the new landscape of care: implications and challenges for the academic community paul stanton...

The new landscape of care:implications and challenges

for the academic community

Paul StantonAdviser on StandardsDepartment of HealthPaul.stanton@ncgst.nhs.uk

AimsAims• Review the national policy drivers for system reform• Consider the implications and challenges for the health and

social care academic communities• Does the NHS £1.3billion education and training spend

deliver ‘value for money’ from the perspective of patients, local communities and the tax payer?– Does Qualifying training deliver a workforce that is ‘fit

for current purpose’?– Does CME and CPD expenditure deliver evidenced value Does CME and CPD expenditure deliver evidenced value

for money in improved patient experience or outcomes?for money in improved patient experience or outcomes?– Would current expenditure stand up to NAO scrutiny?Would current expenditure stand up to NAO scrutiny?

• Has professional education and training stayed abreast of fundamental and on going system reform?

• What challenges and opportunities are posed by this agenda?

• ‘Chatham House Rules’

Faculty of theStatus Quo

Market forces

Public Sector Priorities Public Sector Priorities • ““The imperative for reform is urgent and growing.…The imperative for reform is urgent and growing.…• Now is not the time to rest on our laurels; now is the time Now is not the time to rest on our laurels; now is the time

to step up the pace of reform” to step up the pace of reform” Hewitt: Introduction Health Reform In England: Update and Next Steps 2005

• ““We start from a very low base … the system has suffered We start from a very low base … the system has suffered from a combination of monopoly statism and professional from a combination of monopoly statism and professional power”power” Corrigan 2006

• ““The time has come for audacious and deep seated reform The time has come for audacious and deep seated reform …..It’s absolutely ludicrous that for as long as most of us …..It’s absolutely ludicrous that for as long as most of us can remember, public sector managers have spent their can remember, public sector managers have spent their lives staring up at Whitehall targets instead of looking to lives staring up at Whitehall targets instead of looking to their customers in the street…”their customers in the street…” Sir Sandy Bruce-Lockhart Chair of LGA 2006

• Customers?Customers?

The Policy Imperative The Policy Imperative

• Major NHS structural changeMajor NHS structural change• Forthcoming Local Government White PaperForthcoming Local Government White Paper• From re-active deficit based provision, to pro-From re-active deficit based provision, to pro-

active promotion of ‘health and well being”active promotion of ‘health and well being”– Our Health, Our Care, Our SayOur Health, Our Care, Our Say

• Shift in emphasis from organisational performance Shift in emphasis from organisational performance to ‘system performance’ and ‘integration’…to ‘system performance’ and ‘integration’…

Integration Architecture Aligned

InspectionAligned

Performance ManagementAligned Budget Cycle

Strategic Care Needs

Analysis

Joint Outcomes

Local Area Agreements

Joint Commissioning Framework

Practice Based Commissioning

Direct Payments & Individual Budgets

Joint Teams

Personal Health &

Social Care Plan

Joint Infrastructure

Integrated Capital Market

Unbundled Tariff

Year of Care Tariff

Joint Electronic Records

Liam Byrne [former] Minister for Care Services

Integration Architecture Aligned

InspectionAligned

Performance ManagementAligned Budget Cycle

Strategic Care Needs

Analysis

Joint Outcomes

Local Area Agreements

Joint Commissioning Framework

Practice Based Commissioning

Direct Payments & Individual Budgets

Integrated Workforce

Joint Teams

Personal Health &

Social Care Plan

Joint Infrastructure

Integrated Capital Market

Unbundled Tariff

Year of Care Tariff

Joint Electronic Records

Liam Byrne [former] Minister for Care Services

The PM’s Four Principles of Public Sector Reform

NationalStandards

National Standards• Defined by Government• “Social Care Standards” – 2002• Independent Health Care National Minimum

Standards Regulations - 2002• “Standards for better health” (S4BH) - 2004

– “Standards for Better Health sit at the heart of the new relationship between central Government and the NHS, under which it is the role of the Department of Health to set broad, overarching standards defining the Government’s high level expectations of the health service” Standards for Better Health July 2004

