Health Commissioning Toolkit: a Resource for Local Advice Organisations September 2015

Health Commissioning Toolkit: A resource for local advice organisations September 2015

How do I find what I need to know?

How is commissioning organised in the NHS? Page 5

Clinical Commissioning Groups Healthwatch Health and Wellbeing Boards Public Health

What are the key steps in the commissioning process? Page 10

Commissioning cycle Procurement Market development Lead provider model

What are the key national health outcomes? Page 17

NHS England's Five Year Forward View NHS Outcomes Framework Public Health England's Five Year Strategy Public Health Outcomes Framework

How are local health needs identified? Page 21

Public health profiles Wider social determinants of health Joint Strategic Needs Assessment Commissioning intentions

How do I get involved and respond to opportunities? Page 23

Initial engagement with commissioners Service redesign workshops Supporting the health needs assessment Presenting a business case

Are there any examples I can use to engage my commissiioners? Page 29

NHS South Tees CCG The Bromley by Bow Centre NHS Newcastle Gateshead CCG NHS Liverpool CCCG Wirral CAB Middlesbrough CAB

What other resources are available to help me? Page 32 Policy documents Research on the impact of advice Commissioning guidance

Glossary

Clinical Commissioning Groups (CCGs)‐ Clinical commissioning groups are NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England. CCGs are clinically led groups that include all of the GP groups in their geographical area. The aim of this is to give GPs and other clinicians the power to influence commissioning decisions for their patients. CCGs are overseen by NHS England (including its Regional Offices and Area Teams). A directory of CCGs can be accessed at http://www.england.nhs.uk/resources/ccg‐directory/.

Commissioning Intentions‐ Commissioning intentions indicate to current and potential new providers how a commissioning organisation intends to shape the healthcare system that serves their local population. They demonstrate how the commissioning organisation will respond to health needs, local clinical priorities and the national priorities for the NHS outlined by NHS England. Commissioning organisations can invite a wide range of organisations to respond to published commissioning intentions to help the organisation delivery its strategic aims.

Healthwatch‐ Healthwatch is the independent consumer champion in health and care, working to gather and represent the views of people who use health and care services. The Healthwatch network is made of up of local Healthwatch across each of the 152 local authority areas, and, at a national level, Healthwatch England. Nationally, Healthwatch England uses the knowledge gathered by local Healthwatch to build a picture of health and care and identify patterns and any potential emerging issues. Locally, Healthwatch voices people’s concerns and provides feedback to service providers and commissioners.

Health & Wellbeing Boards (HWB)‐ The Health and Social care Act 2012 established health and wellbeing boards as a forum where key leaders from the health and care system work together to improve the health and wellbeing of their local population and reduce health inequalities. Each top tier and unitary authority will have its own health and wellbeing board. Board members will collaborate to understand their local community’s needs, agree priorities and encourage commissioners to work in a more joined up way.

Boards will bring together clinical commissioning groups and councils to develop a shared understanding of the health and wellbeing needs of the community. They will undertake the Joint Strategic Needs Assessment (JSNA) and develop a joint strategy for how these needs can be best addressed. This will include recommendations for joint commissioning and integrating services across health and care. Through undertaking the JSNA, the board will drive local commissioning of health care, social care and public health and create a more effective and responsive local health and care system. Other services that impact on health and wellbeing such as housing and education provision will also be addressed.

Local communities and partners can hold health and wellbeing boards to account in a number of ways. Statutory membership of elected members and local Healthwatch will be important in ensuring that the voice of local communities are heard and taken into account within JSNAs and JHWSs. Health and wellbeing boards will also be subject to scrutiny by the local authority. Kings Fund Health and Wellbeing Board Directory.

Joint Strategic Needs Assessment (JSNA)‐ A Joint Strategic Needs Assessment looks at the current and future health and care needs of local populations to inform and guide the planning and commissioning (buying) of health, well‐being and social care services within a local authority area. Each HWB is required to design a Joint Health and Wellbeing Strategy (JHWS), underpinned by a Joint Strategic Needs Assessment (JSNA).

The JSNA assesses the current and future health needs of local populations to inform and guide the commissioning of health services within a local authority area. The JHWS outlines priorities and issues that matter most to the local population. The JSNAs and JHWSs form the basis of commissioning plans by determining the actions that commissioners need to take to meet current and future health needs locally.

NHS Commissioning Support Units‐ Commissioning support units are set to take on important functions in the new NHS structure. They support clinical commissioning groups by providing business intelligence, health and clinical procurement services, as well as back‐office administrative functions, including contract management. Further information can be accessed at http://www.england.nhs.uk/commissioning/comm‐supp/csu/.

NHS England‐ NHS England is an executive non‐departmental public body of the Department of Health. NHS England oversees the budget, planning, delivery and day‐to‐day operation of the commissioning side of the NHS in England as set out in the Health and Social Care Act 2012. NHS England is a clinically led organisation. It has a budget of just over £95 billion. Within this overall funding, it allocates over £65 billion to CCGs and local authorities, which commission services locally for patients. The remainder is allocated to direct commissioning activities and to operational costs.

