DLM Online Modules Complete PDF

The Structure of Healthcare Delivery within the UK is complex, and essentially consists of four separate healthcare systems: NHS England, Health and Social Care (Northern Ireland), NHS Scotland and NHS Wales. The national system was established in 1946 under the National Health Service Act and in 19...

The Structure of Healthcare Delivery within the UK is complex, and essentially consists of four separate healthcare systems: NHS England, Health and Social Care (Northern Ireland), NHS Scotland and NHS Wales. The national system was established in 1946 under the National Health Service Act and in 1947 in Scotland under the National Health Service (Scotland) Act. In the late 1990s, the national system was devolved into four separate systems. The UK government sets the overall budget available to NHS England and provides block grants to the other three countries. After successful completion of this module, you should be able to: Describe the structure and function of the NHS in England, Wales, Northern Ireland and Scotland Outline the arrangements for indemnity or insurance for NHS and private work Understand the independent contractor status of GPs and what the Performers List requirements are across the UK Describe issues of access to healthcare and the role of NICE and the SMC Define clinical governance From the Syllabus [https://fflm.ac.uk/exam-regulations-guidance] Candidates should have an understanding of the structure and organisation of healthcare in the UK including: 1.1. Structure of the NHS and the differences due to devolved government in the four jurisdictions; 1.2. Independent contractor status of GMS GPs, GDS GDPs, PMS GPs; 1.3. GP & GDP Performer's Lists; 1.4. Private medical/dental practice 1.5. NHS indemnity and other indemnity/insurance arrangements; 1.6. Clinical governance; 1.7. Issues of access to healthcare; and 1.8. The National Institute for Health and Clinical Excellence and the Scottish Medicines Consortium. 1. Structure of Healthcare 2. Regulation of Healthcare 3. General Practice 4. Indemnity 5. Clinical Governance 6. NHS appraisal of medicines 7. Out of area treatment and Overseas Visitors 8. Impact of Brexit on the NHS Module updated 31 May 2023 The NHS was established in 1948. It is funded from general taxation and is, on the whole, delivered by public service providers with the fundamental principles of being accessible, comprehensive and free at the point of use. Over the years, it has come under increasing pressure due to demand outstripping resources. Challenges include: Demographic – growing and ageing population living with more long term conditions Expectations – with advancing scientific developments and the democratisation of healthcare associated with digital developments Workforce – nursing and medical shortages The NHS Five Year Forward View recognised the necessity of shifting from a model of reactive care focussing on sickness, to a more proactive model of wellness. In January 2019, the Long Term Plan (10 year plan), built further upon the foundations of the Five Year Forward View. The Health and Care Act 2022 (available at: Health and Care Act 2022), introduced new legislative measures that aimed to make it easier for health and care organisations to deliver integrated care for people relying on multiple services. Models across the four nations At the most basic level, health care systems can use either: a. Market type levers – pricing, competition and contracts. In this type of system, there is a separation of providers into entities offering services in a market, competing for customers based upon quality and price. A market system encourages providers to be more accountable to patients.Of the 4 nations, England is the only to have retained this purchaser/provider split b. Bureaucratic type levers – performance management, targets, standards and direct control. In this type of system, power flows down the system. Service providers account for their work to intermediaries and ultimately to the government Minister in charge. This is the model for Northern Ireland, Scotland and Wales. The Health and Care Act 2022 (England) introduced the Provider Selection regime, giving NHS bodies a wider range of options when commissioning services. Healthcare Reform “Health care reform has been one of the worldwide epidemics of the 1990’s.” (Klein). Following on from devolution, the NHS in each of the four nations has undergone several major reconfigurations. The most recent reform in England, as legislated for by the Health and Care Act 2022 include: Integrated Care Systems Clinical Commissioning Groups became Integrated Care Boards (ICBs) Formalised merger NHS England & NHS Improvement. The new body, NHS England is to provide “unified national leadership for the NHS” Merger of NHS Digital & Health Education England with NHS England Formalises Health Services Safety Investigation Body (HSSIB), previously known as the Healthcare Safety Investigation Branch. HSSIB has gained statutory powers. Changes to clinical service procurement – greater flexibility over when to use competitive procurement processes Secretary of State has been granted powers to intervene in local service reconfiguration Secretary of State has gained general powers to direct NHSE beyond the objectives set out in the NHS Mandate In Northern Ireland, the Health and Social Care Act (NI) 2022, (available at: Health and Social Care Act (NI) 2022), led to the dissolution of the Health and Social Care Board, and its replacement with the Strategic Planning and Performance Group (SPPG). In a move towards an Integrated Care System, there is a plan to replace local Commissioning Groups with Area Integrated Planning Boards. Pending reform, the current local Commissioning Groups have been continued until September 2023. In Scotland, Integrated Joint Boards were set up under the Public Bodies (Joint Working) (Scotland) Act 2014. Summary of NHS Structures across the UK While health policy has been devolved, the UK Government retains power on certain issues. With the Windsor Framework, it appears that Northern Ireland is likely to come under the MHRA remit rather than the EMA. Whilst each jurisdiction has arrangements with regards to blood and platelet donation, NHS Blood and Transplant is the organ donation organisation for the UK. Funding In England, general taxation accounts for the majority of NHS funding, with some funds being raised by patient fees e.g. meanstested charges for prescriptions and other services. After devolution, Scotland, Wales and Northern Ireland abolished prescription charges. Devolved administrations receive a block grant of funding from the UK government each year. This is calculated using the Barnett formula, which determines the change in the year-on-year grant money based on the change in UK government spending. This figure is calculated against all UK government spend and is not ringfenced to any particular devolved policy area. NHS spending per head of population varies between the four nations. It is highest in Northern Ireland and lowest in England. Integration of health and social care across the four nations a) England There have been several initiatives to promote better integration of health and social care, including: Health and Wellbeing Boards Better Care Fund Re-branding of the Department of Health to the Department of Health and Social