• Independently audited and inspected by CSCI or Independently audited and inspected by CSCI or Healthcare CommissionHealthcare Commission

• Factored into performance managementFactored into performance management

National Standards

• Shelf-lifeShelf-life

• Merger of CSCI & HCC (2008) – Merger of CSCI & HCC (2008) – “Offcare”“Offcare”

• ““Revised and converged standards” - Revised and converged standards” - 20092009

Devolution to the ‘front

line’

NationalStandards

The PM’s Four Principles of Public Sector Reform

Devolution• ““More freedom for all NHS organisations as More freedom for all NHS organisations as

emphasis shifts from Whitehall-led to emphasis shifts from Whitehall-led to patient-led improvements” patient-led improvements” Corrigan 2006Corrigan 2006

• ““Double devolution”Double devolution” (Milliband) (Milliband)• A more active voice for the public via LINks A more active voice for the public via LINks • For Local Strategic Partnerships in For Local Strategic Partnerships in

establishing prioritiesestablishing priorities• More active Local Scrutiny of NHS More active Local Scrutiny of NHS

performance via LA OSCsperformance via LA OSCs

Devolution• Renewed impetus for Foundation Trust Renewed impetus for Foundation Trust

status – Foundation Communities?status – Foundation Communities?• Supported growth of the ‘third sector’Supported growth of the ‘third sector’• Greater clinical involvement in Greater clinical involvement in

‘commissioning’ via Practice Based ‘commissioning’ via Practice Based CommissioningCommissioning

• Fostering innovation and change

CompetitionDevolution to the ‘front

line’

NationalStandards

The PM’s Four Principles of Public Sector Reform

The case for competition

•““The interests of the providers of The interests of the providers of services came to take precedence services came to take precedence over the interests of the users of over the interests of the users of services.services.•The NHS’s monopoly over the The NHS’s monopoly over the provision of services compounded provision of services compounded these problemsthese problems … •[and] meant that the system lacked [and] meant that the system lacked both alternative sources of capacity, both alternative sources of capacity, and the inbuilt challenge and spur to and the inbuilt challenge and spur to innovation and efficiency that a innovation and efficiency that a plurality of providers can bringplurality of providers can bring ” Hewitt 2005

Competition led efficiencyCompetition led efficiency• Broad political consensusBroad political consensus• ““Hospitals like other organisations need to be paid Hospitals like other organisations need to be paid

for the work they do not get an annual grant … we for the work they do not get an annual grant … we need incentives to hospitals to improve services - need incentives to hospitals to improve services - cost control and productivity are the roads to cost control and productivity are the roads to thriving organisations” thriving organisations” Corrigan 2006

• Payment by ‘results’Payment by ‘results’• In the region of 15% of care delivered by the In the region of 15% of care delivered by the

private sector by 2008 private sector by 2008 (Priorities & Planning (Priorities & Planning Framework 2005/2008) DH 2004Framework 2005/2008) DH 2004– Currently £4 billion (5.5%) of clinical services budgetCurrently £4 billion (5.5%) of clinical services budget

Competition led efficiencyCompetition led efficiency• Rationalisation of historical basis of hospital Rationalisation of historical basis of hospital

provision & transfer of point of careprovision & transfer of point of care– Major workforce implicationsMajor workforce implications

• ““Allowing different providers to compete for Allowing different providers to compete for services” services” Our health, our care, our say & fostering development of the capacity and capability of the independent sector to compete for contracts alongside the public and private sector

• ““If there are barriers that prevent collaboration, we If there are barriers that prevent collaboration, we will remove them. If there are rules that prevent will remove them. If there are rules that prevent private and third sector bodies bidding against the private and third sector bodies bidding against the public sector, we will change them”public sector, we will change them” PM June 2006PM June 2006

• Market pluralismMarket pluralism

CompetitionDevolution to the ‘front

line’Choice

NationalStandards

The PM’s Four Principles of Public Sector Reform

Choice

• Giving consumers (some) customer Giving consumers (some) customer leverageleverage – Promoting choice from a diverse provider

market– Extension of direct payments?