NHS Outcomes Framework‐ The NHS Outcomes Framework, alongside the Adult Social Care and Public Health outcomes frameworks, sits at the heart of the health and care system. The NHS Outcomes Framework: provides a national overview of how well the NHS is performing; is the primary accountability mechanism, in conjunction with the Mandate, between the Secretary of State for Health and NHS England; and drives up quality throughout the NHS by encouraging a change in culture and behaviour focused on health outcomes not process.

Public Health England (PHE)‐ Public Health England is an executive agency of the Department of Health in the United Kingdom that began operating on 1 April 2013. Its formation came as a result of reorganisation of the National Health Service (NHS) in England outlined in the Health and Social Care Act 2012. It took on the role of the Health Protection Agency, the National Treatment Agency for Substance Misuse and a number of other health bodies. PHE's mission is to protect and improve the nation’s health and to address inequalities.

Public Health Outcomes Framework‐ The Public Health Outcomes Framework for England, 2013‐ 2016 was published in January 2012 and sets the context and ‘strategic direction’ for the new public health system with the vision of ‘improving and protecting the nation’s health while improving the health of the poorest fastest’.

QIPP‐ The Quality, Innovation, Productivity and Prevention (QIPP) programme. A programme developed by the Department of Health to drive forward quality improvements in NHS care

Social Prescribing‐ Social prescribing is a structured way of linking patients with non‐medical sources of support within a community. These opportunities may include opportunities for arts, creativity, physical activity, learning new skills, volunteering, mutual aid, befriending and self‐help, as well as support with, for example, employment, benefits, housing, debt, legal advice, or parenting problems.

Voluntary and Community Sector‐ Voluntary and community sector (VCS) organisations have a vital role in addressing health and social care needs of communities. The VCS can represent the voice of the communities it serves, often marginalised, harder to hear views and experiences. You can access details of the membership of the National Association for Voluntary and Community Action (NAVCA) using the following link.

Introduction and Context

This toolkit is primarily aimed at local advice organisations who wish to achieve a greater understanding of strategic commissioning within the NHS, the opportunities and challenges, and some tools to operate more effectively in the context of modern public service delivery. It provides an overview of the commissioning landscape at both national and local levels, guidance on how to learn more about local commissioning priorities and top tips on ways in which you can engage in the commissioning process. The toolkit is split into the following sections:

1. The commissioning landscape 2. Understanding the commissioning cycle 3. Local health needs and commissioning priorities 4. Responding to opportunities 5. Advice sector commissioning examples 6. Sources of further information and resources

The annexes provide additional checklists and resources. How to use the toolkit

This toolkit aims to provide you with a simple overview of commissioning and some ideas to support you to engage in the commissioning process. The toolkit incorporates links to other sources of information or guidance that will prove helpful in navigating and understanding the commissioning landscape. However the most important message is for you to be proactive and engage in conversations with local commissioners in order to explore opportunities to work in partnership for the benefit of the communities you are supporting.

For local advice organisations that are new to commissioning NAVCA has produced a helpful Beginners Guide to Commissioning and the Advice Services Alliance has produced A Strategic and Tactical Guide for advice agencies.

The context

During the last few years the roles and functions of public bodies have been changing. Increasingly, instead of providing many services directly, public bodies are now looking to external organisations and companies to provide services on their behalf. Public bodies have been moving in the direction of becoming purchasers, rather than direct providers of services, for a number of years. Commissioning involves making decisions about whether to commission, what to commission and from whom, so enabling priorities and strategies to be translated into services delivered by different organisations and companies. Commissioning is therefore not just a set of technical exercises to purchase services, but is also profoundly shaped by the political environment and priorities of a local area.

The challenge for local advice organisations is to understand the new structures and locality led commissioning approaches in the NHS in England. The four key structures at a locality level are Clinical Commissioning Groups, Health and Wellbeing Boards, Public Health teams and Healthwatch. This toolkit provides further information on these three structures and outlines their role and relevance for local commissioning.

The Commissioning Landscape

Since the introduction of the Health and Social Care Act 2012, the NHS has undergone a significant restructure including the abolition the 10 Strategic Health Authorities at regional level and the 151 Primary Care Trusts at local level. In their place are now Clinical Commissioning Groups (CCGs) which make commissioning decisions in health for the local population, and a national commissioning board, NHS England, which commissions GPs, oversees the CCGs and commissions some low volume services‐ specialised commissioning. The following diagram provided by the Nuffield Trust (2013) outlines the new structure of the NHS in England.

The principle behind these changes is to ensure clinical expertise lies at the heart of the commissioning process and to place decision making as close to patients as possible. Regulation and accountability within the new NHS structure is outlined below.

Clinical Commissioning Groups Across England there are currently 211 CCGs. Many do not follow the local authority boundaries, so knowing who to influence can be a challenge. Further information on the location of all CCGs can be found using the CCG map created by NHS England. All GP practices within a geographical area are part of the CCG for that locality. Each CCG has a governing board which must include:

• GPs • registered nurse (from non‐commissioned service) • doctor who is a secondary care specialist (from non‐commissioned service) • lay member to champion patient and public involvement • lay member to oversee governance, including audit, remuneration and managing conflicts of interest

It should be noted that CCGs are developing locally to suit local needs and priorities. There are therefore differences in commissioning approaches in different parts of the county and in some cases in neighbouring CCGs. This may present some challenges to local advice organisations covering more than one CCG. Contact details for all CCGs can be accessed using the following link. When making contact with new commissioners you should be aware that they may not know about your work and how you support (or could support) the delivery of better health outcomes for your services users / the local community.

