UNDERSTANDING THE NEW NHS A guide for everyone working and training within the NHS 2 Contents 3

NHS ENGLAND INFORMATION READER BOX Introduction 4 Directorate ◆ The NHS belongs to us all Medical Operations Patients and information Nursing Policy Commissioning development Foreword (Sir ) 5 Finance Human resources NHS values 6 Publications Gateway Reference: 01486 ◆ NHS values and the NHS Constitution Document purpose Resources ◆ An overview of the Health and Social Care Act 2012 Document name Understanding The New NHS Structure of the NHS in England 8 Author NHS England ◆ The structure of the NHS in England Publication date 26 June 2014 ◆ Finance in the NHS: your questions answered

Target audience Running the NHS 12 ◆ Commissioning in the NHS Additional circulation Clinicians working and training within the NHS, allied ◆ Delivering NHS services list health professionals, GPs ◆ Health and wellbeing in the NHS

Description An updated guide on the structure and function of Monitoring the NHS 17 the NHS, taking into account the changes of the Health and Social Care Act 2012 ◆ Lessons learned and taking responsibility ◆ Regulation and monitoring in the NHS Action required None

Contact details for Dr Felicity Taylor Working in the NHS 20 further information National Medical Director's Clinical ◆ Better training, better care Fellow, Medical Directorate NHS leadership 21 80 Road SE1 6LH ◆ Leading healthcare excellence

www.england.nhs.uk/nhsguide/ Quality and innovation in the NHS 22 ◆ High-quality care for all Document status This is a controlled document. While this document may be printed, the The NHS in the United Kingdom 24 electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this ◆ The NHS in Scotland, Wales, Northern Ireland document should not be saved onto local or network drives but should always be accessed from the intranet. Glossary 26

Understanding The New NHS 4 Introduction Foreword 5

Clinical was a collaborative process; it was not The NHS belongs to us all professionals the role of one person alone. Change in training are only happens when clinicians, fundamental managers, policy makers, and all This guide is for everyone working and training within the NHS*. Together we to the success sorts of people who are expert in the are the guardians of the NHS and it is us who will help to steer the NHS through of the NHS; different aspects of healthcare have the clinical and economic challenges of the next generation. These challenges whether a nurse, the will to work together to achieve are unprecedented in the history of the NHS: rising costs unmatched by funding, scientist, doctor, the same goal or vision. an ageing population with multiple chronic conditions, and a system that is not or allied health Young, enthusiastic clinicians can add currently structured to meet modern standards of quality of care that surpass professional, it is you who will provide significant insight into our biggest patients' expectations. the insight and solutions to the many healthcare challenges, but unless you challenges that the NHS faces. know how to channel this enthusiasm For most healthcare professionals, training is focused solely on the provision of As a medical student and a junior and how the system works, nothing will clinical care. Yet, for every interaction with a patient (and NHS staff have contact doctor I personally gave little thought happen. I had to learn by experience, with more than 1.5 million patients and their families every day) there is a vital to how the NHS worked – I was busy but if I had understood the system system of purchasing and planning, financing, and regulatory activity required learning or looking after patients, properly from the beginning, I would to support it. and I felt that 'management' was have avoided a great deal of trial and someone else's responsibility. Over error, as well as frustration. This is why I To truly effect change and improve the quality of care for our patients, we need the years I began to appreciate that want you to have this guide. to go beyond our clinical training, and learn to understand and engage with the this perception was misguided. If I I know that clinical trainees have organisations, systems and processes that define, sustain and regulate the NHS. really cared about how well patients sometimes felt at the mercy of This is no easy task; the NHS is an increasingly complex system, and finding your were treated then I had a moral 'management' or 'policy'. Let's change way through the maze can be confusing. and professional responsibility to that. Instead I invite you to be part understand the system in which I of it. By all means use this guide for In reading this guide, we hope that the structures of the NHS, and your place practised. general interest, to answer interview within it, become a little clearer. With understanding comes the confidence to I know that many trainees feel questions, to understand policies, engage with and challenge the system, helping to improve our NHS for patients undervalued and disenfranchised buzzwords and 'management speak'. and staff, now and in future generations by the organisations in which they Use it to immerse yourself in the work. This feeling discourages them system in which you work. But more * This guide mainly refers to the NHS in England, but we hope it will be of use to from engaging enthusiastically importantly, I hope that you will also colleagues in other countries. with others to change the way NHS use it to empower yourself and your organisations deliver services. This is colleagues to get to know how the Dr Felicity Taylor a huge loss, given that our trainees in NHS works and to really make it your Dr Salman Gauher all professions not only have a unique own. You are an integral part of the insight into how things really work, but NHS system and you are tomorrow's Dr Leann Johnson also have the most innovative ideas for clinical leaders. Dr Rachael Brock how the NHS could be improved for the Dr Marc Wittenberg benefit of staff and patients alike. NHS England National Medical Director's Clinical Fellows 2013/14 I want our trainees to play a central role in improving the NHS. Throughout my career I wanted to improve things. I could see some of the problems, but I didn't know how to go about making Professor Sir Bruce Keogh KBE, MD, changes within the system. Over time I DSc, FRCS, FRCP realised that making real improvement National Medical Director