Care More recently, wider sweeping reforms have been introduced by the Health and Care Act 2022, including the formalisation of Integrated Care Systems (ICSs) as legal entities with statutory powers and responsibilities. ICSs compromise: Integrated Care Boards (ICBs) – statutory bodies responsible for planning and funding most NHS services in the area Integrated Care Partnerships (ICPs) – statutory committees that bring together a wide range of system partners to develop a health and care strategy. ICPs have four key aims: 1. Improve outcomes in population health and healthcare 2. Tackling inequalities in outcomes, experience and access 3. Enhancing productivity and value for money 4. Helping the NHS to support broader social and economic development b) Scotland The Public Bodies (Joint Working) (Scotland) Act brought health and social care under one system. There are 31 integration authorites across Scotland, responsible for £9bn of funding for local services. Only Highland has adopted a lead agency arrangement with the Local Authority having responsibility for Children’s health and social care, whilst the Health Board has responsibility for Adult health and social care. The other areas have adopted Integrated Joint Partnership Boards (IJPB), with the Local Authority and Health Board delegating functions and budgets to the IJPB. The IJB is required to produce a single strategic plan to deliver the nine National Health and Wellbeing Outcomes. The IJB then commissions (or ‘directs’) the local authority and health board to deliver services in line with the strategic plan, and the IJB allocates the budget for delivery accordingly. The local authority and health board deliver these services within the budget and any other parameters directed by the IJB. c) Wales The Social Services and Well-being (Wales) Act 2014 places a legal duty on local authorities to promote the integration of health and social care. The Wellbeing of Future Generations (Wales) Act 2015 promotes the principles of long-term collaboration of public bodies to better plan for the wellbeing of Welsh citizens. The Integrated Care Fund was created to facilitate collaboration across the social services, health, housing, the third and independent sectors. d) Northern Ireland Northern Ireland has had integrated health and social care since 1973. Further changes have been implemented and are planned following the Health and Social Care (NI) Act 2022. This includes the planned introduction of Area Integrated Partnership Boards. The Health and Social Care Act 2012 introduced the most wide-ranging reform to the structure of the NHS since it was established in 1948. The Government aims were to: Reduce central control of the NHS Engage doctors in commissioning Give patients greater choice Many of the provisions came into force on 01 April 2013, including: NHS England and Clinical Commissioning Groups (CCGs) assumed statutory responsibility for commissioning services Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) were abolished Local Authorities (LAs) took on new public health responsibilities Local Healthwatch organisations came into being Part 3 of the Care Act 2014 established Health Education England (HEE) and the Health Research Authority (HRA) as statutory non departmental bodies (NDPBs). More recent changes introduced by the Health and Care Act 2022 have included: NHS and local government coming together legally as part of integrated care systems Repealing S75 of the Health and Social Care Act 2012, meaning NHS commissioners will no longer be compelled to put services out to competitive tender Placing a new ‘duty to collaborate’ on all NHS bodies Formal merger of NHS England and NHS Improvement. The new organisation is NHS England NHS Digital and Health Education England have been merged into NHS England Expanding the power of the Secretary of State for Health, including increased power to direct NHS England, create new NHS Trusts, intervene in reconfiguration disputes and amend/abolish Arms Length Bodies (ALBs) Healthcare Safety Investigation Branch (HSIB) to gain statutory footing, tasked with encouraging the spread of a culture of learning within the NHS through promoting better standards for investigations into safety incidents The UK Secretary State for Health and Social Care has a duty to promote a comprehensive health service in England and has responsibilities for the work of the UK Department of Health and Social Care. The UK Department of Health and Social Care has an overall responsibility for healthcare provision in the UK, and specific responsibility for organising the NHS in England. The work of this department is mostly scrutinised by the House of Commons’ Health Committee. The Department of Health and Social Care (DHSC) retains its responsibility for overall stewardship of the system, but manages the NHS using Arms Length Bodies (ALBs), who commission and regulate care. One of the stated aims of the 2010 Government’s health reforms was to end political interference in the NHS. Under the Health and Social Care Act 2012, the Secretary of State sets the strategic direction for the NHS in England through a ‘mandate’ to NHS England. However, the Health and Care Act 2022 has given the Secretary of State additional powers to direct NHS England, to intervene regarding service reconfiguration and to merge or abolish healthcare regulators. The Secretary of State sets the overall budget for NHS England. NHS England then sets the budget for CCGs.Integrated Care Boards. The Chief Executive of NHS England is accountable both to the Department of Health and Social Care and to Parliament. Parliamentary select committees examine the policy, administration and expenditure of the DHSC and its associated bodies. Overall responsibility for commissioning healthcare in England rests with NHS England. The Kings Fund has produced a video explaining the structure of the NHS in England, however, it should be noted that there have been some changes since this was last updated. It is available at: https://www.kingsfund.org.uk/audio-video/how-does-nhs-in-england-work NHSE - STRUCTURE NHS England is an executive non-departmental public body (i.e. an Arms Length Body). Services are commissioned by Integrated Care Bodies, overseen by NHS England on a regional and national level. NHS England directly commissions the following services: Armed forces Health and justice Primary care commissioning (although some ICBs are direct commissioning responsibility for primary care) Specialised services NHS England works closely with UK Health Security Agency and the Department of Health and Social Care to provide and commission a range of public health services. NHS seasonal flu vaccination programme NHS seasonal flu vaccine programme – advice and reimbursement guidance NHS Breast Screening Programme (NHS BSP) NHS England and NHS Improvement Diabetic Eye Screening Programme (DESP) NHS England and NHS Improvement Abdominal aortic aneurysm (AAA) screening programme NHS Cervical Screening Programme NHS Bowel Screening Programme NHS Antenatal Newborn Screening (ANNB) NHS Newborn Hearing Screening Programme (NHSP) Newborn and Infant Physical Examination (NIPE) Screening Programme Infectious diseases in pregnancy screening programme (IDPS) Fetal anomaly screening programme Down’s syndrome, Edwards’ syndrome and Patau’s syndrome screening pathway 20-week screening