CCGs are also statutory members of their Health and Wellbeing Boards and are required to use the Joint Strategic Needs Assessment (JSNA) and joint Health and Wellbeing Strategy (HWS) developed with the Health and Wellbeing Boards when drawing up their commissioning plans.

Health and Wellbeing Boards The Health and Social Care Act 2012 established Health and Wellbeing Boards for each top tier and unitary authority as a forum where key leaders from the health and care system work together to improve the health and wellbeing of their local population and reduce health inequalities. Board members will collaborate to understand their local community’s needs, agree priorities and encourage commissioners to work in a more joined up way.

Health and Wellbeing Boards bring together CCGs and councils to develop a shared understanding of the health and wellbeing needs of the community. Each is required to design a joint Health and Wellbeing Strategy, underpinned by a Joint Strategic Needs Assessment. The JSNA assesses the current and future health needs of local populations to inform and guide the commissioning of health services within a local authority area. The HWS outlines priorities and issues that matter most to the local population. The JSNAs and HWSs form the basis of commissioning plans by determining the actions that commissioners need to take to meet current and future health needs locally. Other services that impact on health and wellbeing, which may include housing and advice needs, can also be addressed as part of the strategy.

Local communities and partners, including advice organisations, can influence health and wellbeing in a number of ways including through the local Healthwatch and also hold them to account as part of local authority scrutiny panels. Details of local Health and Wellbeing Boards can be accessed using the Kings Fund Health and Wellbeing Board Directory.

Healthwatch Healthwatch is the independent consumer champion in health and care, working to gather and represent the views of people who use health and care services. The Healthwatch network is made of up of local Healthwatch across each of the 152 local authority areas, and, at a national level, Healthwatch England. Nationally, Healthwatch England uses the knowledge gathered by local Healthwatch to build a picture of health and care and identify patterns and any potential emerging issues.

Locally, Healthwatch voices people’s concerns and provides feedback to service providers and commissioners. They are statutory members of Health and Wellbeing Boards. Local advice organisations can play an important role in contributing to the design and delivery of services that aim to reduce health inequalities. Establishing links with your local Healthwatch can help you to represent the voice of your service users, including those that are often marginalised. Collectively this can provide a stronger voice when engaging commissioners in particular to raise the profile of local advice services contribution to stronger health and care outcomes and identifying causes for concern such as, for example, the impact of welfare reform on the health and wellbeing of the local population. Additionally individual GP practices will have patient representative groups. These often feed in to local Healthwatch intelligence. You can find details of your local Healthwatch using the following link.

Public Health In April 2013, most public health duties at a local level transferred to local government. This was based on the rationale that local authorities have direct contact with many of their residents on a day to day basis and are able to take a population approach which is essential for public health. Local authorities are also well placed to try new ways to tackle public health problems and address health inequalities as many of the social determinants of health fall within their remit.

As the expert national public health agency, Public Health England has a statutory duty to promote health and wellbeing, protect health and address inequalities. Priorities for the next 5 years have been set out by PHE and can be accessed on their publication From evidence into action: opportunities to protect and improve the nation’s health.

Local authorities are now at the heart of the new public health system, backed by a ring‐fenced grant and a specialist public health team, led by a Director of Public Health. They are expected to:

• embed health in all policies, to make 'reducing health inequalities' a major priority; • ensure resources are targeted at those in greatest need and represent best value for local people; • focus on preventing ill health and improving 'wellbeing'; • work closely with the NHS;

• work with other partners through the local health and wellbeing board, prioritising needs, creating a joint strategic needs assessment, which summarises the main health priorities in a local area; • use the joint strategic needs assessment process to commission safe and quality services; and • measure the impact of public health work in meeting the needs of vulnerable and disadvantaged groups, to ensure that the poorest health is improved fastest

In commissioning services, local authorities are encouraged to adopt a diverse provider model, based on their experience of commissioning with a range of providers. In theory, this should help you to engage public health commissioners to co‐design and develop innovative and preventative work which can contribute to meeting the objectives outlined in the Health and Wellbeing Strategy. Contact details for Directors of Public Health can be accessed using the following link.

The next section of this toolkit looks at the commissioning cycle and how this can provide opportunities for local advice organisations to engage commissioners and potentially co‐design services with health partners.

Understanding the Commissioning Cycle

Commissioning is the process of deciding what public services are needed and their priority, what resources to allocate to provide these services and why, how and where. It can be a complex process, involving the assessment and understanding of a population’s health needs, the planning of services to meet those needs and securing services on a limited budget, then monitoring the services procured. Commissioning is commonly described as the whole cycle of identifying and delivering services. The diagram below outlines the key stages of a commissioning cycle. For further details see NAPCs essential guide to GP commissioning.

The above simplified model includes several sub‐stages, each of which will require capabilities and expertise. These may be available in‐house within the CCG or local authority or shared across consortia or outsourced to an expert provider of commissioning services. The eight principles of good commissioning are provided in Annex 1.

