1. Proposed approach to continuing reform in NHS
without major legislation

2. Agenda for Reform
 Nicholson Challenge (QIPPR)
 Patients at the centre (no decision about me .…)
 Greater patient and public involvement
 Clinicians in charge
 Reduce bureaucracy and management
 Improving outcomes
 5 Year plan?
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3. Key Reform Themes
 Clinically led commissioning
 Acute – primary shift – prevention
 But investment required and potential strains on social care
 Specialisation (tier one/two/three) as for trauma, stroke etc
 Reducing unacceptable variation (costs and outcomes)
 Reducing inequality of outcomes
 Social – health care integration and integration around
patient needs
 Elephant – Social Care collapsing - Dilnott
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4. Without Primary Legislation
Using Existing Powers

5. Key Principles
 No major primary legislation
 Use existing SoS powers or Bill without Part 3.
 Integrated local commissioning – clinically led
 Earned autonomy
 Convergence with local authorities
 Competition within managed framework
 System planning approach to reconfiguration
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6. Stabilisation Plan
 Concentrate on Nicholson Challenge/Quality
 Consult, then develop and publish proper 5 year plan
 Planning and system management with genuine involvement
 Keep CSHAs and CPCTs as proper statutory bodies
 Introduce NCB (operational not policy)
 Tell SoS and NCB not to micro manage
 Actually culture change not organisational change required.
 Complete provider transition
 Facilitate reconfiguration across systems (acquisitions & mergers?)
 Build on commissioning strengths
 Provide flexibility in commissioning support
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7. Stabilisation Plan
 Increase clinical involvement – devolve through earned
autonomy
 Allocate commissioning functions to right level
 Local wherever possible
 Begin serious engagement with local authorities
 Provide incentives use existing flexibilities
 Continue developing incrementally tariff, outcomes
framework, PRCC.
 Park further changes until after NC is achieved
 Consult on longer term plans.
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8. Secretary of State Role
 Promotes the comprehensive NHS - secures provision
 Legally and politically accountable
 Delegates powers and duties
 Intervenes when necessary in best interests of NHS
 BUT not compelled to interfere
 Defines the foundations
 Directs the system (Op. Framework or Mandate)
 Sponsors key bodies
 Nice, CQC, SpHAs
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9. Foundations
 NHS Constitution
 Principles and Rules for Cooperation and Competition
 NHS Tariff (could be set by independent body)
 Standard contract terms
 Outcomes Framework
 Commissioning Outcomes Framework
 National Service Frameworks
 Terms and Conditions – GPs contracts
 Mandate (Operating Framework)
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10. Competition
 Valuable as one tool – within managed framework
 Retain existing Principles and Rules for Cooperation and
Competition (PRCC)
 Retain Cooperation and Competition Panel to advise on
disputes
 Set boundaries for services open to competition through
Mandate (choice mandate as from Future Forum)
 Flexibility to extend AQP already used
 Clarification of EU position
 Protection for commissioners acting in good faith
 No externally applied imposition of competition
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11. Provider Development
 Accept role for some NHS Trusts (safe haven)
 Complete TCS transition
 Empower PDA to manage pipeline to FT status
 Continue with supervision through TPAs
 Review pipeline and challenged FTs on whole system basis
(Monitor looking at this)
 Revise reconfiguration process – mandate use
 Needs planning and leadership – much faster route than
market/failure
 Allow de authorisation by choice to enable reconfiguration
 Rather than under pressure from commissioners or regulator
 Licensing can wait – reconsider 2016
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12. Monitor
 Maintains current role
 Regulator of providers of service to NHS
 Continues to authorise FTs
 Continues to oversee FTs (including PP Cap)
 Change to PPI Cap requires legislation
 Compromise possible if cap set by local governance
 Can advise SoS on prices, contract conditions and
competition rules
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13. Failure Regime
 Focus on prevention of failure – whole system
approach
 Continue deauthorisation of FTs
 Introduce pre–failure regime
 Strengthen but streamline reconfiguration process
 Implement Special Administration powers
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14. Wellbeing Boards
 Use existing local authority “wellbeing” powers
 Continue to promote pro-active community involvement
 Use access to funding incentives to join up provision of care
 Wide membership base including public and patient
representatives
 Inclusion of elected members (Councillors)
 Support and drive integration across all public services
 Joins up public health, social care and health care
 Involve and engage with Tier Two authorities if present
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15. Wellbeing Boards
 Produce strategic needs analysis (as now)*
 Produce wellbeing strategy (generally as now)*
 Produce integrated commissioning plan*
 *Working with CPCTs and CCGs as appropriate
 Sign off commissioning plans from CPCTs and CCGs
 Oversee implementation of plans
 and can refer to SoS if any dispute or disagreement
 Could be integrated with CPCTs to become
Commissioning Authorities - as recommended by Health
Committee
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16. Simplifying Structures