scan pathway NHS England has seven regional teams. The NHS Constitution The NHS Constitution for England sets out: the principles and values of the NHS rights, pledges and responsibilities for patients and staff in the NHS Patients’ legal rights are protected by law, however, the pledges are commitments that the NHS aims to achieve. Principles include: The NHS provides a comprehensive service, available to all Access to NHS services is based on clinical need The NHS aspires to the highest standards of excellence and professionalism The patient will be at the heart of everything the NHS does The NHS works across organisational boundaries and in partnership with other organisations in the interests of patients, local communities and the wider population The NHS is committed to providing best value for tax payer’s money The NHS is accountable to the public, communities and patients that it serves. Rights include: to receive NHS services free of charge, with some limited exceptions (e.g. dentist, prescription charges etc.) to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality not to be unlawfully discriminated against when receiving NHS services to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of suitable alternative providers if this is not possible access to drugs and treatments recommended by NICE if clinically appropriate to accept or refuse treatment The Secretary of State for Health and Social Care, all NHS bodies, private and voluntary sector providers supplying NHS services, and the local authorities in the exercise of their public health functions are required by law to take account of the NHS Constitution in their decisions and actions. The Constitution sets out that patients have the right to access certain services within maximum waiting times or be offered alternatives. The Handbook to the NHS Constitution gives details of what patients, the public and NHS staff can do if they think these rights are not upheld. The DHSC is required to renew the NHS constitution at least every 10 years, with the involvement of the public, patients and staff. The NHS Constitution is available at: https://www.gov.uk/government/publications/supplements-to-the-nhs- constitution-for-england/the-handbook-to-the-nhs-constitution-for-england The Long Term Plan (10 year plan), was published in January 2019. This builds upon the Five Year Forward View and subsidiary strategies covering general practice, cancer, mental health and maternity services. Some of the key clinical priority areas addressed in the Plan include cancer, cardiovascular disease, maternity and neonatal health, mental health, stroke, diabetes and respiratory care. There is also a strong focus on children and young people’s health. More information is available at: https://www.longtermplan.nhs.uk The Long Term Plan sets out a “Triple Aim” which is now a legal duty on NHS bodies requiring them to consider the effects of their decisions on: 1. the health and well-being of the people of England (including inequalities in that health and well-being) 2. the quality of services provided or arranged by both themselves and other relevant bodies (including inequalities in benefits from those services) 3. the sustainable and efficient use of resources by both themselves and other relevant bodies. Key areas addressed include: Funding commitments include: The funding settlement applies to NHS England’s budget only. It is a plan for the NHS, not the whole Health and Social Care system. The Spending Review was published in Dec 2021. It is available at: https://www.gov.uk/government/publications/autumn-budget-and-spendingreview-2021-documents In recognition of the additional pressures due to the pandemic, a 3-year funding settlement was announced in September 2021, this includes an average resource budget rise by an average of 3.8% each year until 2024/25. More information is available at: https://www.gov.uk/government/publications/build-back-better-our-plan-forhealth-and-social-care Integrated Care Systems A key tenet of integrated care systems is that commissioning to tackle inequality and improve population health, should be undertaken by collaborative planning over smaller areas. We now have the “systems, places, neighbourhoods” approach, although the scheme of delegation is not as yet clear. Systems – covering populations of 500,000 – 3 million people. Health and care partners collaborate to set overall system strategy, manage budgets and performance, plan specialist services and drive improvements. Places – covering populations of 250,000 – 500,000 people (often based on local authority boundaries). Partnerships of health and care organisations in a town or district collaborate to join up the planning and delivery of services, engage local communities and address health inequalities. Neighbourhoods – covering populations of 30,00-50,00 people. Primary Care Networks are an example – where groups of GP practices work with NHS community services, social care and other providers. The Health and Care Act 2022 has placed a duty on the CQC to review health care and adult social care in each ICB including looking at how partners in the ICS are working together. Integrated Care Boards Clinical Commissioning Groups (CCGs) were created by the Health & Social Care Act 2012, replacing Primary Care Trusts (PCTs). They were clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. The Health and Care Act 2022, replaced CCGs with Integrated Care Boards. Their role is to allocate the NHS budget and commission services for the population. The ICB is directly accountable to NHS England. Each ICB must prepare a 5-year plan setting out how it will meet the needs of the population, having regard to the partner ICP’s integrate care strategy and the joint health and well-being strategy published by the local health and well-being board. ICB membership includes – a chair, chief executive officer and at least 3 other members from NHS trusts and foundation trusts, general practice and local authorities within the relevant area. One member must have knowledge and expertise in mental health. There is a requirement to involve patients and communities in the planning and commissioning of services. ICBs have taken on some commissioning responsibilities from NHS England including commissioning of primary care and some specialised services. Integrated Care Partnerships These have arisen out of the Sustaining and Transformation Plans (STPs) but how have a statutory basis. The ICP is a statutory joint committee of the ICB and local authority within the area. Involivng a wide range of “system partners” the ICP develops an “integrated care strategy” to address the relevant population’s wider health care, public health and social care needs. ICP membership includes one member appointed by the ICB, one member appointed by the relevant local authority and flexibility with regards to other members. National Institute for Health and Care Excellence (NICE) This was established in April 2013 as an executive non-departmental body by the Health and Social Care Act 2012. Prior to that, it was a Special Health Authority. It also acquired responsibility for providing guidance for social care. The NHS Constitution states that patients have the right to drugs and treatment that have been recommended by NICE for use in the NHS, if the doctor believes they are clinically appropriate. NHS