NHS | Presentation to [XXXX Company] | [Type Date]1

NHS Commissioning Board- Clinical leadership

The role of Local Dental Networks

Sam Illingworth

Dental, Pharmacy, Eye Care Lead

NHSCB Authority

21st May 2012

Aim to cover

• Update on NHSCB

• Key features of (proposed) NHSCB operating model for primary care

• Concept and context of local professional networks

• Focus on local dental networks

• NHSCB strategic role

• NHSCB operational/specific roles

• NHSCB dental commissioning strategy – all dental services

• Timescales for sign off and implementation

2

Primary Care Commissioning: a single operating model

Focus for the design and transition• The safe transfer of functions that must continue

• Creation of a system capable of transforming primary care services (and ALL dental services)

• Prioritising the single operating procedures needed on day 1

• Ensuring effective alignment with critical interdependencies

• Clear outcome measures, indicators and a single accountability framework

• How to encourage and support the right behaviours for a new system to:

• Be effective from the start

• Mature over time through continued co-production, which will continue beyond April 2013

• Develop in tandem with those around it e.g. CCGs, HWB, PHE, LETBs

Design challengeThe Department of Health has been responsible for negotiating the contracts, providing guidance to PCTs and high level

strategic planning

These functions will transfer to the NHSCB

Primary Care Commissioning has been defined and delivered in different ways by PCTs. Some PCTs have had a strategic

approach others have ‘managed contracts’

The NHSCB will define and deliver it in one way

Behaviour has ranged from mature, collaborative relationships through to adversarial

The NHSCB will define expectations of behaviour but it takes two to tango and behaviour change takes time

The new environment will be very different

CCGs as statutory bodies, Commissioning Support Organisations, no boards in a local office, more things done centrally, risk based

approach, fewer managers than currently, more clinicians than currently with a different leadership challenge

Proposed operating model

Three elements

What happens locally (including regions)

What happens nationally

The interface and relationships between the two – key iterative relationship

Key features

• Single system with a consistent operating model

• Organising principle of quality and safety

• Clinically led throughout system with local professional networks at more local level

• Shared values and behaviours and productive relationships

• Common policies and procedures

• Clear outcome measures, indicators and a single accountability framework

• But do not want to stifle local innovation in service and quality improvement

NHS Commissioning Board Structure

National Support Centre

NHSCBRegion

NHSCBRegion

NHSCBRegion

NHSCBRegion

Local Area Team

Local Area Team

Local Area Team

NHSCB local area teams• The local area teams will be responsible for contract management, service

development and support functions leading to overall quality improvement.

• CCGs anticipated to play major role in improving quality of primary medical care and will have a statutory duty to assist and support the Board in doing so.

• For the other 3 independent contractor groups (dentistry, optometry and pharmacy) local professional networks will be embedded into the local teams to provide local intelligence and expertise into the quality improvement work for primary care

• For dentistry, local professional networks will play a key role in the development of care pathways and could be the commissioning vehicle for the Board for dental services.

9

NHSCB central

NHSCB local teams (contracting relationship with individual practices)

CCGs

Implementation and development plans to reflect local circumstances

Strategy, policy, contract, procedure and assurance of achievement of outcomes

Aggregation of need and assurance of performance

Peer review, benchmarking and development to deliver the contract

Maximising performanceLocal intelligence, clinical expertise, innovation and development of integrated care pathways

Informing needs, demand, supply in primary care

LETBs (Local Education &

Training Boards)

Health and wellbeing

boards

Patients, carers and the Public

Local representative

committees

PC providers/Contractors LPNs

Interdependencies and wider system• Intelligence for commissioners

• CQC concordat

• PHE concordat

• HWB/LA – local memorandum of understanding/agreement

• Commissioning support service requirements – BSA and CSUs

• Transition programme

• Testing the LPN concept – learning is refining our proposals and will inform transition planning

Local dental networks – learning from testing and wider system establishment

NHSCB: Commissioning Dental Services

• The NHSCB will be responsible for commissioning all dental services, primary, community and secondary (inc urgent care and OOH)

• Single operating model provides a unique opportunity for consistency where it is required (but must maintain flexibility where it is justified)

• Opportunity to commission dentistry in an integrated way – concentrating on care pathways not care settings

• Key to this is to maximise quality and performance across pathways against consistent measures

• Quality and consistency of primary and community care dental services key driver for transformation agenda of the future – significant move to a preventative approach (dental contract pilots) and consistent care pathway (advanced care)

• Clinical leadership key to our model to deliver continuous quality improvement, consistency and transformation (innovation!)