Understanding The New NHS Understanding The New NHS 6 NHS values NHS values 7 An overview of the Health Working together for patients and Social Care Act 2012 Patients come first in everything we do. We fully involve patients, staff, families, carers, The Health and Social Care Act 2012 nation's health and to address communities, and professionals inside introduced radical changes to the health inequalities. and outside the NHS. way that the NHS in England is Everyone counts We speak up when Compassion We maximise our things go wrong. We ensure that compassion organised. The legislative changes D. A streamlining of 'arms-length' resources for the benefit is central to the care we of the whole community, provide and respond with from the Act came into being on bodies. The Act conferred additional and make sure nobody is humanity and kindness to responsibility on the National Institute excluded, discriminated each person’s pain, distress, 1 April 2013 and include: against or left behind. anxiety or need. for Health and Care Excellence (NICE A. A move to clinically led – formerly the National Institute commissioning. Planning and for Clinical Excellence) to develop NHS purchasing healthcare services for guidance and set quality standards local populations had previously been for social care. The Health and Social Commitment to performed by England's 152 primary Care Information Centre (HSCIC) was Improving lives VALUES quality of care We strive to improve We earn the trust placed care trusts (PCTs). The Act replaced the also tasked with responsibility for health and wellbeing in us by insisting on and people’s experiences quality and striving to get PCTs with 211 clinical commissioning collecting, analysing and presenting of the NHS. the basics of quality of groups (CCGs), led by clinicians. CCGs national health and social care data. Respect and dignity care – safety, effectiveness and patient experience – now control the majority of the NHS We value every person right every time. – whether patient, their budget, with highly specialist services E. Allowing healthcare market families or carers, or competition in the best interest of staff – as an individual, and primary care being commissioned respect their aspirations by NHS England. patients. The Act aimed to allow and commitments in life, and seek to understand fair competition for NHS funding to their priorities, needs, abilities and limits. B. An increase in patient involvement independent, charity and third-sector in the NHS. The Act established healthcare providers, in order to give independent consumer champion greater choice and control to patients organisations locally (Healthwatch) in choosing their care. To protect and nationally (Healthwatch the interests of patients under these England) to drive patient and public new arrangements, Monitor was involvement across health and social established as the sector regulator for NHS values and the Constitution care in England. The Healthwatch health services in England. Monitor network has significant statutory issues licences to NHS-funded providers, The NHS values describe what we NHS to explicitly set out what patients, powers to ensure the voice of the has responsibility for national pricing aspire to in providing NHS services, to the public and staff can expect from the consumer is strengthened and heard and tariff (in conjunction with NHS facilitate co-operative working at all NHS and what the NHS expects from by those who commission, deliver and England) and helps commissioners levels of the NHS. The NHS values were them in return. The Constitution cannot regulate health and care services. ensure that local services continue derived from extensive discussions be altered by government without the if a provider is unable to continue with staff, patients and the public, full involvement of staff, patients and C. A renewed focus on the importance providing services. and provide a framework to guide the public, and so gives protection to of public health. The Act provided everything that we do within the NHS. the NHS against political change. the legislation to create Public Health â Find out more about the changes The NHS Constitution was published by â For details on the NHS Constitution England (PHE), an resulting from the Act at: www.gov.uk/ the Department of Health in 2011. It is or to download a copy, go to: www. of the Department of Health. PHE's government/publications/health-and- the first document in the history of the nhs.uk/nhsconstitution aim is to protect and improve the social-care-act-2012-fact-sheets