organisations in England are legally required to make funding available for treatments that NICE recommends following a Technology Appraisal or Highly Specialised Technology evaluation, no later than 90 calendar days (30 calendar days for Fast Track appraisal or Early Access to Medicines Scheme) of final guidance being published. Early Access to Medicines Scheme (EAMS) – The scheme aims to give patients with life threatening or debilitating conditions access to medicines that do not yet have marketing authorisation. NICE facilitates engagement meetings for developers of pharmaceutical products to apply for a “promising innovative medicine” (PIM) designation. The Medicines Healthcare Regulatory Agency (MHRA) will give a scientific opinion on the benefit/risk balance of the medicine. The opinion lasts for 1 year and can be renewed. The Technology Appraisal process involves considering: Evidence from clinical trials and peer reviewed research, considering likely impact on mortality and quality of life Economic evidence on how much it costs to the NHS Views of clinicians, patients and other stakeholders In addition to looking at clinical effectiveness of a treatment, technology appraisals assess a treatment’s cost effectiveness. This is usually measured in terms of the cost per additional Quality-Adjusted Life Year (QALY) that the treatment provides. QALYs are a measure of the years of life remaining for a patient, weighted on a quality of life scale. One QALY is equal to one year of life in perfect health. NICE does not decide on topics for guidance and appraisals. These are referred to NICE by the Department of Health and Social Care. There are three processes for assessing technologies: Single technology appraisal Multiple technology appraisal Fast track appraisal In 2017, NICE announced a fast track process for approvals. Essentially this includes the ability to fast track drugs which represent exceptional value for money and budget impact test for drugs if: The company’s base-case incremental cost-effectiveness ration )ICER) is less than £10,000 per quality-adjusted life year (QALY) gained. It is likely that the most plausaible ICER is less than £20,000 per QALY gained, and it is highliy unlikely that it is greater than £30,000 per QALY gained. OR A cost comparison case can be made that shows it is likely to provide similar or greater health benefits at similar or lower cost than technologies already recommended in technology appraisal guidance for the same indication. NICE also publishes advisory clinical guidelines and public health guidelines. Commissioners are not required to follow these. In the absence of guidance, NHS organisations can determine their own policy on funding, but cannot have a blanket ban policy and must consider individual cases. The Health and Social Act requires commissioners to have due regard to NICE Quality Standards. Public Health England (PHE) PHE has been replaced by UK Health Security Agency (UKHSA) and the Office for Health Improvement and Disparities (OHID). UKHSA was announced in March 2021. It is an executive agency. The OHID is located within the DHSC and has taken over PHE’s functions regarding wider public health including public improvement and population health. It is jointly accountable to the Secretary of State for Health and Social Care and the Chief Medical Officer (England). Regulation See section on Regulation. In England, the key regulators are the Care Quality Commission (CQC) and NHS England. Since 1973, Health and Social Care have been integrated in Northern Ireland. The Department for Health is responsible for providing Health and Social Care Services in Northern Ireland. The Department of Health sets the policy and legislative context for health and social care in Northern Ireland (NI). An annual Commissioning Plan Direction sets out Ministerial priorities, key outcomes and objectives and related performance indicators. The Strategic Performance and Planning Group (SPPG) in conjunction with the Public Health Agency (PHA) then produces a Commissioning Plan. The relevant legislation relating to the current structure in Northern Ireland is The Health and Social Care (Reform) Act (Northern Ireland) 2009, available at: https://www.legislation.gov.uk/nia/2009/1/contents and the Health and Social Care Act 2022 available at: https://www.legislation.gov.uk/nia/2022/3/contents/enacted Strategic Performance and Planning Group (SPPG) Commissioning Resource management Performance management Service improvement 5 Local Commissioning Groups (note plan to replace with Area Integrated Partnership Boards – AIPBs) Cover same footprint as the 5 HSC Trusts 6 Health & Social Care (HSC) Trusts 5 Trusts plus Ambulance Trust Works with the HSCB to identify and meet needs of local population AIPBs will be the local area bodies underpinning the Integrated Care System in Northern Ireland. Manage and administer: Hospitals, health centres, residential homes, day centres etc. Public Health Agency (PHA) Improving health & wellbeing, health protection Professional input to commissioning Works in partnership with local government & other organisations Patient & Client Council (PCC) Regional body, local offices. Provide a powerful, independent voice for patients, clients, carers and communities on health & social care issues Business Services Organisation (BSO) Provision of business support and specialist professional services to the Health & Social Care sector including HR, finance , legal, procurement, ICT and other services. Regulation & Quality Improvement Authority (RQIA) Independent regulatory body NI Guardian Ad Litem Agency Safeguard and promote the interests of children by providing independent social work investigation and advice in specified proceedings under the Children (NI) Order 1995 and Adoption (NI) Order 1987; provide effective representation of children’s views NI Blood Transfusion Service (NIBTS) Supply the needs of all hospitals and clinical units with safe and effective blood and blood products The National Health Service (Scotland) Act 1947 came into effect on 05 July 1948 and created the National Health Service in Scotland. Many sections of the Act were repealed by the National Health Service (Scotland) Act 1972 and the remaining provisions were repealed by the National Health Service (Scotland) Act 1978. NHS Scotland The Cabinet Secretary for Health & Wellbeing has ministerial responsibility in the Scottish Cabinet for the NHS in Scotland. The Scottish Government: Determines what resources are allocated to the NHS Sets national objectives and priorities for the NHS, signs delivery plans with each of the 14 NHS Boards and 7 Special NHS Boards plus a public health board Monitors performance The NHS Boards Plan, commission and deliver NHS services (the Scottish equivalent of the former English CCGs). The 8 national NHS Boards provide national services The Special NHS Boards Provide national services. Include: Public Health Scotland, Healthcare Improvement Scotland, NHS Education for Scotland, NHS National Waiting Times Centre, NHS24, Scottish Ambulance Service, the State Hospitals Board for Scotland Health Care Improvement Scotland provides scrutiny and public assurance of health services and sets standards. GPs are contracted by their local Health Board do not commission services Integration of health and social care The Public Bodies (Joint