Market development Given the increasing emphasis on prevention, self‐care and better management of long‐term conditions commissioners are likely to need to engage and develop a wider pool of potential providers that can help to design new approaches to address identified local health priorities. Market development describes the process by which commissioners aim to expand the number of providers available to deliver services. Market development activities may include direct grant funding, or funding infrastructure, networks and training for potential providers to develop.

It is important for you to ensure that commissioners are both aware of your services but also understand what support and/or workforce development may be required to enable you to engage effectively in a commissioning cycle and deliver new services.

Procurement Procurement is one part of the commissioning process. It is about purchasing the service the public body has decided to buy and giving a contract to the organisation that provides the service. Because of the legal rules that govern this process, it usually involves competitive tendering. There is no single way of doing this, but the diagram below shows the main stages you can expect:

You should also note that CCGs do still have the power to award grants to community and voluntary organisations, rather than always going through competitive tendering processes and/or requiring formal contracts for services to be put in place.

If the value of a commissioning support contract exceeds the OJEU threshold buyers, in this case the CCG or public health team, have two high level options, namely to go to full tender in accordance with Public Contract Regulations which can take 7‐12 months for a complex procurement, or approach pre‐qualified suppliers on a framework agreement which is typically a much quicker process, taking around 3 months. You will need to familiarise yourself with the procurement models that your local commissioners are using.

Lead Provider Commissioners may seek to simplify their procurement process by commissioning a lead provider to deliver specific services, for example community mental health services or social prescribing programmes. It may be more attractive and cost‐effective for commissioners for a consortium of local advice agencies to come together to delivery services on a commissioned basis. You may wish to engage other local advice organisations to explore the possibility of developing a partnership to facilitate discussions with commissioners and identify opportunities for strategic collaboration.

In addition there are many large healthcare providers that are likely to be competing to deliver services on a commissioned basis from CCGs and public health teams. Consequently you should also consider approaching these providers to explore opportunities to collaborate. In some areas commissioners may actively seek to bring together providers from a range of sectors in order to facilitate collaboration and the development of service delivery partnerships.

Clinical Programme Approach

Within the context of local health services focusing on treating patients the commissioning cycle will involve a range of activities within each stage. The following diagram provides an overview of a clinical programme approach to commissioning.

Key messages for local advice organisations include:

• There is a focus on the whole population not just people currently receiving treatment within the NHS. Consequently organisations that can evidence their role in preventing or delaying people requiring treatment should engage commissioners in the planning and design phase.

• Commissioners are interesting in exploring innovative approaches to meet local health priorities. This can open the door to working with local advice services.

• In the design of programmes there is a degree of flexibility in exploring what measurement systems should be put in place to evidence the performance of a commissioned service. This may require advice organisations putting in place data collection systems to collect evidence over and above what are available using existing systems (e.g. Charitylog or Petra).

Top Tips:

• Be proactive and seek out opportunities to participate in market development activities hosted by commissioners. Your local voluntary sector infrastructure organisation may be a useful place to start.

• Determine if and how you want to be involved in the commissioning process. Your role may simply be to provide information and intelligence on local health priorities or gaps in services rather than seeking to deliver services. You may also decide that pursuing opportunities through Trusts and Foundations is a better route for your organisation.

• Speak to commissioners about the procurement process and what is required to establish you as a potential provider. Be aware that this process may require you to provide a fair amount of legal, financial and organisational information. Your local voluntary sector infrastructure organisation may be able to provide support to navigate the procurement systems.

• Explore the possibility of developing a partnership of local advice organisations to facilitate discussions with commissioners and identify opportunities for strategic collaboration in response to commissioning opportunities.

Local Health Needs and Commissioning Priorities

One of the key messages for local advice organisations is the importance off making a clear and crediblee link between the positive outcomes delivered through quality advicce services and their contribution to local health priorities. This may sound like a daunting task but in essence it means simply thinking about which of the outcomes and indicators that the NHS uses to measure performance you can focus on in your discussions with commissioners.

The examples of advice organisations and services that have been commissioneed to support health outcomes provided in this toolkit can give you some ideas on how to demonstrate your contribution using the language that commissioners will understand. A blog written by the Head of Strategy and Outcomes at Liverpool CCG about Liverpool Advice on Prescription project also provides a useful commissioner perspective.

It may be helpful for you to think about the following steps. These don’t have to be undertaken in isolation and you may find it useful to collaborate with other advice organisations. You should also identify opportunities to involve commissioners in the process of developing your business case.

STEP 1 Local Health Priorities: Familiarise yourself with the health priorities in your area. This should include the language used iin NHS Outcomes Framework so you can be specificc and reference health indicators and measures that commissioners understand.

STEP 2 The Contribution of Advice: Once you have identified the key local health priorities use existing research and evidence to establish a plausible link between advice services and health outcomes.

STEP 3 Local Advice Services: Advice services differ from area to area. Speak with commissioners to discuss whatt advice services are currently provided but also whaat could be developed with investment to meet local health needs.

STEP 4 Developing a Business Case Focusing on the outcomes to which advice services can make the strongest contribution and drawing on existing research or commissioning examples, produce an outline business case which demonstrates to commissioners how advice organisations can respond to local health priorities.