• "The idea would be to give such patients a choice between receiving a package of care from the NHS, as they do now, or instead having their own budget - an NHS credit - which they could control directly." Alan Milburn Former Secretary of State for Health

• To improve the flexible responsiveness of To improve the flexible responsiveness of provisionprovision

Patient Voices

• This was where Andrew’s stroke story was inserted

• All of the digital stories that were used in this presentation can be found at www.patientvoices.org.uk

• They are available free of charge and can be used in education, training and organisational development

Choice

• ‘‘Choosing health’Choosing health’– Promoting health and well beingPromoting health and well being– Illness awarenessIllness awareness

– Disease prevention Disease prevention

– The management of long term conditionsThe management of long term conditions

Choice• Co-production of services (cf Degeling & Sang)Co-production of services (cf Degeling & Sang)• ““must extend far beyond hospitals. … it means must extend far beyond hospitals. … it means

involving residents in the development of local involving residents in the development of local services and the regeneration of their own services and the regeneration of their own neighbourhoods – all helping to create a virtuous neighbourhoods – all helping to create a virtuous circle of healthier people in safer communities circle of healthier people in safer communities supported by responsive public services ”supported by responsive public services ” Hewitt Hewitt 20052005

• Reform as process – not event

The reform agenda

Health Reform In England: Update & Next Steps DH December 2005

Nine further policy initiatives by December 2006Health Reform In England: Update & Next Steps DH December 2005

Eight further policy initiatives by December 2006

The primary focus for 2006/7The primary focus for 2006/7

Assuring short termAssuring short termfinancial balancefinancial balance

£

Cost & Value Cost & Value • Financial stringency + broader engagement Financial stringency + broader engagement

with resource and ‘value’with resource and ‘value’• “Currently, an estimated 80 per cent of

costs and over two thirds of NHS activity relates to the one third of the population with the highest need. People with longer-term health and social care needs want services that will help them maintain their independence and well-being and lead as fulfilling a life as possible” DH 2006

Cost & Value Cost & Value • ““Because the patients and users of the NHS are Because the patients and users of the NHS are

also its taxpayers and contributors, we must also its taxpayers and contributors, we must ensure that we are seen to provide value for ensure that we are seen to provide value for money”money” Treasury 2005Treasury 2005

• ““To secure the future of the NHS as a publicly To secure the future of the NHS as a publicly funded service free at the point of use, there is a funded service free at the point of use, there is a need for an honest and realistic debate about what need for an honest and realistic debate about what the NHS can and cannot deliver in a cost-the NHS can and cannot deliver in a cost-constrained system” constrained system” ipsos/MORI 2006ipsos/MORI 2006

• The education and training budgetThe education and training budget

Is Public Sector Reform On The University & Professional Education and Training Agenda?

To what extent is the public sector reform

agenda a key topic of debate for the University:

0 1 2 3 4 5 6 7 8 9 10

Is Public Sector Reform On The Faculty/School Professional Education and Training Agenda?

To what extent is the public sector reform

agenda a key topic of debate for the faculty/school:

0 1 2 3 4 5 6 7 8 9 10

[School]

[Faculty] [Centre for Medical Education][Faculty of Health& Social Care]

[Depends upon individuals, rather than schools/faculties]

= Joint score for Faculty and/or School

Is Public Sector Reform On The Pre and Post Registration Education and Training Agenda?

To what extent is the public sector reform agenda a key topic of debate

within the curriculum for professional pre and post registration students?

0 1 2 3 4 5 6 7 8 9 10

[Pre-reg]

[Post-reg]

[Level I Nursing & SW]

[Basic Medicine]

[Higher Level Nursing& SW]

[Pre-reg]

[Post-reg]

[Depends upon individuals, rather than curriculum]

[Higher Level Medicine]

Is Public Sector Reform On The Agenda?