Understanding The New NHS Understanding The New NHS 8 Structure of the NHS in England Structure of the NHS in England 9

Secretary of State for Health Department of Health The Secretary of State has overall responsibility for the work of the Department of Monitoring & Training & Health (DH). DH provides Commissioning Regulation Development strategic leadership for public health, the NHS and social care in England.

Trust Health Chief Medical Officer Public Health NHS England Development Education The Chief Medical Officer England Authority England is the UK government’s principal medical and scientific adviser, the Healthwatch professional lead for England doctors in England, and the professional lead of all directors of public Clinical Commissioning Healthwatch Local health in local government. Commissioning Support Units Local Authorities Groups Monitor National Medical Director The Medical Director of NHS England is responsible for Health and Wellbeing Board clinical policy and strategy, Care Quality promoting a focus on Commission clinical outcomes, enhancing Local Education clinical leadership and & Training promoting innovation. Healthcare services Boards Chief Nursing Officer Data & The Chief Nursing Officer is Evidence the professional lead for nurses and midwives in England and oversees quality Community Local public Secondary care Mental health Rehabilitation improvements in patient services services services health services safety and patient experience. NICE Chief Professional Officers Locally commissioned services The Chief Professional Officers (including the Chief Scientific Officer, Chief Dental Officer, Chief Pharmaceutical Immunisation, Health & Social Officer and Chief Health Specialised Offender Armed forces Local education Primary care screening, Care Information Professions Officer) are the services healthcare healthcare providers young children Centre heads of their respective professions and provide expert clinical advice across Nationally commissioned services the health system.

Understanding The New NHS Understanding The New NHS 10 Structure of the NHS in England Structure of the NHS in England 11 Finance in the NHS: your questions answered

How does the money flow from the Treasury to patient services? Where does the money How does NHS England decide The Treasury allocates money to the Department of Health, which in turn allocates come from? how much each CCG gets? money to NHS England. The Department of Health retains a proportion of the The money for the NHS comes CCG budgets are allocated on a budget for its running costs and the funding of bodies such as Public Health from the Treasury. Most of the 'weighted capitation' basis. This England. money is raised through taxation. means that budgets are set based NHS England currently receives around £96 billion a year from the Department of on the size of the population, and Health (2012/13). Approximately £30 billion is retained by NHS England to pay for adjusted for other factors: the its running costs and the services it commissions directly: primary care (including age profile of the population; the GP services), specialised services, offender and military healthcare. The remainder health of the population; and the is passed on to clinical commissioning groups (CCGs) to enable them to commission location of the population. services for their populations. How is the budget for Service providers are paid in a number of different ways (see opposite for further the NHS calculated? details). The diagram below illustrates the flow of money from the Treasury to CCGs. The Treasury holds a Spending Review every two to three years, How the money flows through which the budgets for all How is money paid to major public services are agreed. service providers? Health is a major national issue: Historically, service providers All figures based on HM Treasury Spending Review 2010 it receives around £107 billion a were paid an annual lump sum year, compared with £53 billion to provide a service locally. These HM Treasury for education and £25 billion were known as 'block contracts', for defence. and were not linked to the number of patients seen, the work actually carried out, or the quality of care provided. In 2003/04 the What is the money spent on? government introduced 'Payment Nearly half (47%) of the NHS by Results' (PbR), an activity- Clinical budget is spent on acute and based system that reimburses £107 Department £96 NHS £64 Commissioning billion billion billion emergency care. , providers for the work that they of Health England Groups community care, mental health carry out, at an agreed national and prescribing each account for price. Currently, PbR represents around 10% of the total spend. almost 30% of NHS expenditure. The NHS Mandate, issued annually Most of the remainder is covered from the government to NHS by old-style block contracts and England, sets out what must be local variations on these. NHS Centrally managed projects and services achieved in return for the taxpayer England and local commissioners Nationally Locally investment in the NHS. are working towards a payment Arms Length system based on quality of care Body funding commissioned commissioned services services and health outcomes achieved. Public health spending