National Outcomes NHS England’s Five Year Forward View sets out a clear direction for the NHS, demonstrating why change in needed and what it will look like. Whilst the document outlines the dramatic improvements within the NHS over the last fifteen years, it acknowledges that quality of care can be variable, preventable illness is widespread and health inequalities deep‐rooted. The Forward View states that although some of what is needed can be brought about by the NHS itself, other actions require new partnerships with local communities and local authorities and employers.

One of the key arguments outlined in the Forward View is that the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health. This shift in focus provides an opportunity for local advice organisations to engage commissioners to highlight the contribution that advice services can provide in improving public health outcomes and tackling health inequalities. This is important context for you to make reference to in your discussions with local commissioners.

Public Health England’s five‐year strategy also highlights a need for a fundamentally new approach to creating and sustaining health, mental and physical, at every stage of life. The strategy identifies that whilst individuals’ behaviour impact on health, it is also impacted by a range of wider determinants including:

• good employment; • higher educational attainment; • safe, supported, connected communities; • poor housing and homelessness; • living on a low income; • social isolation, exclusion and loneliness; and • stigma and discrimination

Improving health and closing the gap between those with the most and those with the least requires action across all of these. The strategy also emphasises a need to recognise the link between mental illness and physical health. In this context commissioners are increasingly seeing benefits from working with providers outside of the immediate health community. Advice organisations have a strong track record of demonstrating their contribution to tackling these wider determinants of health and so you may wish to reference this strategy in developing your business case to local commissioners.

A report of the inquiry on health equity for the north of England, Due North, was commissioned to explore fresh insights into policy and actions to tackle health inequalities, in particular in the context of the new public health responsibilities locally and nationally. The report suggests that CCGs and other NHS agencies should work together to encourage the provision of services in primary care to reduce poverty among people with chronic illness, including, for example, debt and housing advice and support to access to disability‐related benefits. This report, and others outlined in this toolkit, may help local advice organisations to start a conversation with commissioners on the role of the advice sector in supporting better health outcomes.

When engaging commissioners it is important for local advice organisations to understand and where necessary make reference to the key outcomes that commissioners are working towards (for example tackling fuel poverty with associated winter deaths, increased attendance at general practice and admissions to hospital or alleviating anxiety and stress by addressing an individual’s debt concerns). Establishing a visible link between advice services and health outcomes will help commissioners to more clearly understand the relevance and potential of the advice sector to contribute toward the achievement of local health priorities.

National Outcomes Framework The NHS Outcomes Framework provides an overview of how well the NHS is performing and encourages a change in culture and behaviour focused on health outcomes not process. It includes a set of 68 indicators which measure performance in the health and care system at a national‐level. It is not intended to be an exhaustive list of health indicators. Rather, it has been designed to be a set of outcomes that together form an overarching picture of the current state of health and care services in England. Indicators in the NHS Outcomes Framework are grouped into five domains:

NHS England has also developed the Clinical Commissioning Group Outcomes Indicator Set (CCG OIS) to support the NHS Outcomes Framework. The CCG Outcomes Indicator Set comprises NHS Outcomes Framework indicators that can be measured at CCG level. These provide clear, comparative information to support CCGs, and Health and Wellbeing Boards identify local priorities and demonstrate progress on improving outcomes, as well as delivering public transparency about local health services.

A separate but linked Public Health Outcomes Framework provides an overarching vision for public health, key outcomes to be achieved and indicators that will help to measure progress in improving and protecting health. The framework is focused on the two high‐level outcomes, namely:

1. Increased healthy life expectancy; 2. Reduced differences in life expectancy and healthy life expectancy between communities

Public health indicators are grouped into four domains:

When engaging local commissioners advice organisations should, where appropriate, make reference to the contribution of advice services to relevant indicators included within either in the NHS Outcomes Framework, the CCG OIS or the Public Health Outcomes Framework. Example indicators that local advice organisations may be able to demonstrate the strongest contribution toward by drawing on existing research include:

NHS Outcomes Framework

Domain 2‐ Enhancing quality of life for people with long‐term conditions Objective‐ Ensuring people feel supported to manage their condition Indicator‐ Proportion of people feeling supported to manage their condition Objective‐ Enhancing quality of life for carers Indicator‐ Health‐related quality of life for carers Objective‐ Improving quality of life for people with multiple long‐term conditions Indicator‐ Health‐related quality of life for people with three or more long‐term conditions Domain 3‐ Helping people to recover from episodes of ill health or following injury Objective‐ Helping older people to recover their independence after illness or injury Indicator‐ Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation service

PHE Outcomes Framework

Domain 1‐ Improvements against wider factors that affect health and wellbeing and health inequalities Indicators‐ Children in poverty, Adults with a learning disability / in contact with secondary mental health services who live in stable and appropriate accommodation, Sickness absence rate, Statutory homelessness, Fuel poverty and Social isolation Domain 4‐ Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities Indicators‐ Health‐related quality of life for older people

CCG Outcomes Indicator Set 2015/16

Local Health Needs

Within the NHS there has been a clear shift to move resources towards prevention and self‐care and better management of long‐term conditions, including mental health. To assist local authorities in developing their Health and Wellbeing Strategy, Public Health England annually produce health profiles which provide a snapshot overview of health for each local authority in England. These profiles present a set of health indicators that show how the area compares to the national average.

