HFMA UK/USA EXCHANGE 2005

1. “Sharing the Vision – Taking Healthcare Finance into the Future”27th–29th July 2005, St. Andrew’s, Scotland HFMA UK/USA EXCHANGE 2005 Dr. Patricia Oakley Director, Practices made Perfect Ltd Teaching and Research Fellow Organisational Psychology and HRM Kings College London

2. HFMA UK/USA EXCHANGE 2005 Reform, modernise & focus a complex mix of service providers. Develop service commissioning to drive up quality, operational gearing & value for tax payers’ money. Develop more flexible working practices, and evidence-based quality assurance procedures. Melissa Dora The NHS and Social Care Policy Framework

3. HFMA UK/USA EXCHANGE 2005 Reform acute and primary care service provision to improve access, reduce waiting times, and build more focused programmes of evidence-based clinical care. Increase the operational gearing, intensity and performance of how clinical care is organised and managed. Develop new ways of working to reduce bureaucracy. Shift incrementally from fixed to more variable cost structures. Embed quality assurance and risk management within the service’s design and provision including the education and training “pipeline”. The Policy Objectives

4. HFMA UK/USA EXCHANGE 2005 Acute – Emergency Care • Foundation Trusts and £ Gearing • Emergency Care Networks • Surgical Services Segmentation Human Resource Management Policies Community - Long Term Care • New GMs and pharmacy contacts & Primary Care services • “Community Matrons” and “Hospital @ Home” Services • Complex multi-agency networked services eg. Children’s & Older People’s Services • Agenda for Change, Consultants’ New Contract & EWTD • Multiple Job Holding and ‘Chambers’ • Post-Shipman Review and Quality Assurance Reforming, Modernising & Focusing Service Providers PolicyGoal –Develop morefocused & integratedcare organised in coherent expert systems that reduce risk and satisfy patients

5. Surgical Services Segmentation Emergency Surgical Services • General surgical cover – sufficient numbers & skill sets for new requirements? Specialist Surgical Services ElectiveSurgical Services • Cancer, CHD, Neuro, Vascular – concentrating in centres→ implications? • Private sector to increase NHS capacity – marginality being eroded → implications? PaediatricSurgical Services • “Grandfather” clause expiring and ? new regulations coming in – concentrating in paediatric centres → implications? Day Surgery The District General Hospital – ?At Biggest Risk? • Private sector to increase NHS capacity – growing to 85% - 90% → implications? Servicing Emergency Care, Organising Cross Cover and Training

6. Primary Care Led NHS Elderly Trauma Centre • Parkinson’s • ALC • Dementia Specialist Medical • Dermatology • Oncology • Diabetes M.I.U. Pain Clinic Carer Support • Acupuncture • Osteopathy • Chiropractice GPs Specialist Mental Health Day Surgery • CPN • Psychology • Psychotherapy • Counselling X-ray & Imaging The New General Medical Services and Community Pharmacy Contracts

7. Care Planning & Management InvolvingPatients & Carers Complex Case Management Programmewith a Case Manager who coordinates care from several groups of experts joining up care for patients and carers. c. 20% of chronic Care Management (but c.80% of resources). Level 3:Highly complex patients who need case management. Disease Care Management Programmeand Proactive support from Multi-disciplinary Teams using Care Protocols & shared information. Level 2: High risk patients who need disease management support e.g. diabetes. 70-80% of Chronic Care Management. Level 1: right support, many people can look after themselves, living with and managing their condition(s). “Expert Patient” Programmesand Carer Support involving Voluntary Groups eg. BDA, Age Concern etc. Health Promotion Health Promotion Programmeseg. Diet, exercise, and education. *Practices made Perfect Ltd., Alpha House, 100 Borough High Street, London SE1 1LB Tel: 0870 241 9937; Fax: 0870 241 9938; email: office@practices.co.uk

8. Children’s Services Trusts Education Authority (Accounting Officer) • Sure Start & Mum’s support • Skills for Life & Education Reforms • Exclusions & Referral Units PARTNERSHIP AGENDA • Integrated Legal Trust? • Group Commissioner of Children’s Services? • Information and Informatics Network? • Talking Shop? • Discrete focus eg. CAMHS? Health Services • Primary Services • Secondary Services • Tertiary Services • Child Protection • Custody & CJD • Links with HMPS & NPS for Children being resettled Social Services • Child Protection & Adoption • Families & Children @ Risk & in Care • Young Adults Support Police Authority

9. Strategic Development Framework • PREVENTION • Accidents, • mobility, • isolation • Diet, exercise, • concordance • Warmth, • physical and • psychological • well-being • PROMOTINGINDEPENDENCE • Carer support • Night-sitting • service • Respite beds • SUPPORTING ILLNESS • Homecare team • Hospital @ home • Day Hospital and Resource Centres • SUPPORTING TRAUMA • Elderly Crash Team • Specialist Assessments and Care Pathways • Multi-disciplinary care and support • REHABILITATION • Preparation for • discharge • Maintenance and • on-going support • Diet, exercise, medicines • END STAGE MANAGEMENT • Carer/home support • End-stage management • Bereavement support What can GPs and social services do to promote independence and well-being? ? What can GPs do to develop effective emergency and high-level interventions that increase people’s chances of survival? ? What can GPs and social services do to ensure that the vast majority of people successfully complete their rehabilitation? ? What can GPs and social services do to support end-stage management whenthis arises? ? Caring for Older People (#Stroke, Dementia, Falls)

