choice over who treats them, the review also gives them more power over how they are treated.

Everyone with a long-term condition will have a personalised care plan and personalised health budgets will piloted, with direct payments used where possible.

Andy Burnham described personal budgets in his first major speech as the “ultimate expression of power and influence being handed down to the individual patient”. The DoH is due to pilot them among 5,000 patients with chronic conditions. “These pilots will give patients the power of the purse strings: making decisions with the help and guidance of GPs or consultants that directly affect their own budget is spent.”

A more preventative approach to public health

The NHS, through partnership working, will focus on improving health alongside treatment. Every PCT will commission comprehensive wellbeing and prevention services in partnership with local authorities. And there’s a new coalition for Better Health with voluntary agreements between the Government, private sector and charities to improve health. GP’s Quality and Outcomes Framework is to be improved to provide incentives for maintaining health as well as providing care.

Better guidance and regulation

The Care Quality Commission will have new enforcement powers to improve safety and reduce healthcare associated infection.

NICE will be expanded to set and approve more independent quality standards. A New National Quality Board will set priorities and feedback to government.

Promoting innovation

There is new emphasis on innovation and fostering an enterprise culture. Strategic health authorities will be under a statutory duty to promote innovation and regional innovation funds will be launched to invest on a commercial basis in good ideas. There will be a pilot programme of ‘health innovation and education clusters’ to stimulate partnership working between clinicians, universities and business.

Empowering staff

More support is promised in the Darzi review for clinicians who want to move out of the NHS to set up independent social enterprises. Their pensions will be protected. Integrated care organisations will also be piloted, bringing together health and social care professionals together. There is also a pledge to reinvigorate practice-based commissioning and give greater freedoms and support to high-performing GP practices to develop new services for patients.

Clinical leadership will strengthened, with medical directors and quality boards featuring at regional and national level.

Darzi review update – one year on

Darzi launched a new set of proposals in High Quality Care For All: Our Journey So Far, which charts the progress of the Darzi Review one year on.

Clinical budget ownership is to be extended to hospital doctors and nurses, with the aim of promoting entrepreneurship and innovation in service delivery.

Two “obsolete” clinical targets are also to be removed: the 13-week outpatient and 26-week inpatient performance targets. A review into other targets was also launched.

A voluntary peer review accreditation system will also be introduced to assess the standards of clinical teams and create competition among clinicians to improve. The royal colleges are currently developing a consistent approach, and it will be overseen by the National Quality Board.

Darzi’s resignation

Lord Darzi resigned, in July 2009, returning to research and surgery. While the public reason for his early departure was his concern for his patients, it’s been suggested he found the culture of Whitehall challenging.

Tags: Darzi review, Personal budgets, Polyclinics, Practice-based commissioning, Quality, Targets
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Sign up before you lose practising privileges

By Stephen Campion, chief executive of HCSA - 16th July 2009 11:24 pm

Was I surprised to learn that health minister Lord Darzi had resigned from the government? Well it was a bit of a shock when the announcement came, but I can’t say I lost much sleep over it. I guess his patients need him more than he needs to be a non-elected Minister of State. But that is his decision.

Am I surprised that only 50% of doctors have decided to be licensed by the GMC? Thinking about it I think the answer is “not really” given that even today there are senior doctors complaining that they have to through tortuous bureaucracy to apply for Article 14 recognition to secure a CCT. Some complain that they were never advised of this change - and yet the GMC is adamant that all doctors had received comprehensive details of these “new” requirements. I say “new” because all this happened over 10 years ago and there are some today who say that they were not made aware of what was going on.

This is not a matter of “who is right and who is wrong” but a reflection of fact. Communications are never perfect; and neither often is the response, or lack of it. But in something as critical as being licensed with the GMC, whether one likes it or not, my bet is that after the closing date of 14 August this year there will be some doctors in limbo - or worse. Worse, because unless properly signed up with the GMC employment, practicing privileges and livelihoods are at stake.

So if doctors have yet to respond to the GMC now is the time to do so. Hospital Dr is right to highlight this. Don’t just rely on the GMC to tell you all you need to know!

Tags: Darzi review, GMC, Licence to practise
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17th most influential doctor ignored by Brown and his GOATs

By Jerry Nelson - 15th July 2009 4:27 pm

So, another one of Gordon’s GOATs bites the dust. His Majesty The Lord Kharzi of Polyclinic has decided to step down from his role as health minister, in order to spend more time looking up people’s arses. I expect he’ll be giving back his life peerage too, now he doesn’t need it any more.

GOAT, by the way, is an acronym derived from Gordon Brown’s plan to create a Government Of All the Tossers. Most of the high profile Tossers recruited from industry and the professions have resigned, but luckily for Gordon, there is a near-infinite supply of Tossers in the Labour Party to replace them.

Sorry if I sound a tad bitter, but the PM rather missed a trick by appointing such a lightweight quitter, when he had the opportunity to engage someone vastly better: me.

That’s right. I, Jerry Nelson, offered my services based on my skill and experience in real surgery (not all this ‘minimal access’ nonense - that’s just for wimps who are scared to make a really BIG hole), and the fact that I was judged to be the 17th most influential figure in health care by leading publication Hospital Doctor Magazine.