Additional comments and scores:

0 1 2 3 4 5 6 7 8 9 10

[Statutory bodies]

[Students/customers]

Professional bodies [e.g. BMA etc] playing ostrich

LG White Paper + NHS ReconfigurationLG White Paper + NHS Reconfiguration

• ‘New’ and ‘distinctive’ organisations with ‘new’ functions

• “Counterfeits of the past, under new names, can easily be mistaken for the future… We must be wary of the trap” Victor Hugo: 1872 Les Miserables

The new landscape of care The new landscape of care • SHAs from DH ‘enforcers’ to ‘system reform SHAs from DH ‘enforcers’ to ‘system reform

leaders’leaders’

• With key workforce development, education With key workforce development, education and training responsibilitiesand training responsibilities– Though not mentioned in SHA Model Corporate Though not mentioned in SHA Model Corporate

Governance FrameworkGovernance Framework

• Focussed on financial balance …Focussed on financial balance …

• and PCT commissioning performanceand PCT commissioning performance

Primary Care Trusts – the story so farPrimary Care Trusts – the story so far

• “Well kids, you tried your best…

• and you failed miserably…

• and the moral is

• never try”

• “Well kids, you tried your best…

• and you failed miserably…

• and the moral is

• never try”

Primary Care Trusts – the story so farPrimary Care Trusts – the story so far

The ‘new’ PCT The ‘new’ PCT • New Governance and Standing OrdersNew Governance and Standing Orders

– The role of the PEC?The role of the PEC?

• New focus on collaborative governanceNew focus on collaborative governance– Local Strategic Partnerships Local Strategic Partnerships

• From a hierarchy of focus uponFrom a hierarchy of focus upon– Provided ServicesProvided Services– Independently Contracted ServicesIndependently Contracted Services– Commissioned careCommissioned care

• To …To …– Commissioning for financial balance and system reformCommissioning for financial balance and system reform– PBC alignment & Independent Contractor quality assurancePBC alignment & Independent Contractor quality assurance– Transition from provision to outsourcing provided servicesTransition from provision to outsourcing provided services

The primary foci of ‘new’ PCT functionsThe primary foci of ‘new’ PCT functions

A comprehensive LSPA comprehensive LSPassessment of communityassessment of community

health need & opportunity health need & opportunity

The primary foci of ‘new’ PCT functionsThe primary foci of ‘new’ PCT functions

A comprehensive LSPA comprehensive LSPassessment of communityassessment of community

health need & opportunity health need & opportunity

A comprehensive PCT/SHA A comprehensive PCT/SHA analysis of patterns, models, analysis of patterns, models,

locations and cost effectivenesslocations and cost effectiveness

of inherited provision of inherited provision

The primary foci of ‘new’ PCT functionsThe primary foci of ‘new’ PCT functions

A comprehensive LSPA comprehensive LSPassessment of communityassessment of community

health need & opportunity health need & opportunity

GAP ANALYSISGAP ANALYSIS

A comprehensive PCT/SHA A comprehensive PCT/SHA analysis of patterns, models, analysis of patterns, models,

locations and cost effectivenesslocations and cost effectiveness

of inherited provision of inherited provision

Strategic priorities Strategic priorities for system reformfor system reform

Medium term strategy for Medium term strategy for managed transitionmanaged transition& benefit realisation& benefit realisation

Short term strategy forShort term strategy forminimising dislocation whileminimising dislocation whilefostering choice & reform fostering choice & reform

Strategic priorities Strategic priorities for system reformfor system reform

Medium term strategy for Medium term strategy for managed transitionmanaged transition& benefit realisation& benefit realisation

Short term strategy forShort term strategy forminimising dislocation whileminimising dislocation whilefostering choice & reform fostering choice & reform