10. Future NHS Structure and Career Pathways The Office of the Regulator The Health & Social Care Commission The Marketing Unit The Auditor & Comptroller General The National Audit Office Financial Flows Service Infrastructure Clinical Services • Long term investment programmes in capital stock through private sector (PFI, PPP, LIFT). • Long term leases for major equipment (replacement/ upgrade) & partnership arrangements to run at full operational gearing for the NHS. • Manage and staff infrastructure to support clinical services & administrative functions, eg. HRM, IT, Finance. • Develop Clinical and Care networked services and partnerships involving public, private and voluntary sectors. • Develop Education and Training syndicated services in partnerships involving Universities, FE colleges, private voluntary sectors. • Develop Research and Development knowledge domains in partnerships involving Universities, Pharmaceutical and Biotechnical Companies and commercial research organisations. • National and Regional Group Commissioning Schemes; financial allocations, reconciliation and audit vs. planning priorities eg. transplant and genetics services. • Group Commissioning Schemes as above involving GPs, Clinical Networks and Specialist groups eg. NCT, MIND, MENCAP and Children’s services. • Patients’ Choice (via GPs and Community Matrons) involving direct and co-payments.

11. HFMA UK/USA EXCHANGE 2005 Developing Service Commissioning • Contestability and Foundation Trusts • The Tariff and Contract Currencies • “Choice” and Administration Costs • Commissioning and Contracting Services • Contract Compliance, Market Regulation & Service Inspection

12. Developing Contestability in Public Services Regional/Intermediate Tier Central/National Tier Local/Provider • Contestability & Commissioning Care Management Programmes: • Accredited supplier of programmes. • National Standards of Service. • Service Objectives to deliver Public Services: • seamless pathway. • silo mentality. • Patient focused. • Inspectorate vs. Service Standards & Performance Management Framework. • Managed Market/Public Services Contestability Regulatory Framework. • Ombudsman & Citizen’s “voice & amplification”. • children’s programmes. • women’s programmes. • elderly care programmes (inc. EMI). • Delivers contract/pathway clinical & care outcomes. • Meets Public Service Specification (HMT) for good financial management and controls. • Meets Public Service Specification for good Human Resource Management Practices (inc. EO and CRE requirements). • Meets Public Services Specification for local representation and involvement. • Meets Public Service Specification for Good Governance. • Performance Management Framework. • Metrics. • Methodology. • Informatics. • Change Management & Service Modernisation inc. Financial Allocations & Controls Governance. Political context: “small government”; “regionalisation”; “going local”; “public involvement”; “value for money”;

13. Developing Commissioning Practices • Rules: • Fixed price by tariff. • Drive operational gearing ratios. • Service dumping and Minimum Operating Standard Pain Clinic • Commissioning: • Case by Case Programmes? • Bundle of Cases? • Mixed Bundle of Cases/Block Contract? • Trauma & Emergency/Urgent Care Networks. • Intensive Care Networks. • Diagnostic and Backup Services. • Elective/Planned Care Procedures. • Rehabilitation/Aftercare Programmes. • Diagnostic and Backup Services. • Chronic Disease Management Programmes. • Diagnostic and Backup Services. • End-stage Care Services.

14. 5-levels of Commissioning National Commissioning Schemes eg. Transplant Programmes Regional Group Commissioning Schemes eg. Genetics Services Emergency Services Intensive Services Specialist Care Group Commissioning Schemes eg. Mental Health Services Children’s Services Cancer & CHD Services GP Group Commissioning Schemes GP – individual level choice

15. GP-Based Commissioning Development Framework £ H.M. TREASURY ALLOCATION GP Commissioning Group (100k - 300k) Integrated Primary and Community Care Services £ • Health Strategy • Care Group Focus • Specialist Input Financial allocation reconciliation and audit • GP/Community based • Care Managers • Micro-purchasers Contract management and administration Public Health Agency HRG/HBG National Case Mix Office £ Medicines Management University £ National networks of Drug Information Centres, MCA, PPB, Med. Man. Centre Acute Hospitals

16. Contract Compliance, Market Regulation &Service Inspection Clarify Roles, Authority and Relationships • The Performance Management Team (DH) • The Health & Social Care Commission • The Office of the Regulator (Monitor) • The Auditor & Comptroller General • The National Audit Office

17. Developing More Flexible & EffectiveWorking Practices • Shift from Fixed to Variable Cost Structures. • Update Regulatory and Legal Framework. • Clarify Roles and Authority of the August Bodies. • Introduce post-Shipman Review Requirements. • Build-up Quality Assurance Procedures.

18. Shifting from Fixed to Variable Costs • Full-time Employee of NHS(F) Trust. • Part-time Employee of NHS(F) Trust and time/session(s)for golf, church, family etc; +/or private practice, locums; +/or other duties eg. Royal College, Networks. • Network Employee – Full-time/part-time/sessional. • Chamber Member (Principal) – Employee. • Self-Employed (Schedule D).

19. Regulatory and Legal Context • Practice and development • Education and training • Behaviour and attitudes Standards Regulations Education and Training • Revised legal context • Health Council and registration • Revalidation and accreditation • Core curricula • Post-basic programmes • Practice research

20. Clarify roles & Authority of the August Bodies • Service Standard-setting Bodies • Education & Training Standard-setting Bodies • Staff Representative Bodies • Inspectorate Bodies • Professional Registration Bodies

21. Professional Accreditation & Validation Post-Shipman Review-December 2005 • What does “fitness to practice” mean? • How do you assess “competence”? • What is the correct periodicity? • What is the future of professional bodies? • Where does Professor Kennedy’s Health & Social Care Commission Fit?

22. Fitness to Practice • Knowledge • Skills • Aptitude • Attitude • Experiences • Motivation profile • Psychological contract • Kinsmanship • Organisational citizenship • Voice & Amplification CompetentIndividuals • Community of Practitioners • Knowledge Management • Learning Modalities & Mentorship