Working) (Scotland) Act 2014 and the Community Empowerment (Scotland) Act 2015 (the Act) introduced key reforms. Public Bodies (Joint Working) (Scotland) Act 2014 http://www.legislation.gov.uk/asp/2015/6/contents/enacted The Public Bodies (Joint Working) (Scotland) Act 2014 set out the legislative framework for integrating health and social care. It creates new public organisations called Integration Authorities. The aim was to reduce potential inefficiencies and variations between areas. IAs are responsible for the governance, planning and resourcing of social care, primary and community healthcare and unscheduled hospital care for adults. Some areas have also integrated additional services including children’s services, social work, criminal justice services and all acute hospital services. Health and Social Care Partnerships 31 Health and Social Care Partnerships have been set up, between 14 NHS boards and 32 Local Authorities. These health and social care partnerships manage a budget of almost £9 billion of health and social care resources. There are two potential models: Integration Joint Board (IJB) model The vast majority have adopted this model. The NHS Board and Local Authorities delegate the responsibility for planning and resourcing service provision for delegated health and social care services to the IJB. The budgets are delegated. 30 areas have adopted this body corporate model. IJB membership is broad, including councillors and NHS non executive directors plus other members. The IJB is required to produce a single strategic plan to deliver the nine National Health and Wellbeing Outcomes. Lead Agency model The NHS Board or Local Authority takes the lead in planning and delivering integrated service provision in the area. Only one area (Highlands) has adopted this model. This means there are 30 Integration Joint Boards (IJBs) and 1 Joint Monitoring Committee (Highlands) across the 32 Local Authority areas in Scotland. Each IA must establish at least 2 localities in order to ensure there is local involvement in how resources are spent within their area. More information on Health and social care integration is available at: https://www.gov.scot/policies/social-care/health-and-social-care-integration The Community Empowerment (Scotland) Act 2015 places legal duties on NHS Boards, Integration Authorities and Local Authorities regarding involvement of the public. The Minister for Health and Social Services retains responsibility and is accountable to the Welsh Government for the exercise of all powers in the Health and Social Services portfolio. In Wales, 7 local Health Boards are responsible for planning and delivering healthcare services and aim to integrate specialist, secondary, community and primary care and health improvements. Each Health Board is subdivided into locality offices. The 7 Health Boards commission General Practice services via the GMS (General Medical Services) contract. There are 3 NHS Trusts with a regional focus. Welsh Ambulance Services NHS Trust Velindre NHS Trust (specialist services in cancer care and a range of national support services) Public Health Wales The NHS Wales Shared Services Partnership (NWSSP) is an independent organisation, owned and directed by NHS Wales. It provides support functions and services. In April 2018, Health Education and Improvement Wales (HEIW) was set up. This sits alongside Health Boards and Trusts and is responsible for education and training and workforce modernisation. The NHS in Wales is accountable both to Welsh Ministers and to Community Health Councils which provide a link between patients and the organisations that plan and deliver services. The Community Health Councils, which mirror local authority areas, are statutory lay bodies that represent the interests of the public in their areas. England Wales Scotland Northern Ireland Responsible to Parliament Devolved Devolved Devolved Commissioning NHS England Health Boards Health Boards Strategic Planning & Performan Group (SPPG) Healthcare Inspectorate Wales Healthcare Improvement Scotland (HIS) Regulatory and Qualit Improveme Authority (RQIA) Integrated Care Boards Regulation Care Quality Commission (CQC) NHS England SPPG Sector/Nation England Wales Scotland Northern Ireland Hospitals and acute care Care Quality Healthcare Commission Inspectorate (CQC) & Wales (HIW) NHS England Healthcare Improvement Scotland (HIS) Regulation and Quality Improveme Authority (RQIA) GP practices Care Quality Commission Healthcare Inspectorate Wales Healthcare Improvement Scotland and RCGP Scotland SPPG Mental Health services Care Quality Commission & NHS Improvement (NHSI) Healthcare Inspectorate Wales Mental Welfare Commission for Scotland and Healthcare Improvement Scotland Regulation and Quality Improveme Authority Social care Care Quality Commission Care Inspectorate Wales The Care Inspectorate and Healthcare Improvement Scotland Regulation and Quality Improveme Authority The Health and Safety Executive (HSE) is the national independent regulator for health and safety within the workplace. It works in partnership with co-regulators in local authorities to inspect, investigate and where necessary, take enforcement action. In general, the HSE will only investigate where: The accident or incident is reportable under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) and falls with the incident selection criteria. E.g. trips, falls, scalding, incidents arising from people handling; or The accident or incident is not RIDDOR reportable but has clearly been caused by well-established standards not being achieved and the failure to meet them arises principally from a systemic failure in management systems and death has occurred or where the harm was so serious that death may have resulted. CARE QUALITY COMMISSION (CQC) The Health and Social Care Act 2008 established the CQC as the regulator of all health and adult social care services in England. Responsible for the registration regulation, inspection and rating of all providers. Health and social care providers, whether an individual, partnership or organisation must be registered with the CQC before they are able to offer any services.In the case of partnerships, e.g. GP Practices, each individual partner must be included on a registration and the CQC must be notified of any changes. CQC Insight brings into one place the information the CQC holds about services and produces monitoring reports. If CQC Insight indicates a change in the quality of care for a service, the CQC may follow this up. The CQC has introduced a new single assessment framework. The key lines of enquiry (KLOEs) are being replaced with new “quality statements”. Six categories of evidence have been identified: People’s experiences Feedback from staff and leaders Observations of care Feedback from partners Processes Outcomes of care Ratings: outstanding, good, requires improvement or inadequate Reports are published on the CQC website, and unless exempt, registered providers are required by law to display their ratings publicly. Enforcement Suspension/cancellation of registration Fixed penalty notices Criminal prosecution Special measures In the case of GP practice, OOH service or other primary care service, the CQC can place the service directly into special measures, but must liaise closely with NHS England. The CQC can only recommend that NHS Foundation Trusts and Trusts