Understanding The New NHS Understanding The New NHS 12 Running the NHS Running the NHS 13

Direct commissioning Who are the CCGs? Commissioning Clinical Commissioning Groups are designed to be clinically led and responsive to NHS England has responsibility the health needs of their local populations. They are membership bodies made up The day-to-day operations of the NHS for commissioning: of GP practices in the area they cover. The members set out in their constitution can be split into two major functions: the way in which they will run their CCG. Constitutions are agreed with NHS commissioning services for patients n Primary care England and published. The law requires that members appoint a governing body and providing them. who oversee the governance of the CCG and which must have at least six members n Specialised healthcare services including a chair and a deputy chair: (provided in relatively few Commissioning organisations: The CCG's Accountable Officer NHS England hospitals and accessed by The Chief Finance Officer comparatively small numbers of A registered nurse NHS England was formally established patients; accounts for around A secondary care specialist as the NHS Commissioning Board in 10% of the total NHS budget) Two lay members October 2012. It is an independent organisation, which is at 'arm's length' n Health services for serving Many CCGs have appointed additional members to bring added perspectives to to the government. Its main aim is personnel and families in the their governing body. Details must be set out in their constitution. Although the members of CCGs are GP practices, CCGs are required to obtain expert advice from to improve health outcomes and armed forces a broad range of health professionals. deliver high-quality care for people in England by: n Health services for people who n Providing national leadership for are in prison or other secure services and some have responsibility system is that CCGs are clinically led improving outcomes and driving up accommodation, and for victims of for offender or armed forces local organisations that know the area the quality of care; sexual assault (adults and children) commissioning. The oversight function in which they are working, and so are n Overseeing the operation of clinical for area teams and regional teams able to commission services that are commissioning groups (CCGs); is vital. These teams also provide specifically required by the population n Allocating resources to clinical an important link with the national that they serve. CCGs are responsible commissioning groups; NHS England team and it is hoped for commissioning the following n Commissioning primary care and these relationships will improve services in their 'patch': directly commissioned services The mandate communication between national n Urgent and emergency care (for (specialised services, offender strategy and local delivery example, A&E); healthcare and military healthcare). To ensure that the taxpayer (to of healthcare. n Elective hospital care (for example, NHS England is a clinically led whom the government is outpatient services and elective organisation. It has a budget of just accountable) has a say in how â You can find out more about surgery); over £95 billion. Within this overall NHS money is spent, a Mandate the work of NHS England at: n Community health services (services funding, it allocates over £65 billion is published yearly to provide www.england.nhs.uk/about that go beyond GP); to CCGs and local authorities, which ambitions and directions for n Maternity and newborn; commission services locally for patients. NHS England. NHS England has Commissioning organisations: n Mental health and learning The remainder is allocated to direct a duty to achieve the ambitions disabilities. commissioning activities and that are set out in the Mandate clinical commissioning groups Clinical commissioning groups can to operational costs. and will be held to account by The Health and Social Care Act 2012 commission services from a range NHS England's responsibilities are the Secretary of State for Health replaced the previous system of of providers, including from the discharged through four regional to do so. However, the day-to-day primary care trusts with 211 clinical voluntary and private sectors. Any teams (North, Midlands & East, London running of the NHS is determined commissioning groups (CCGs), each body that provides these services and South) and 27 Local Area Teams by NHS England, independent serving a median population size of must be registered with a regulating (LATs). Out of the 27 area teams, ten of political control. around 250,000 people (range 61,000 body (for further information see the have responsibility for specialised to 860,000). The advantage of the new section on Monitoring the NHS).