Health and Wellbeing Boards have a statutory duty to undertake a Joint Strategic Needs Assessment to underpin and inform their joint Health and Wellbeing Strategy. The JSNA assesses the current and future health needs of local populations to inform and guide the commissioning of health services within a local authority area. The joint Health and Wellbeing Strategy outlines priorities and issues that matter most to the local population and forms the basis of commissioning plans by determining the actions that commissioners need to take to meet current and future health needs locally.

They are not an end in themselves, but a continuous process of strategic assessment and planning. They help determine what actions local authorities, the NHS and other partners need to take to meet health and social care needs and to address the wider determinants that impact on health and wellbeing. JSNAs should look at the wider determinants of health and wellbeing for the whole community, including marginalised groups and people of different ages. They can also look at wider economic, social and environmental factors. JSNAs should also set out where there are inequalities in outcomes and access to services as well as identify the causes of inequalities.

Regional Voices has produced useful guidance for the voluntary and community sector on influencing local commissioning for health and care. Their guidance provides a number of ideas that are relevant for local advice organisations seeking to input into the JSNA process:

• Look up the JSNA and what is currently happening with it on your council’s website. They may be refreshing the whole document or perhaps looking at certain themes. • Consider how you could contribute to the JSNA. Looking up existing case studies of how the VCS has previously inputted into JSNAs could help your planning. • Plan who you are best talking to about your issues to get them heard. It could be a combination of the JSNA lead at the local authority, a councillor or commissioner on the health and wellbeing board, a Healthwatch representative, someone from your CCG, your council for voluntary services and/or any voluntary sector representatives on the board. Looking up existing good practice examples of how to influence health and care commissioners could help.

The Local Government Association has produced a map which highlights the Health and Wellbeing Board priorities across England. Common themes evident across the published strategies include:

• Investing in evidence‐based preventive interventions across the life‐course; • Working through effective partnerships to address the inequalities in health; and • Reflecting the importance of mental health and emotional wellbeing alongside physical health priorities.

Commissioning Intentions Following an assessment of local health needs both CCG and public health commissioners publish high‐level commissioning intentions which outline how they intend to commission services to meet the health priorities identified in the Health and Wellbeing Strategy. Using the following links you can view examples of published commissioning intentions from Sheffield CCG, Luton CCG and Durham Dales, Easington and Sedgefield CCG.

Top Tips:

• Review the outcomes frameworks governing the work of CCGs and public health teams so that you can use language that commissioners understand when discussing advice services.

• Identify key priorities or outcomes included in the Health and Wellbeing Strategy where you feel that your advice service can demonstrate the strongest contribution.

• Spend some time familiarising yourself with existing research and evidence that establishes a link between your advice work and health and wellbeing outcomes.

• Review the commissioning intentions to identify potential opportunities for advice services to support commissioners and use this as the basis for an initial approach.

• Seek out and cultivate champions and advocates for the value of advice to health from amongst influential members of your local health community. This could include influential GPs or the Director of Public Health.

Responding to opportunities

Assessing whether commissioning is for you

Public sector commissioning is not appropriate for every organisation involved in delivering social welfare law advice. Engaging in the commissioning process can provide benefits local advice organisations but may require significant investment of time with no guarantee of success in securing investment. Given the current context of funding cuts and reduced capacity facing many advice services senior managers and board members will need to carefully assess whether it is appropriate to engage in a commissioning process and if so in what role.

The following diagram outlines some key questions that you should consider before seeking to engage in a commissioning process1. While flexibility and working in partnership can help local advice organisations to successfully secure commissioned work, lack of information about opportunities and poor relationships with commissioners may frustrate efforts.

1 Reproduced from NPC (2014)‐ ‘Opportunities for Alignment: Arts and cultural organisations and public sector commissioning’.

Initial engagement

The Commissioning Intentions published by commissioners should outline the commissioning cycle and how providers can engage in the process. However before engaging in the commissioning process and meeting with commissioning it is important that local advice organisations spend time preparing their ideas and/or service offer to ensure that their message is as clear and relevant as possible to meeting local health priorities. To do this local advice organisations should:

• find out CCG priorities to ensure that message can be tailored to them;

• develop a 30 second and 5 minute pitch; and

• summarise key points on 1 side of A4

Forming effective relationships with key stakeholders involved in the commissioning process is increasingly important for voluntary and community organisations. Local advice organisations may consider working in collaboration with other voluntary and community organisations to effectively communicate their understanding of local health issues and outline their contribution to supporting stronger health outcomes.

Local advice organisations can play a key role in supporting CCG and public health commissioners in undertaking an accurate health needs assessment and identifying gaps in existing health and care services. They can:

• provide intelligence about community needs and assets

• input into areas affecting the wider determinants of health

• support engagement between health and wellbeing boards and the community

• assist local Healthwatch input patient, service user and public voice into health and wellbeing board processes

• help marginalised groups input their voice into the development of health and care services

• input into care pathway redesign

• provide high quality and innovative services

• review and challenge commissioning plans

There are several examples of CCGs undertaking reviews of their investment in the voluntary and community sector and delivering workshops to identify priority areas for joint work (see Norwich CCG). These can provide valuable opportunities for local advice organisations to learn more about CCG priorities for improving health and wellbeing and their potential role in designing new services.