are put into special measures. The final decision is made by NHS Improvement. The Health and Care Act 2022, gives the CQC powers to assess whether Integrated Care Systems are meeting the needs of their local populations and to assess how well local authorities are meeting their duties under the Care Act 2014. NHS IMPROVEMENT (NHSI) NHSI has now merged with NHS England and is known as NHS England. The Regulatory & Quality Improvement Authority (RQIA) is the independent health and social care regulator. It was established in 2005. Four key outcomes focussed on during inspections: Safe, effective, compassionate and well led. Does not give ratings, but will where appropriate provide: Recommendations for improvement where standards are not being met Housekeeping points to assist providers to make rapid improvements to more minor problems Recognition of good practice Enforcement If providers fail to meet standards, the RQIA can take a range of actions including issuing improvement notices, cancellation or alteration of registration and prosecution. The RQIA can recommend to the Department of Health that special measures are taken in respect of performance of a HSC Trust. The Strategic Planning and Performance Group (SPPG) Previously the Health and Social Care Board. The statutory body responsible for commissioning health and social care services in NI. It is also responsible for monitoring and appraisal of HSC (Health and Social Care) GP services. In cases of serious underperformance the chief executive has the authority to suspend the registration of general practitioners. Complaints Complaints about healthcare in Northern Ireland are dealt with in the first instance by the service provider. HSC Trust staff or the Patient Client Council can provide information on how to raisea concern or the SPPG can assist with complaints relating to GPs. If not satisfied with the response, the patient can refer the complaint to the Northern Ireland Public Services Ombudsman (NIPSO). Healthcare Improvement Scotland (HIS) HIS began operating in 2011. It is described more as an Improvement Body for the NHS, rather than as a regulator. It has a key role in setting standards for care and treatment and inspecting Boards’ performance against these standards. Health Boards have a large degree of autonomy, and HIS has few legal powers to enforce sanctions. HIS is responsible for the regulation of independent healthcare. It can take enforcement action against an independent provider and can cancel registration. HIS published aims are: - To empower people to have an informed voice that maximises their impact in managing their own care and shaping how services are designed and delivered - To reliably spread and support implementation of best practice to improve healthcare - To comprehensively assess the quality and safety of healthcare Statutory responsibilities are set out in the Public Services Reform (Scotland) Act 2010. Therefore, it has a significant range of activities in addition to regulation of healthcare in Scotland. These include: The Healthcare Environment Inspectorate (responsible for inspecting hospital compliance with Healthcare Associated Infection standards). Scottish Health Technologies Group Scottish Health Council SIGN Scottish Medicines Consortium Mental Welfare Commission for Scotland (MCWS) – founded in 1960. Investigate individual cases and inspect providers. Work closely with other organisations including HIS and the Care Inspectorate. The Mental Health (Care and Treatment)(Scotland) Act 2003 gave the MWC a duty to monitor the operation of the 2003 Act and to promote best practice. It also has a role in monitoring the operation of the Adults with Incapacity (Scotland) Act 2000. The Care Inspectorate The Care Inspectorate regulates a range of care services, undertakes strategic inspections of Local Authorities social work departments and is also responsible for the scrutiny of children's services as set out in the Public Services Reform (Scotland) Act 2010.The Care Inspectorate’s regulatory and scrutiny functions ensure that: Vulnerable people are safe The quality of these services improves People know the standards they have a right to expect They can report publicly on the quality of these services across Scotland They can support and encourage the development of better ways of delivering these services Audit Scotland Audit Scotland scrutinises the financial performance, efficiency and effectiveness of the NHS in Scotland. Complaints Complaints about NHS services are dealt with in the first instance by the relevant Health Board. Patients have the right to complain to the Scottish Public Services Ombudsman (SPSO) if not resolved to their satisfaction. They may also pursue legal action through civil courts. The Patient Rights (Scotland) Act 2011 gave patients the right to complain and placed a duty on Scottish Ministers to publish a comprehensive Charter of Patient Rights and Responsibilities. Enforcement Actions Scotland Only Scottish Ministers and the Courts have power to enforce a particular action on a health board. Healthcare Inspectorate Wales (HIW) regulates the quality of NHS and independent healthcare in Wales. 3 key quality themes: Quality of patient experience Delivery of safe and effective care Quality of management and leadership Where issues identified, HIW suggests improvement actions and requires providers to draw up improvement plans. Once agreed, these are published online. It does not give ratings. Enforcement actions include: non-compliance notices intensified monitoring mandatory action plans criminal prosecutions. It can place NHS providers into special measures, but only with the authority of the Welsh Government. The Wales Audit Office (WAO) contributes to healthcare quality regulation, working with HIW to provide financial regulation as the external auditor of the Welsh NHS. Community Health Councils (CHCs) act as a form of independent ‘watchdog’ of health services in Wales, representing and promoting the views of patients and the public. Care Inspectorate Wales regulates social care and social services throughout Wales. Regulate Inspect/monitor Rate Enforcement Powers NHS Trusts & hospitals Inspect all regulated services Outstanding Suspension/cancellation of registration Inspects and reviews all regulated services Do not give ratings ENGLAND CQC GP practices Mental Health Social Care Good Fixed penalty notices Requires improvement Prosecution Special Measures Inadequate Independent providers Others NORTHERN IRELAND RQIA HSC trusts and hospitals MH services Suspension/cancellation of registration Prosecution Social care Special measures – if authorised by the DoH Independent providers SPPG Improvement notices GP practices Inspects GP practices on rolling programme Do not give ratings Suspension of practitioner registration NHS Trusts & hospitals Do not give ratings Impose condition notices SCOTLAND HIS Independent providers Inspects Suspension/cancellation of registration Social care services (with Care Inspectorate) General Practice (with RCGP Scotland) MWCS Mental health services Care Social care Inspectorate Inspect providers in response to patient complaints and monitor compliance with mental health laws Do not give ratings Inspect all social Rates care services (joint inspections with HIS) No direct enforcement powers – provide recommendations for action to the authorities