Understanding The New NHS Understanding The New NHS 14 Running the NHS Running the NHS 15

Support for commissioning organisations: Commissioning Support Units, Strategic Clinical Networks and Clinical Senates Delivering NHS services CCGs are supported in their work by a helps to ensure that the CCGs' output Once commissioned, NHS services are organisations are predominantly known number of organisations at national, is focused on improving the health and delivered by a number of different as trusts, which can be classified as NHS regional and local level. This support wellbeing of their local population. organisations called providers. Provider foundation trusts or NHS trusts:

Commissioning Support Units Differences between NHS foundation and NHS trusts

Commissioning support units (CSUs) assist CCGs in the more practical aspects of NHS foundation trust NHS trust their roles. CSUs are hosted by NHS England and provide support in Government Not directed by government, Directed by a number of areas, including: involvement therefore more freedom to government n Transactional commissioning – for example, market management, contract make strategic decisions negotiation, information and data analysis. n Transformational commissioning – for example, service redesign. Regulation: There are 9 groups of CSUs across England. They do not have defined boundaries Financial Monitor Trust Development and can serve any CCG. CCGs can use CSUs as they wish, from a very minimal Authority amount to a much broader partnership – there is no obligation to use them and Quality CQC CQC accountability for delivery of services will always remain with CCGs. Finance Free to make their own Financially financial decisions according accountable to an agreed framework set to government Strategic Clinical Networks out in law and by regulators. Can retain and reinvest surpluses Strategic clinical networks focus on priority service areas to improve equity and quality of care and health outcomes for their population. They bring together those who use, provide and commission services (including local government) Delivery of NHS services involves: to support more effective delivery of services. Current focus areas are: n Primary care services are delivered non-emergency hospital transport n Cardiovascular (including cardiac, stroke, renal and diabetes); by a wide variety of providers services and/or the NHS 111 service. n Maternity, children and young people; including general practices, dentists, n Mental health trusts provide n Mental health, dementia and neurological conditions; optometrists, pharmacists, walk-in community, inpatient and social care n Cancer. centres and NHS 111. There are more services for a wide range of psychiatric than 7,500 general practices in England and psychological illnesses. Mental providing primary care services. heath trusts are commissioned and n Acute trusts provide secondary care funded by CCGs. Mental health services Clinical Senates and more specialised services. The can also be provided by other NHS Clinical senates are multi-professional advisory groups of experts from across majority of activity in acute trusts are organisations, the voluntary sector and health and social care, including patients, volunteers and other groups. There commissioned by CCGs. However, some the private sector. are 12 clinical senates, covering the whole of England. Their purpose is to be specialised services are commissioned n Community health services are a source of independent, strategic advice and guidance to commissioners and centrally by NHS England. delivered by foundation and other stakeholders to assist them in making the best decisions about healthcare n Ambulance trusts manage non-foundation community health for the populations they represent. This is so that they can make informed emergency care for life-threatening trusts. Services include district nurses, decisions and ensure that organisations are in alignment with each other to and non-life threatening illnesses, health visitors, school nursing, improve the quality of healthcare. Clinical senates are comprised of a core including the NHS 999 service. In community specialist services, hospital Clinical Senate Council and wider Clinical Senate Assembly or Forum. some areas the ambulance trusts at home, NHS walk-in centres and are also commissioned to provide home-based rehabilitation.

Understanding The New NHS Understanding The New NHS 16 Running the NHS Monitoring the NHS 17 Health and wellbeing in the NHS Lessons learned and