Local professional networks: Context and concept

• An integral part of the NHS CB local offices (NOT an external body or network)

• No independent status or constitution – part of NHSCB local area teams

• Accountable to most senior clinician/ commissioner in NHSCB local office with professional accountability to CPO

• Ensure clinical leadership at the heart of the local operating model

• Delivering functions where clinical expertise and leadership can add most value

• Commissioning managers and clinicians delivering NHS CB (and wider) vision together

• Common purpose grounded in national and local priorities

• Local dental network role far greater in commissioning agenda than pharmacy and eye care – potential future vehicle for delivering NHSCB dental commissioning agenda

Our testing has shown that we need to support LDN development within clear framework…

What some testing the concept have attempted…

Local dental networks overarching objectives

An NHSCB vehicle for clinically led and clinically owned delivery of;

• Local implementation of NHSCB strategy – turning national mandate and local priorities into a deliverable implementation plan (within finite resources)

• Improving and assuring quality and performance – CQC, local offices (networks rather than isolated clinical advisors), performance and links to performer list management

• Planning and designing local care pathways and dental services - Best use of NHS resources and advocacy for patients on consistency of NHS offer

• Oral health strategy and oral health improvement for dental services - Best outcomes for patients that reflects local need via JSNA, oral health strategies – turning national and local strategy into local commissioning and improvement plans.

• Clinical and professional leadership and engagement – ensuring engagement across all providers, performers and LDCs.

What have we have learned from the past?• The evidence over the past few years suggests that ‘commissioning’ primary and community care as opposed to

contract management leads to better services and outcomes for patients.

• Strong commissioners have improved services for patients and achieved greater value for money through the removal or remediation of poor performance and inefficiency, but...

• Commissioners who have engaged clinicians and patients have come up with innovative solutions to local problems and some of those innovations are now influencing at a national level e.g. new primary care contracts

• That a pre-occupation with the contract as opposed to the relationship with contractors can stifle quality improvement.

• That a sound evidence base of causes and consequences and a fair and transparent process is required if poor performance is to be addressed.

• That a clinician has greater impact in conversations with a contractor than a manager and can evidence change as a result of their intervention.

Core Local Dental Network Team (commissioning

managers, clinical quality and network leaders,

public health)

Clinical Networks

(clinical expertise for ‘task and finish’ projects, quality improvement, pathway re-design, strategic development and

planning)

All dental providers and performers

(influence, communications, roll out, embedding)

Local dental networks operating model

Core LDN Team - led by clinicians, with priorities focussed in national and local delivery. Driver should be oral health and oral health improvement plans as priorities.

LDN Networks – opportunities to engage clinicians to lead specific areas of LDN programme. Delivering short or longer term objectives within and between local office areas. Wider opportunities for other interested clinicians to be involved in projects.

Wider engagement – opportunities for all providers, performers and wider teams to engage with LPN work, two-way communications, implementation across all providers, learning and sharing best practice.

Core Local

Dental Network Team

Clinical Networks

All dental providers and performers, stakeholders

Local dental networks: Core teamCore LDN Team•Small team with ownership of LDN agenda across a local area team and links into national and across other NHSCB areas•Clinicians and commissioners delivering NHSCB agenda – admin and financial support from local team and CSS where required •Accountability at local and national level for dental delivery – to senior local area likely via a direct commissioning forum•Employed/contracted clinical time to NHSCB local area team to deliver NHSCB dental agenda within a clear operating framework•Professionally accountable to CDO and links to national dental development agenda, including clinical senates and national networks•NHSCB likely to formally appoint clinicians to LDN, so current ‘testing’ arrangements are interim•Role and clinical leadership will evolve and develop over time•Key priority is quality and performance assurance and improvement•Need to clearly distinguish LDN and LDC role – they are not the same. LDC invited stakeholder/partner not key core member

Core Local

Dental Network Team

Clinical Networks

All dental providers and performers, stakeholders

Local dental networks: Network delivery modelsDental Networks – example models being collected•Many models emerging from testing have common key themes•Focus and capacity requirements will depend on national and local priorities – networks managed by core team•Allows flexible and efficient approach to progressing specific areas of programme – some networks may be time limited project specific•Opportunities for other clinicians and interested professionals to get involved•Networks feed other strategic and operational interdependencies via core team

Core Team

Specialistareas

Special CareDentistry

Oral Surgery

RestorativeQuality

Assurance And Imp

STRATEGIC AND OPERATIONAL INTERDEPENDENCIESPatients, Providers, Workforce, Engagement, HWB, JSNA, Commissioning Priorities

Core Local

Dental Network Team

Clinical Networks

All dental providers and performers, stakeholders

Local dental networks: Wider engagement

Clinical and Professional Leadership & Engagement•NHSCB local area teams and national support centre will want to establish efficient and effective engagement with all providers and performers and wider dental provider teams•Testing has provided some innovative examples of this – local web-based networks providing updates and means to engage for wider clinical community•Clinical leaders employed within NHSCB local dental networks need ability to bring the profession with them•Clinical consensus (as far as possible) on standard and quality of patient care