I offered Gordo very reasonable terms - peerage, obviously, modest high six-figure salary, the use of a couple of grace-and-favour homes, and an ermine theatre hat - but what happened? I didn’t even get an arsing reply.

So, like fools, they missed out on my revolutionary ideas for the NHS based on named consultant car parking spaces. What will this cost us in the long run? We’ll never know.

Tags: Darzi review, Humour
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Health minister Lord Darzi quits government

BBC Health - 14th July 2009 10:48 pm

Top surgeon Lord Darzi, one of several non-political figures brought into Gordon Brown’s government, is to resign as health minister.

Downing Street confirmed he will remain as a government adviser but quit as a minister “to devote more time to his clinical role and academic research”.

In his resignation letter he said he had overseen the implementation of his report’s conclusions and was “deeply grateful” for the chance to serve in the government but now wanted to step down as a minister.

“As you know, I have maintained my busy clinical practice and research contributions during my time as a minister. The time has now come for me to return to care for my patients, lead my academic department, and continue my research on a full time basis,” he wrote.

Darzi’s proposals bring forward Pimms o’clock

By Stephen Campion - 3rd July 2009 11:12 am

It is good to know that at times when the country is in need of good advice the NHS is up there with the best. I am sure many of you will have taken advice about what to do in the recent very hot weather.

Did you know that the NHS has a Heat wave plan for England?

Well top of the list of “10 ways to keep cool” is that we should use “pale, reflective, external paints to keep our houses cool”. It does not go on to say what colour paint we should use to keep our homes warm in winter, but I am sure that will have been far from people’s minds as they have spent last week in the blistering heat painting their houses white!

Failing that litter the house with bowls of water, the ensuing evaporation helps cool the building.

We decided not to paint the office’s external walls. And instead of getting out bowls we procured a jug and invested in a bottle of Pimms, some lemonade, ice and fruits from the local shop.

Perhaps that was not what the NHS would recommend, but if the weather was sufficient to make me boil this week, so too did the latest Darzi update.

That certainly called for something stronger than a glass of water. While one arm of the NHS is giving advice about how to keep cool, Darzi seems to prefer the opposite.

His advice is that the NHS should create a new voluntary peer review system in which clinicians will judge the standard of their peers in order to drive up quality and achieve a gold standard of care. We already have revalidation, licensing, appraisal, job plan reviews, local affiliate pilot studies - and now a new voluntary peer review system?

My heart sank; my temperature rose - and we bought a second bottle of Pimms to cool down.

Tags: Darzi review, Heat wave
Posted in HCSA | 4 Comments »

Darzi wants consultants to own budgets

By Mike Broad - 1st July 2009 2:00 pm

Clinical budget ownership is to be extended to hospital doctors and nurses, health minister Lord Darzi announced this week.

It’s one of a new set of proposals in High Quality Care For All: Our Journey So Far, which charts the progress of the Darzi Review one year on.

The report says that through giving consultants and nurses ownership of their clinical budgets - like with GPs and practice-based commissioning - entrepreneurship and innovative delivery of services will be promoted. They’ll also be more patient focused.

Lord Darzi said: “Quality is what we aspire to and innovation is how we achieve it. High quality care is better for patients and often better value for tax payers.

“The progress made since last year in the quality provided to patients and the safety of their care was not driven through top-down targets but by giving responsibility to the staff at local level.”

But Stephen Campion, chief executive of HCSA, doubted whether trust finance directors would give clinicians the level of ownership and protected funding required for them to make a real difference to how their services are delivered.

He said: “The principle of budget ownership by clinicians has been around for some time. It has largely failed because the responsibility to manage these budgets is not matched by giving effective authority to clinicians.”

Two “obsolete” clinical targets are also to be removed: the 13-week outpatient and 26-week inpatient performance targets. A review into other targets was also launched.

Professor Ian Gilmore, president of the Royal College of Physicians, welcomed the report.

He said: “The challenge for the NHS is to ensure that the components of the quality agenda are practical and deliverable ensuring that the laudable aspirations can be transferred from paper into practice, especially in an increasingly cash-strapped environment.

“The College is delighted to be leading the national pilot project on the accreditation of stroke services. Service accreditation is a highly complex area but we believe it is a logical extension of our existing programme of guidelines and audit. We believe that service accreditation will complement the regulatory work of the Care Quality Commission and provide the organisational context for individual medical revalidation.”

The Department of Health report also highlights a number of successes over the past year such as a significant reduction in hospital-acquired infections and longer opening hours at many GP surgeries.

Tags: Darzi review, Practice-based commissioning, Targets
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Practice-based commissioning extended to hospitals

Pulse - 30th June 2009 6:50 pm

Practice-based commissioning is to be extended to cover hospital staff in a move that may intensify the competition for funding between primary and secondary care.

Under the plans, outlined by health minister Lord Darzi, hospital trusts will be encouraged to buy in services under PBC.

Consultants, hospital nurses and allied health professionals - including physiotherapists and midwives - will be given the opportunity to reorganise healthcare services and develop proposals for new income streams.

Lord Darzi, speaking on the anniversary of his NHS Next Stage Review, said widening out commissioning powers was now seen as a more effective way of driving improvements than setting a new array of central targets.

But PBC leaders warned the plan risked further undermining GP engagement in PBC, and could divert money into hospitals’ coffers.