Health is not simply an absence of the public. and taking responsibility disease. A key aim of the Health and Health and Wellbeing Boards have the Social Care Act 2012 was to renew the remit to protect and improve the nation's The NHS Values describe how everyone Trust, it is vital that everyone involved importance of improving the health of health and to address health inequalities. using or working within the NHS should in the NHS learns from the findings be treated. Following the failings at of the subsequent Francis inquiry and Public Health England Mid Staffordshire NHS Foundation Keogh and Berwick reviews. Public Health England (PHE) is an operationally autonomous executive agency of the Department of Health and was established in April 2013 in place of the Health Protection Agency. Robert Francis QC led a public inquiry into the failings at Mid Staffordshire NHS Foundation Trust. The inquiry, which The main functions of PHE are: cost £13m, identified many reasons for why things went so FRANCIS INQUIRY wrong and the report made 290 recommendations. At the Health Knowledge and Health protection Operations February 2013 heart of these was a need to develop: a culture of openness improvement information and transparency; a system of accountability for all; a system For example, Responsible for For example, Ensuring delivery promoting clinical leadership and an emphasis on always notifiable developing a 21st disease of consistently putting patients first. disease outbreak century health and registration, high-quality â www.midstaffspublicinquiry.com prevention, wellbeing service research and services – for recording and addressing health development example, management and inequalities – for the national major incident example, health microbiology unit Sir Bruce Keogh was asked to lead a review of 14 hospital response promotion and trusts which had a persistently high mortality rate. The inspections used a new methodology involving teams of screening services clinicians of differing grades and specialties. Eleven of the KEOGH REVIEW 14 trusts inspected were put into special measures and scheduled for re-inspection, and the review report set out Health and Wellbeing Boards Who sits on the HWBs? July 2013 eight key ambitions for improving care. The Care Quality Health and Wellbeing Boards (HWBs) n Locally elected representatives Commission has built on the Keogh review in developing its promote co-operation from leaders n Healthwatch representative process of inspecting all trusts throughout England. in the health and social care system n Representative from each www.nhs.uk/NHSEngland/bruce-keogh-review to improve the health and wellbeing â local CCG of their local population and reduce health inequalities. The boards, which n Director of Adult Social sit within local government authorities Services (LGA) In response to the Francis inquiry report, Professor Don (LGAs), bring together bodies from n Director of Children's Services Berwick was asked to look at how 'zero harm' could be made the NHS, public health and local a reality in the NHS. In total ten recommendations were made (LGA) BERWICK REVIEW government, including Healthwatch with core themes around transparency, continual learning, August 2013 as the patient's voice, to plan how to n Director of Public Health (LGA) leadership, regulation and seeking patient and carer opinions. meet local health and care needs, and n Other invited persons to provide â www.gov.uk/government/publications/berwick-review- to commission services accordingly. specific expertise into-patient-safety

Understanding The New NHS Understanding The New NHS 18 Monitoring the NHS Monitoring the NHS 19

Regulation and monitoring The General Medical Council (GMC) The Nursing and Midwifery Council is the independent regulator of (NMC) regulates more than 670,000 Revalidation is the process by which How does it work? Revalidation is based nearly 260,000 doctors in the UK nurses and midwives in the UK. Key clinicians have to demonstrate to their on local evaluation of the clinician's and was established in the Medical responsibilities include: regulatory bodies (for example, GMC performance through appraisal. All Act 1958. The GMC: and NMC) that they are up to date and doctors already participate in an annual n Setting professional standards of fit to practise. It is a way of regulating appraisal and maintain a portfolio of n Sets the standards that are education, training, performance the professions and contributing to the supporting information. Revalidation required of doctors practising and conduct, and ensuring that ongoing improvement in the quality of for nurses and midwives is expected in the UK; these standards are upheld; care delivered to patients. to start in 2015. n Decides which doctors are n Investigating nurses and midwives qualified to work in the UK who are thought to fall short of and oversees their education its standards. Monitor is the financial regulator of The Trust Development Authority and training; foundation trusts. Monitor works to (TDA) is responsible for ensuring make sure that: that non-foundation trusts develop n Ensures that doctors continue the capability to achieve independent to meet these standards n NHS foundation trusts are well-led foundation trust status. Key throughout their careers The General Dental Council (GDC) and well-run, so they provide functions of TDA include: through a five-yearly cycle of regulates all dental professionals quality care; n Monitoring performance; revalidation; including dentists, nurses, n Essential NHS services are technicians and hygienists. n Assurance of clinical quality; n Can take action when a doctor maintained if a provider gets may be putting the safety of into difficulty; n Transition into foundation status; The General Pharmaceutical Council patients at risk. n Appointment of chairs and (GPhC) is the independent regulator n The NHS payment system non-executive members to the trust. for more than 70,000 pharmacists, promotes quality and efficiency; technicians and pharmacy premises in the UK. n Procurement, choice and Healthwatch has been set up as an competition operate in the best independent consumer champion The General Optical Council interests of patients. The (CQC) for health and social care. Its (GOC) regulates around 26,000 is the independent regulator for purpose is to represent the public's optometrists, dispensing opticians, quality in health and social care in view on healthcare by gathering student opticians and optical England (including private providers). views on health and social care businesses. The National Quality Board (NQB) It registers and inspects hospitals, at both local and national levels. is a multi-stakeholder board care homes, GP surgeries, dental Every local authority in England The Health and Care Professions established to champion quality practices and other healthcare has a Healthwatch. It is hoped that Council (HCPC) regulates a wide and ensure alignment of quality services. If services are not meeting through the Healthwatch network range of professions including art goals throughout the NHS. It fundamental standards of quality the voices of people who use the therapists, biomedical scientists, aims to bring together multiple and safety, CQC has powers to NHS will be heard. Healthwatch will chiropodists and podiatrists, clinical organisations with an interest in issue warnings, restrict the service, gather these views by conducting scientists, dietitians, hearing aid improving quality to agree the NHS issue a fixed penalty notice, research in local areas, identifying dispensers, occupational therapists, quality goals, while respecting the suspend or cancel registration, gaps in services and feeding into social workers in England and independent status of participants. or prosecute the provider. local health commissioning plans. speech and language therapists.