Service design

The increased emphasis on improving the wider determinants of health and moving resources towards prevention and better management of long‐term conditions means that CCG and public health commissioners will be exploring new models of service delivery and interventions to improve local health outcomes.

Many CCGs have hosted service redesign workshops to discuss services relating to specific conditions affecting the local population. These can provide local advice organisations with an opportunity to contribute to service development and improvement, in particular through:

• identification of gaps in service provision; • bespoke development of innovative solutions to meet the health needs of people with new developments; and • learning and development support for Commissioning teams on services provided by and support available through local advice organisations

Presenting evidence

As part of the process of engaging commissioners local advice organisations should draw together compelling and relevant evidence of the contribution of advice services on improving health outcomes and supporting local health priorities. Presenting data on the profile of clients groups supported by local advice organisations can help commissioners to recognise the potential for improving health outcomes by working collaboratively with advice services, in particular with regards to tackling the wider determinants of health.

You may wish to develop a strategic outline case or outline business case where the broad rationale for commissioning local advice services support health outcomes is made but the specific details of the service have yet to be worked through. Producing a strategic outline case or outline business case can assist commissioners in obtaining approval from their governing body / board and resources to co‐design a new service in partnership with local advice organisations.

The following resources that can assist local advice organisations in presenting evidence to commissioners:

• Citizens Advice‐ Health and Advice Toolkit • Advice Services Alliance research on The Role of Advice Services in Health Outcomes • Advice UK report‐ The impact of debt advice on health and wellbeing • Citizens Advice report‐ An overview of possible links between advice and health • The Low Commission report‐ Tackling the Advice Deficit

You should recognise that every commissioner is different. Receiving positive feedback from one commissioner, for example in Public Health, does not necessarily mean that the same approach will be successful in making a case to another commissioner, for example within a CCG. Persistence will be important as well as continued dialogue to help commissioners to clearly understand the contribution that advice services can make to meet their strategic priorities.

Organisational information

In line with their published procurement process you may be required to complete a Pre‐ Qualification Questionnaire (PQQ) which ensures that commissioners have the necessary information about your organisation to ensure that you are regarded as a competent provider of services. The following checklist gives you an idea of the type of organisational information that you may be required to provide:

Top Tips2:

1. Understand what the functions of different commissioners are.

2. Know where and when you might be able to speak with them.

3. Make sure VCSs and other key CSO infrastructure bodies know what your key messages are about community needs.

4. Join forces with others, at a locality level, to make more of an impact.

2BIG (2013)‐ ‘How the voluntary sector can influence and get involved in the new health commissioning structures’.

5. Know what you want to say to Commissioners. Practice run using the ‘elevator pitch’.

6. Prepare well before approaching Commissioners according to Commissioner’s specific interests and remit.

7. Make sure your evidence is compelling.

8. Provide evaluated data for Commissioners.

9. Find ways of presenting your project as adding value or making savings.

10. Use case studies to support your key points.

Advice sector commissioning examples

Examples of advice organisations and services that have been commissioned through CCGs are provided below with further information available by clicking through each link. You may find it helpful to reference these in discussion with your local commissioners to demonstrate the collaborative work between health and the advice sector that is already underway in several areas.

NHS South Tees CCG Community Innovations Fund To support the delivery of its vision of 'Improving Health Together' NHS South Tees CCG have established a £200k Community Innovations Fund to enable local groups and organisations to promote health and wellbeing and make a positive difference to the lives of local people.

NHS Newcastle Gateshead CCG Ways to Wellness Project The CCG have partnered with VONNE and ACEVO to develop the Ways to Wellness project that will improve the quality of life of people with long‐term conditions in Newcastle West by giving them access to 'social prescribing'. Social prescribing activities including physical activity, healthy eating/cooking, social interaction, welfare rights advice and support with positive relationships will be delivered by charities and community groups.

Primary Care Advice, Liaison and Advocacy Service ‐ Wirral Citizens Advice Bureaux Wirral Citizens Advice Bureau deliver a generalist advice service for patients referred by their GP with common mental health needs and other long‐term conditions, providing a telephone gateway and appointment booking service for face‐to‐face advice. Clients in need of advocacy services are referred to the Bureau's commissioned partner, Advocacy in Wirral Health. The service has gradually grown to serve all of the 60 plus GPs surgeries and medical centres in the area and is now commissioned by the CCG. It has been recognised as an example of good commissioning by NHS Clinical Commissioners in the ‘Taking the lead' report.

The Bromley by Bow Centre Social Prescriber Project Since the development of the Bromley by Bow Health Centre in 1997, doctors have been referring patients to programmes and projects at the Centre. In recent years the Centre has received funding from the local Clinical Commissioning Group and local GP Network to expand this work and take this model to other GP practices. Since this new phase of the programme began in January 2013 the Centre’s Social Prescriber project has supported local people to access local services and programmes in the borough and in doing so increased their health and well‐being. Social Welfare, Legal Advice and Money Management groups are all incorporated within the Social Prescriber project.

Liverpool CCG Advice on Prescription Project Liverpool Advice on Prescription Programme (APP) an innovative social prescribing service for health professional launched in 2014. In the first six months of going live, this service has worked with health professionals and vulnerable patients across Liverpool via 93 GP practices. The APP team have dealt with 3,057 enquiries, helped patients managed £1.8 million of debt and maximised patient income to the value of nearly £3.5 million. The scheme enjoys the full support of many partner agencies including the Mayor’s office, Public Health Liverpool and a number of patient and service user groups.

