The Operating Framework for 2010/11 for the NHS in England (published 16 December 2009)
The Operating Framework for the NHS was published on 16 December. The document sets out priorities for the NHS over the next year. National priorities remain the same, for a third year in a row. The priorities are:
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Reducing healthcare associated infections
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18 week wait target and access to GP services
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Prevention and health inequalities
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Improving patient experience, staff satisfaction and engagement
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Emergency preparation for incidents such as pandemic flu.
As expected the document contains a number of relevant points for ABHI members.
Financial climate
1. The NHS will ‘need to generate £15-£20 billion recurringly by 2013/14 from existing resources... to keep pace with system pressures’ (para 1.5).
2. Following the Pre-Budget Report (published 8 December) PCTs can allow for flat real revenue allocations growth for the years 2011/12 and 2012/13 in their medium-term planning (3.13).
3. ABHI commentary: the meaning of point 1above is not made fully clear in the document. The statement in point 2could be qualified, or changed, in due course if a new government takes different decisions.
Policy framework with specific triggers for medical device technology
18 week waiting time target
4. Para 2.13 recognises that there are some specialties where the 18-week waiting time target is not being met. The target continues as one of the NHS ‘Vital Signs’ (page 52).
Procurement
5. Previously agreed government-wide commitments for efficiency are reiterated, including the drive for greater use of collaborative arrangements “including NHS Supply Chain and regional commercial support units – in the light of the [government report] recommendation that 50% of procurement spend in the wider public services go through collaborative channels by the end of 2010/11”. (3.28, p32)
Patient Safety
6. ‘Never events’ are spotlighted for reporting and for focus in contract agreements. These include, as before, a number of device-related risks such as retained instrument post-operation. (3.36).
Payment by Results (PbR)
7. The Framework amplifies some of the issues set out last week in the Department of Health’s “Good to Great” publication (key paras are annexed to this document). However, many of those issues (including a volume cap) are not fully explored in the Framework document and the draft PbR guidance is awaited. Details covered in the Framework document are summarised in the following paragraphs.
8. There will be no increase in tariff – ‘zero per cent uplift’ in 2010/11. This takes into account an efficiency requirement of 3.5% which offsets pay and price impacts from inflation. This requirement is expected to increase over the following three years (3.37). This uplift will apply also to all prices in non-tariff service contractual arrangements, which is expected to be the case over the next Spending Review period (probably 2011/12 onwards; para 3.38).
9. “After 2010/11, we shall move to a position where national tariffs represent the maximum price payable by a commissioner, as opposed to the mandated price for particular activity.” (3.44)
10. Best practice tariffs will be introduced for the first time in 2010/11 for two elective and two emergency service areas:
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Cataracts
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Cholescystectomy
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Fragility hip fracture
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Stroke
“Though we will want to see how successful these best practice tariffs are in reducing the variation in quality between providers... we shall want to expand significantly in future years”. (3.33)
11. Commissioning for Quality and Innovation (CQUIN) will have a more significant impact on provider income in 2010/111, trebling the quantum that can be earned under agreed CQUIN schemes to 1.5% of contract income. All schemes will be required to include a patient experience element, including a national goal linked to outcomes from the national inpatient survey. (3.35)
12. The role of ‘high performing organisations’ (discussed in paras 3.66-3.67) suggests a more integrated cross-organisation approach to patient pathways (as sketched in ‘Good to Great’) but is unclear in terms of likely interactions with PbR.
Office for Life Sciences; creation of NHS
13. Paragraphs 2.52-2.53 refers to the ambitions set out in the Life Sciences Blueprint published in July. This includes the need to increase NHS participation in health research.
14. Specifically, 2.53 refers to the new NHS Life Sciences Delivery Board on the uptake of innovation in medicines and medical technologies. ABHI has supported the creation of this board which provides the first direct link between industry (via the inclusion of a medical device technology representative) and the NHS Operations Board, outside the Department of Health itself.
ANNEX – extract from NHS 2010-2015 – from good to great
Ensuring payment systems support improved quality and efficiency
4.4 A high-quality and productive NHS needs payment systems that offer the right incentives. That means incentivising providers to maximise the efficiency of care; to provide the highest quality of care; and to shift care from hospitals to the community, reducing hospital admissions. So over the coming years we will continue to develop the national tariff and other payment systems with the aims set out below.
4.5 The tariff payment system must incentivise providers to maximise efficiency by limiting or freezing the amount it pays for each procedure carried out in hospitals, by having a maximum uplift of 0% for the next four years. This will drive all providers to become as efficient as the highest performers.
4.6 The tariff payment system must incentivise providers to offer the highest quality care by linking increases in payment to specific quality goals and ensuring that the level of payment reflects best practice rather than average costs. This will bind together quality and financial aims for providers – something that is crucial to realising our vision for a high-quality and productive NHS.
4.7 The tariff payment system must incentivise the shift of care out of hospital settings if this is what patients want. This will mean limiting the payments providers receive when activity exceeds planned levels. Moving care from hospitals to community settings and patients’ own homes will not only improve efficiency, but will also drive increases in quality – for example, by providing patients with renal dialysis and chemotherapy in their own homes and offering more scans and tests in primary care rather than in hospital. This will also mean linking payment systems with whole pathways of patient care, so that providers have incentives to keep patients with long-term conditions, such as diabetes and COPD, healthy and prevent unplanned and unnecessary hospital admissions.
4.8 The tariff payment system must not reward poor quality or unsafe care, which means enabling PCTs to withdraw payments when care does not meet the minimum standards patients can expect. This will be included in contracts with providers from April 2010. The care this covers includes, for example, so-called “never events” – examples of unsafe care such as wrong site surgery. We will consider how this list should evolve over time to cover, for example, cases of VTE or pressure ulcers.
4.9 The payment system for primary care must also deliver improvements in quality and productivity. For 2010/11, we have exceptionally agreed to make no changes to the Quality and Outcomes Framework (QOF)43 in recognition of the pressures arising from pandemic flu. For 2011/12 onwards, there needs to be significant reform to QOF to deliver improvements in quality and efficiency. This is likely to mean raising performance thresholds and retiring indicators that have limited cost-effectiveness to make way for more stretching quality indicators.
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