Improvement notices Alteration or cancellation of registration WALES HIW NHS trusts & Inspect all hospitals regulated services GP practices Do not give ratings Non-compliance notices Increased monitoring Mandatory action plans MH Criminal prosecutions Independent providers Special measures – if authorised by Welsh government Others CHCs NHS services Can inspect NHS premises Do not give ratings CIW Social care Inspect all social Do not give care providers ratings No direct enforcement powers Non-compliance notices Suspension of services Suspension/cancellation of registration Prosecution The core purpose of general practice, as stipulated in the national contract, is very broadly described as the services that GPs must provide to manage their registered list of patients when they are ill. General Practice Contracts There are three main types of core contract: General Medical Services (GMS) Personal Medical Services (PMS) Alternative Provider Medical Services (APMS) General Medical Services (GMS) Personal Medical Services (PMS) Alternative Provider Medical Services (APMS) The national standard contract Locally negotiated Being phased out Locally negotiated. Can be held by the widest group of alternative/independent providers Stipulates essential services Stipulates essential services No requirement for essential services England, Wales, Northern Ireland, Scotland England – many PMS practices have converted to GMS following the recent drive for equitable funding England, Northern Ireland, Wales Nationally negotiated between the BMA and the DoH Scotland – equivalent Section 17c practices GMS contract Essential Services Additional Services Directed Enhanced Services (DES) Core requirements Normally provided Practices can choose by all providers, but whether or not to practices can opt out provide Geographical/population area covered Requirement to maintain a list of patients for the area, who the list covers and what circumstances a patient might be removed the essential services provided standards for premises and workforce and requirements for inspection and oversight expectations for public and patient involvement key policies including indemnity, complaints, liability, insurance, clinical governance, termination of contract Direct consultation and examination Examples include: Examples include: Further investigations & specialist referral Coordination of care Cervical screening, contraceptive services Vaccinations, immunisations Child health surveillance, maternity Extended hours schemes Violent patients schemes Learning disability National Health Service (General Medical Services Contracts) Regulations 2004. INCOME Income is derived on the basis of: Global sum The Global sum is calculated based on the workload from each of the practice’s patients. This takes into account gender, age, levels of morbidity and mortality in the local area, number of registered patients in nursing and residential homes, patient list turnover and local market effects. The Carr-Hill formula is used. The Global sum amount is reviewed quarterly to account for changes in the practice’s patient population. The global sum accounts for around 50% of the money received. Quality and Outcomes Framework (QOF) performance Accounts for around 10% of the practice's income This is a voluntary annual reward and incentive programme for GP practices The Department of Health decides on indicators on an annual basis and awards points based upon performance against these indicators Indicators typically cover: chronic conditions (e.g. asthma and diabetes) public health concerns e.g. smoking and obesity preventative services e.g. screening and blood pressure checks At the end of each financial year, the practice receives an amount of money, based on points achieved in the QOF. Enhanced services These are provided optionally by practices. There are two types: Directed Enhanced Services (DESs) which are commissioned according to national specification and price. These include flu and childhood immunisations Local Enhanced Services (LESs). These are primary medical services other than core services, which are designed around the needs of the local population e.g. extended hours opening, provision of an anticoagulation service, insertion of contraceptive devices etc. Seniority payments Based upon the GP’s number of years of reckonable service to the NHS. Premises (e.g. payment in kind rate rebates) Information technology Dispensing payments (applicable to dispensing GP Practices) GPs – Independent Contractors GPs have worked as independent contractors under the terms of a national contract since the inception of the NHS. GP partners, as owners of their practice, share practice profits with other partners. Increasingly practices rely on salaried GPs. These GPs are essentially employees and as such, do not have rights to practice profits. The core contract is developed through negotiation between the government and the BMA.The biggest change to the contract was implemented in 2004 with the introduction of the Quality of Outcome Framework (QoF) and the ability to opt out of provision of Out of Hours Services. SCOTLAND An historic new contract has been negotiated in Scotland and comes into effect from April 2018. Key elements include: The GP as the expert medical generalist with extended multidisciplinary teams Reduced administrative burdens Leading on complex care in the community e.g. frailty One session per month protected time ‘professional time activities’ Minimum earnings expectation for GP partners from 2019 of £80,430 NHS income Phase 2, which is still under negotiation between GPC Scotland and the Scottish government involves introducing a standard income range with pay progression for GPs (which is comparable to that of consultants) and direct reimbursement of practice expenses, covering staff and premises costs GP Practice Forward View 2016 [https://www.england.nhs.uk/wpcontent/uploads/2016/04/gpfv.pdf] sets out NHSE’s response to pressures facing general practice in England. It is split into 5 key areas: 1. Investment 2. Workforce 3. Workload 4. Care redesign 5. Infrastructure Animation: https://www.youtube.com/watch?v=bMDTp23vy3c Primary Care Networks (PCNs) These formed a key component of the NHS Long Term Plan and the new Five-Year Framework for the GP contract, published in January 2019. There are 1,250 PCNs based on GP registered patient lists, typically serving communities of between 30,000 – 50,000 people. PCNs are led by Clinical Directors. GP practices sign up to the Network Contract DES, which details the core requirements and entitlements, providing significant extra funding. Most networks are geographically based and, between them, cover all practices within a CCG boundary. Some networks cross CCG boundaries. PCNs will eventually be required to deliver a set of 7 national service specifications. Three started in 2020/21: Structured medication reviews Enhanced health in care homes Supporting early cancer diagnosis The expectation is that PCNs will provide a wider range of primary care services to patients, involving a wider set of staff roles that might be feasible in individual practices e.g. clinical pharmacists, social prescribing link workers, nursing associates and physiotherapists. They will also form the footprint around which integrated community-based teams will develop. Community and mental health services