Joint Strategic Needs Assessment (JSNA) for Advice‐ Middlesbrough CAB As part of the process of developing an Advice Strategy for the borough, Middlesbrough CAB produced a Joint Strategic Needs Assessment (JSNA) which adopted the same template already established for the JSNA produced by Middlesbrough Council and South Tees CCG. Drawing on key data sets the JSNA for Advice provides an overview of advice needs across the borough identifying unmet needs, gaps in services and at‐risk groups. By aligning the analysis of advice needs using the standard JSNA format the JSNA for Advice provides a valuable tool for local advice organisations to demonstrate the contribution of advice services to addressing the priorities outlined in the Health and Wellbeing Strategy.

Sources of further information and resources

Policy Department of Health (2013)‐ ‘Statutory Guidance on Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies NHS England (2014)‐ ‘Five Year Forward View’. NHS England (2015)‐ ‘Grants for the Voluntary Sector’. Public Health England (2014)‐ ‘From evidence into action: opportunities to protect and improve the nation’s health’. University of Liverpool and CLES (2014)‐ ‘Due North: The report of the Inquiry on Health Equity for the North’.

Commissioning Advice Services Alliance (2014)‐ ‘Commissioning: A strategic and tactical guide for advice agencies’. Age UK (2015)‐ ‘A reference guide to the NHS: England only’. Age UK (2015)‐ ‘A reference guide to the NHS Commissioning responsibilities’.

BIG (2013)‐ ‘How the voluntary sector can influence and get involved in the new health commissioning structures’. Citizens Advice (2014)‐ ‘Health and Advice Toolkit’.

Citizens Advice (2014)‐ ‘Voluntary Sector Evidence and Health Commissioning: Learning from the Example of Citizens Advice’. Webinar 12th June 2014.

Macmillan (2010)‐ ‘Macmillan Cancer Support’s offer to support the development of – Health and social care services for people affected by cancer’.

NAPC (2010)‐ ‘The Essential Guide to GP Commissioning’.

NAVCA (2011)‐ ‘A beginner’s guide to commissioning: A guide for development workers supporting local organisations with commissioning’.

NHS England (2014)‐ ‘Understanding the new NHS’.

Nuffield Trust (2013)‐ ‘The new NHS in England: structure and accountabilities’.

RAISE has created a ‘Healthier Perspective Toolkit’, which aims to ‘encourage collaboration between commissioners of health and social care, voluntary sector providers and voluntary sector support organisations’, which includes a section for VCS support organisations.

Regional Voices (2012)‐ ‘Clinical Commissioning: A Guide for the Community and Voluntary Sector’.

Regional Voices (2013)‐ ‘Influencing Local Commissioning for Health and Care ‐ Guidance for the Voluntary and Community Sector’.

Regional Voices (2013)‐ ‘Public Health: Policy Briefing for the Voluntary Sector’.

Regional Voices (2013)‐ ‘The voluntary sector: a key partner in local Healthwatch: A Guide for local Healthwatch and the voluntary and community sector’. The Manchester Partnership (2010)‐ ‘A guide for commissioning in Manchester with the third sector’.

Research on the impact of advice

Advice Services Alliance (2015)‐ ‘The Role of Advice Services in Health Outcomes: Evidence Review and Mapping Study’.

Citizens Advice (2012) ‘An overview of possible links between advice and health’. Citizens Advice (2015)‐‘ Everything was falling apart – Citizens Advice helped me get back on track: The value of the Citizens Advice service: our impact in 2014/15’.

Citizens Advice (2015)‐ ‘A very general practice: How much time do GPs spend on issues other than health?’

Healthwatch England (2015)‐ ‘Safely home: What happens when people leave hospital and care settings? Healthwatch England. Special inquiry Findings. July 2015

London Health Inequalities Network (2013) ‘Welfare Benefits Advice through General Practices: A Business case’. London Health Inequalities Network.

Low Commission (2015)‐ ‘Getting it Right in Social Welfare Law’.

Marmot, M. (2010)‐ ‘Fair Society, Healthy Lives.’ Strategic Review of Health Inequalities in England post‐2010.

Annex 1‐ The eight principles of good commissioning

Principles

1. Understanding the needs of users and other communities by ensuring that, alongside other consultees, you engage with the third sector organisations, as advocates, to access their specialist knowledge.

2. Consulting potential provider organisations, including those from the third sector and local experts, well in advance of commissioning new services, working with them to set priority outcomes for that service.

3. Putting outcomes for users at the heart of the strategic planning process.

4. Mapping the fullest practical range of providers with a view to understanding the contribution they could make to delivering those outcomes.

5. Considering investing in the capacity of the provider base, particularly those working with hard‐ to‐reach groups.

6. Ensuring contracting processes are transparent and fair, facilitating the involvement of the broadest range of suppliers, including considering sub‐contracting and consortia building, where appropriate.

7. Ensuring long‐term contracts and risk sharing, wherever appropriate, as ways of achieving efficiency and effectiveness.

8. Seeking feedback from service users, communities and providers in order to review the effectiveness of the commissioning process in meeting local needs.