Clinical leadershipWhat we will need from clinicians in local dental networks

• A progressive approach in thinking, culture and behaviour

• A commitment and desire to improve quality and services for patients

• Population view - public health specialists

• Evidence – based approach to clinical effectiveness

• Strategic and operational skills

• Objective advisory and decision making

• Willingness to take action and responsibility

• Engaging the local profession and local representative committees

• Ensuring success in new relationships, behaviour and culture

• Primary and Secondary Care Commissioners• Dental Public Health• Quality and Performance Improvement Leads – clinical and managerial•Clinical and Professional Expertise• Specialist Clinical Input – secondary and community care• PC clinicians with a specialist interest•Clinical Skill Mix (e.g. dental nurses)

•Health and Wellbeing Board representation •Local Dental Committees • Workforce and Development – deaneries, CPPE (LETBs)• Patient and the Public Representation• CCG Representation • Interdependencies to support as appropriate – e.g. Informatics, Finance, PC regulatory experts

Clinical and professional partnerships

Emerging local dental networks have involvement and engagement from a wide range of stakeholders and partners;

Governance and conflict of interest• Using Towards Establishment of CCGs as outline framework

• Recommendation that NHSCB will formally appoint clinical resource to LPNs

• Learning from governance frameworks of testing and existing best practice PCT arrangements

• Single organisation means working across local office boundaries to support governance can be hard-wired

• Consistent and robust approaches to things like procurement, decision making and reviews

• The single operating model is a key driver in ensuring self governance and spotlighting issues

Local dental networks: measures of success success

• Delivery of clinically owned quality and performance improvement

• Clinically owned care pathway approach to commissioning dental services

• A consistent NHS dental offer for patients

• A consistent experience for all providers in their contractual relationship with NHSCB

• Clinical ownership and relevance to commissioning agenda across dentistry

• Iterative, clinically developed strategy and policy at national level developed through experience and needs of local area teams

• Strong governance, transparency and management of any conflicts of interest

Next steps• Socialising the operating model – we will do this through Primary Care

Commissioning: a single operating model

• Continue to refine the proposals and added value of local dental networks – currently extracting learning and alignment to wider system requirements

• Continue to refine detail of dental commissioning through co-production of ‘Dental Commissioning Framework’ document

• Contributing to central and local structures and ensuring the integrity of the single operating model and the strength of clinical leadership is preserved

• Working with Operations to develop a very clear transition plan and support for PCT clusters

• Continuing to test assumptions and adapt/refine

• Contribution to the OD programmes

NHSCB: care pathway approach to commissioning dental services:Community and secondary care services

NHSCB: Commissioning Dental Services

• The NHSCB will be responsible for commissioning all dental services, primary, community and secondary (inc urgent care and OOH)

• Single operating model provides a unique opportunity for consistency where it is required (but must maintain flexibility where it is justified)

• Opportunity to commission dentistry in an integrated way – concentrating on care pathways not care settings

• Key to this is to maximise quality and performance across pathways against consistent measures

• Quality and consistency of primary and community care dental services key driver for transformation agenda of the future – significant move to a preventative approach (dental contract pilots) and consistent care pathway (advanced care)

• To ensure traction to NHSCB, we are developing an NHSCB dental commissioning framework – future facing vision and strategy

Dental Commissioning Task Group Developing Proposals for NHSCB

• Aims of the group;

• Articulate NHSCBs strategic approach and vision for commissioning all dental services

• Describe the care pathway approach to commissioning and the ‘ingredients’ required to make this a reality

• Identify the enablers and levers required to deliver this and where in the system they need to be developed and delivered

• Outline how the NHSCB will align it’s Directorate resources, skills and commissioning support requirements to deliver this

• Describe the key strategic and operational relationships that the NHSCB will need to deliver the strategy and vision

• Like our primary care work must have two parallel aims;

• Safe and robust transfer of current arrangements, but;

• Designed as a system capable of transforming and improving services

NHSCB Dental Commissioning Strategy• To be an exemplar commissioner we have established that NHSCB will

require;

• Consistent care pathway design across all specialties encompassing procedures, levels of complexity, standards and criteria, costs and coding, specifications and KPIs, including outcome measures

• Consistent method to capture need/diagnosis and level of complexity for all specialties and referrals

• Consistent information and intelligence for performance management and financial control

• National (clinical and commissioner) consensus on these elements, for local translation into implementation

Ingredients for pathway commissioning

NHSCB skills and resources in right

place

Enablers: clinical and commercial

(advanced care, contract pilot, PbR, tariff etc)

Aligning Interdependencies

e.g workforce, market management

Vision and strategy: Commissioning

Development/Operations/Clinical of NHSCB