will be expected to configure their services around PCN boundaries. PCNs will have a role in delivering on improvements on wider population health. LMC Local Medical Committees have statutory duties and were set up in 1912 to represent the local ‘panel’ doctors paid by the state to provide a range of medical services to the population under the National Health Insurance Act of 1911. When the NHS was established in 1948, LMCs were recognised as the representative voice of GPs. The Health and Social Care Act reinforces the requirement for NHS Bodies to consult on the LMC on issues that affect General Practice. They are local representative committees of NHS GPs and represent their interests in the locality. They work with the General Practitioner Committee (GPC).In addition they assist individual GPs with advice regarding: Remuneration Terms and conditions Complaints Employment issues Partnerships Premises Each area has a constitution which defines the geography covered and the constituencies that exist within those boundaries. Elections are held on a two yearly basis for GPs to represent their peers on the committee. Tenure lasts for four years. The committee, once elected, elects a chair and vice-chair(s). PERFORMERS LIST As part of the post-Shipman reforms, the Performers List was introduced to ensure that performers are fit for purpose and suitable to undertake NHS primary care services. Since 2006, in general, doctors may not undertake any NHS primary medical services unless they are general medical practitioners included on the GP register and their name is included in a Performers List. The Performers List provides an extra layer of reassurance for the public that, GPs practising in the NHS, are suitably qualified, have up to date training, appropriate English language skills and have passed criminal record checks and fraud checks. There are National Medical Performers Lists in Northern Ireland, England and Wales. Applications can be made online. In Scotland, the Performers Lists are managed by the individual Health Boards. In general the following information is required as part of the application: GMC registration Evidence of Certificate of Completed Training (CCT) Evidence of GMC GP register inclusion CV 2 references Photographic identification Enhanced Criminal Record check Disclosure & Barring Service check (DBS) England & Wales Disclosure Scotland - Scotland AccessNI – Northern Ireland Proof of Hepatitis B vaccination NHS Counter Fraud Authority checks will also be undertaken. Applicants make undertakings including: To notify the Primary Care Organisation (PCO) within 28 days if their details change To comply with the PCO’s appraisal requirements To notify within 7 days of conviction for criminal offences or investigation by a regulatory body Grounds for removal include: Mandatory Discretionary Conviction of murder Prejudices the efficiency (issues of competence and quality of person) Conviction of a criminal offence with sentence of 6 months or more Involved in a fraud case in relation to any health scheme National disqualification Unsuitable to be included (could be consequence of decision taken by court, professional body, contents of a reference etc). Died Cannot demonstrate that they have performed primary medical services within the area of the PCO for the previous 12 months No longer member of relevant healthcare profession If a Primary Care Organisation (PCO) is considering removing a performer, they must give: Notice of any allegations against them Notice of what action is being considered and on what grounds The opportunity to make written representations within 28 days The opportunity to put their case to an oral hearing within 28 days Appeals can be made: Scotland Removal – to Scottish Ministers Refusal to include – to Scottish Ministers, but only on a point of law England & Wales First Tier Tribunal Northern Ireland The Department of Health RELEVANT REGULATIONS England – National Performers List The National Health Service (Performers Lists) (England) Regulations 2013 http://www.legislation.gov.uk/uksi/2013/335/contents/made Administered Provides the regulatory framework for managing medical, dental and ophthalmic performers who perform primary by Primary Care Support care services. England (PCSE), which is part of Capita plc Northern Ireland – Northern Ireland Primary Medical Performers The Health and Personal Social Services (Primary Medical Services Performers Lists) Regulations (Northern Ireland) 2004 (Statutory Rule 2004 No. 149) List (PMPL), administered by the Business Services Organisation (BSO) Wales – Wales Medical Performers List, administered by Primary Care Services NHS (Performers List)(Wales) Regulations 2004 http://www.legislation.gov.uk/wsi/2004/1020/contents/made Scotland – The National Health Service (Primary Medical Services Performers Performers Lists) (Scotland) Regulations 2004 List, administered https://www.legislation.gov.uk/ssi/2004/114/contents/made by Primary Care Support Services Disciplinary process England More info is available at: https://www.england.nhs.uk/wpcontent/uploads/2017/04/framework-for-managing-performer-concernsv2.pdf This outlines: The process for considering applications and decision making for inclusion, inclusion with conditions and refusal to include on the Performers List. The process by which NHS England teams identify, manage and support primary care performers when concerns arise The application of NHS England’s powers to manage suspension, imposition of conditions and removal from the performers’s list. When a concern arises, the disciplinary process considers “fitness for purpose”. Performance Advisory Group (PAG) consider concerns about a named individual included on the Performers List and determines the most appropriate action. Potential options include: Instruct an investigation Agree voluntary undertakings with a performer where low levels concerns have been identified Refer to PLD PAG membership includes: Chair: a senior NHS manager with a performance role A discipline specific practitioner nominated by the medical director A senior manager with experience in primary care contraction and/or patient safety and experience A lay member Performers List Decision Panels (PLDPs) – the primary role is to make decisions under the Performers List Regulations. PLDP membership includes: Chair – lay member A discipline specific practitioner A senior NHS England manager/director with responsibility for patient safety and experience The medical director for the NHS England team or their nominated deputy. If immediate suspension is required under Regulation 12(6) a decision may be taken by the medical director and one other director, however this decision must then be reviewed by two members of the PLDP within two working days. Subsequently, the case must be reviewed by PLDP. Definitions a. Indemnity – works on the basis that the claim is covered as long as the cover was in place when the incident occurred, rather than when the claim is made. b. Insurance – only provides cover for claims arising during the period of cover. It is necessary to purchase additional “run off” cover. Good Medical Practice, para 63, requires doctors to have adequate insurance or indemnity cover in place where necessary. The GMC now has statutory powers to check registrant’s indemnity/insurance status and to remove or refuse a licence to practise.