17. Under HSC Bill
 National Commissioning Board Part A
 Commissioning of services
 National Commissioning Board Part B
 Oversight of commissioning
 Regional Outposts (4)
 Local Outposts (50)
 Clinical Commissioning Groups (250)
 Commissioning Support Organisations (40)
 Health and Wellbeing Boards (160)
 Clinical Senates (30?)
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18. Under Stabilisation Plan
 Board – no need for separation of fucntions
 Regional directorates (4)
 CPCTs – sub regional – coterminus with LAs (50)
 CCGs (250 reducing over time)
 Wellbeing Boards – to be merged into CPCTs over time
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19. Clustered PCTs
 Public bodies – NOLAN compliant
 Have publicly appointed non executives
 Must include health professionals
 Support development of strategic needs assessments
 Agree commissioning plans - within local wellbeing commissioning
strategy and integrated plan
 Coterminous with Tier One Local Authorities (one or more)
 Integration of commissioning to drive integration of provision
 Commission specialist services
 Commission and manage PMS contracts
 Conduct periodic service reviews to demonstrate VfM
 Delegate hard budgets to CCGs – monitor delivery
 Accountable (through CSHAs) to NCB to SoS
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20. CCGs
 Public governance and accountability – but as sub committees of CPCT
(as now)
 Formal constitutions and Boards (local within a national template)
 Must include lay representatives as well as professionals
 Local commissioning (but not PMS or specialist)
 Delegated Hard Budgets
 Earned autonomy
 Use authorisation framework already developed nationally – apply
locally
 Same relationship of CCG – PCT as already developed for CCG – NCB
 No bonuses!
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21. Functions from CPCTs to CCGs?
CGGs can draw on support as required – not as mandated
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22. Functions from CPCTs to CCGs?
 Do not create market ready CSOs
 Keep functionality within CSHA/CPCT/CCG as
appropriate
 Will vary across localities
 Very large CCGs could have (mostly) own capacity
 Expertise kept within NHS (reduces redundancies)
 Supplement where required (?data analysis) from
external sources
 Some services may be national (economies of scale)
 Some services might be shared with local authority
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23. National Commissioning Board
NHS Management Board? DH?
 Management of Commissioners and NHS Trusts
 Host for specialist commissioning
 Ensures continuity of Commissioning
 Regional outposts with locally appointed Boards/NEDs
Split Operational/Policy
 Policy development - mandate
 Tariff
 National Service Frameworks
 Outcomes etc frameworks
 National programmes
 Resource allocations – capital programme
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24. Other Issues
to be resolved without primary legislation
 Healthwatch (replacing Links)
 H&SC Information Centre
 NICE
 ALBs
 Workforce Regulation
 Training
 Research
Widespread support for changes can be built upon and
existing powers used where necessary.
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25. Solution Headlines
 NCB as SpHA – system performance management
 Commissioning development and oversight
 Reconfiguration
 Hosts national specialist commissioning
 Hosting networks, senates, national services
 Keep SHA and PCT Clusters
 CPCTs and CSHAs have strong governance structures in place
 Appoint clinicians to Boards – keep proper NEDs
 Senate for each CPCT (not PECs - more multi professional)
 where CCG not appropriate or not competent
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26. Solution Headlines
 Merge the CSOs into CPCTs – support to CCGs (no
market)
 Migrate capacity into CCGs as appropriate
 Will vary depending on size and capacity of CCGs
 Converge CPCTS and HWBBs over time
 Colocation, shared posts, pooled budgets, shared systems
and information
 Continue CCG authorisation process as CPCT sub
committees – but genuine delegation
 CPCTs have role in commissioning
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