Primary AccountabilityPrimary Accountability

LSPLSP SHA SHA PCTPCT

Strategic priorities Strategic priorities for system reformfor system reform

Medium term strategy for Medium term strategy for managed transitionmanaged transition& benefit realisation& benefit realisation

Short term strategy forShort term strategy forminimising dislocation whileminimising dislocation whilefostering choice & reform fostering choice & reform

Primary AccountabilityPrimary Accountability

LSPLSP SHA SHA PCTPCT

SHA SHA PCTPCT

Strategic priorities Strategic priorities for system reformfor system reform

Medium term strategy for Medium term strategy for managed transitionmanaged transition& benefit realisation& benefit realisation

Short term strategy forShort term strategy forminimising dislocation whileminimising dislocation whilefostering choice & reform fostering choice & reform

Primary AccountabilityPrimary Accountability

LSPLSP SHA SHA PCTPCT

SHA SHA PCTPCT

PCTPCTPbCPbC

PCT investment in health PCT investment in health promotion and diseasepromotion and disease

preventionprevention

Transitional investment inTransitional investment insustainable supplysustainable supply

chain chain

Short term strategy forShort term strategy forminimising dislocation whileminimising dislocation whilefostering choice & reform fostering choice & reform

Investment ImplicationsInvestment Implications

% PCT total % PCT total commissioningcommissioning

budgetbudget

% PCT total% PCT totalcommissioningcommissioning

budgetbudget

Delegation ofDelegation of% total budget% total budget

to PbCsto PbCs

Strategic priorities Strategic priorities for system reformfor system reform

Medium term strategy for Medium term strategy for managed transitionmanaged transition& benefit realisation& benefit realisation

Tactical adjustments toTactical adjustments tominimise dislocation whileminimise dislocation whilefostering choice & reform fostering choice & reform

Changes to patterns,models

andlocations

of care

=

Whole system thinking• From ‘episode of care’ to ‘care journey’From ‘episode of care’ to ‘care journey’

– Care is delivered by ‘systems’ not by ‘organisationsCare is delivered by ‘systems’ not by ‘organisations– engaging carersengaging carers

• ““Improved health outcomes usually lie outside the Improved health outcomes usually lie outside the scope or control of any single practitioner scope or control of any single practitioner {or {or organisation}organisation}. Real improvements are likely to occur . Real improvements are likely to occur if the range of professionals if the range of professionals {and patients and their {and patients and their own carers}..own carers}.. are brought together to share their are brought together to share their different knowledge and experiences agree what different knowledge and experiences agree what improvements they would like to see, test these in improvements they would like to see, test these in practice and jointly learn from their results” practice and jointly learn from their results” Headrick, Wilcock, Bataldan BMJ 2005

Patient Voices

• This was where the late Ian Kramer’s introduction and ‘Working In Partnership’ story was inserted

• All of the digital stories that were used in this presentation can be found at www.patientvoices.org.uk

• They are available free of charge and can be used in education, training and organisational development

Key challengesKey challenges for the for the academic communityacademic community

• “What are the major threats and the opportunities that are likely to arise as a result of the system reform agenda”

• Pink hexagons = key threatsPink hexagons = key threats• Blue hexagons = key opportunitiesBlue hexagons = key opportunities

Key Opportunities I

Reshape/redefine

the natureof the HEI Work

collaborativelyWith other

HEIsDevelopnew forms

ofpartnership

Focus on learning in& for the

workplace

With patients

&carers

With localLSPs, LAs

SHAs & NHSproviders With

private &‘third’ sector Develop

private& ‘third’ sector

placements

Developprimary

care placements

Developnew types

of healthcareworker

Maximiseopportunities

forIPE

Educatewhole systems

of caredelivery

Agreecommonpriorities

with publicsector

Focus onnew

PCT &primary care

priorities

Developnew

managementcompetences

Key Opportunities II

Maximiseflexible credit

and creditrecognition

Invest ininnovativeways of working/learning

Maximiseuse of

simulations, blended &

open learning

Promote IPE acrossmedicine,health &

social care

Develop& support

communitiesof practice

learning

Exploit Bologna

declaration

Invest indevelopmentof academic

staff &associates

Key Opportunities III

New formsof privateUniversity

Developconsultancy,mentoring,

ODservices

Extractmaximumlearning

FromCETLs

Developnew

markets

Exploitwhole

Universityexpertise

HEIsas

entrepreneurialbusinesses

DevelopcommissioningNHS business

support

Developpublichealth

supportservices

Develophealth

sciencessupportservices

Key Threats

Lack of clarity re

Universityrole in reform

agenda Drivers forHEIs and

public servicesconflict

Existing healthy

relationshipswith SHAsdisrupted

Financial constraints on service

investment intraining

Do HEIprocesseshave timelyresponsivecapability?

Failure toalign

service &education

agendaCosts to

HEIsof profound

change

Will‘practice’

support orinhibit

learning?

Education funding

vulnerable todiversion/

raids

Some HEIs may

withdraw fromunder-gradeducation

Servicechaos-led

disruption toeducation &

training

Somepractice

settings are‘learning free’

zones

Absence of co-ordinated

strategicplanning

(Some)HEIs

accord primacyto research

agenda

‘Arthritisof qualityassurance

joint’

Key Opportunities III

Additional Slides

• The slides that follow were not used in the delivered presentation but are included for your interest

Culture change

• From ‘passive recipient’ to ‘active From ‘passive recipient’ to ‘active partner’partner’– still the still the “Doormouse and the Doctor”“Doormouse and the Doctor” A A A A

Milne?Milne?– engaging carersengaging carers

• Attitudinal shiftsAttitudinal shifts– for existing staff and new entrantsfor existing staff and new entrants

Patient Voices

• This was where the Alison Ryan’s introduction and ‘Who Cares?’ story was inserted

• All of the digital stories that were used in this presentation can be found at www.patientvoices.org.uk

• They are available free of charge and can be used in education, training and organisational development

The new landscape of care The new landscape of care • The ‘anatomy’ of careThe ‘anatomy’ of care• The ‘physiology’ of careThe ‘physiology’ of care• Capacity v capability Capacity v capability

– New rolesNew roles– New functionsNew functions

• Macro and microMacro and micro• New ‘fitness for purpose’ and new ‘competence New ‘fitness for purpose’ and new ‘competence

sets’ demands at all levels in public sectorsets’ demands at all levels in public sector– New entrantsNew entrants– Existing staffExisting staff

DH

SHAs/LSPs

PCTs & LAs

Carers

Local Communities

Service users

Invertingthe pyramid

Public & Independent Care Provider Organisations

DH

Public & Independent Care Provider Organisations

Carers

Local Communities

Service users

PossiblePossiblepillars of pillars of educationeducation& training& trainingsupportsupportfor the for the pyramidpyramid

SHAs/LSPs

PCTs & LAs

Whole system thinking• From ‘episode of care’ to ‘care journey’From ‘episode of care’ to ‘care journey’

– Care is delivered by ‘systems’ not by ‘organisationsCare is delivered by ‘systems’ not by ‘organisations• ““Transitions – lie outside the field of vision of most Transitions – lie outside the field of vision of most

professional staff – but are a frequent, difficult & dangerous professional staff – but are a frequent, difficult & dangerous reality for service users….reality for service users….

• ““Weaknesses in any complex and interconnected system Weaknesses in any complex and interconnected system express themselves most forcefully – from the perspective of express themselves most forcefully – from the perspective of the recipients of a service at:the recipients of a service at:

• intra-organisational sub-system interfacesintra-organisational sub-system interfaces• organisational boundariesorganisational boundaries• sectoral frontierssectoral frontiers• in an escalating hierarchy of problematic disjunction”in an escalating hierarchy of problematic disjunction” Stanton Stanton

20042004

Picker Europe Patient Feedback - Continuity of care

& transition

05

1015202530354045

Percentage of patientsreporting problems

Germany

USA

Picker Europe 2003