Understanding The New NHS Understanding The New NHS 20 Working in the NHS Leadership in the NHS 21 Better training, better care Leading healthcare excellence

The biggest asset of the NHS is its staff. Leadership development for all developing the standards for medical Ensuring that the NHS workforce has Local Education and Training Boards healthcare staff has become increasingly leadership and its vision is to inspire the right skills, values and training, important in recent times. High-calibre excellence in medical leadership and is available in the right numbers, There are 13 Local Education leadership has a direct, positive impact and drive continuous healthcare to support the delivery of excellent and Training Boards (LETBs) that on staff and patients, and this leadership improvement across the UK, for the healthcare is the responsibility of are responsible for the training is needed at all levels and across all benefit of patients. FMLM offers (HEE). HEE is and education of NHS staff, both health professions. A number of development opportunities to medical an independent organisation at arm's clinical and non-clinical, within organisations have a remit to drive staff through: length of the Department of Health. their area. LETBs, which are excellence in healthcare leadership: committees of HEE, are made n An online bank of leadership, The key functions of Health Education up of representatives from local The NHS Leadership Academy management and quality improvement England include: providers of NHS services and resources; n Providing national leadership cover the whole of England. LETBs The NHS Leadership Academy is part n An annual conference providing for planning and developing the have the flexibility to invest in of the NHS and aims to ensure that education and access to some of the whole healthcare and public health education and training to support all sectors and all levels of healthcare UK's top leadership experts; workforce. innovation and development of staff are engaged in leadership n A large national and regional n Appointing and supporting the wider health system. They are development. They offer a range of community of medical leaders, development of Local Education and also able to ensure that money leadership development programmes supported through networking, Training Boards (LETBs) and holding follows students and trainees on accessible to all healthcare staff, peer learning and regional events. them to account. the basis of quality in education including the Edward Jenner n Promoting high-quality education and training outcomes. Programme, an online open-access FMLM supports and manages the and training which is responsive programme aimed at everyone National Medical Director's Clinical to the changing needs of patients working in healthcare. Fellow Scheme, a scheme that places and communities and delivered to â Find out more about the work doctors in training in apprenticeships standards set by regulators. of HEE, along with links to your local â To find out more about the NHS to some of the most senior healthcare n Allocating and accounting for NHS LETB, at: www.hee.nhs.uk Leadership Academy, including leaders across England, offering an education and training resources – self-assessment leadership tools unparalleled opportunity to develop ensuring transparency, fairness and and the leadership development a range of skills including: leadership, efficiency in investments made programmes, go to: www. policy development, project across England. leadershipacademy.nhs.uk/discover/ management, research and analysis, n Ensuring security of supply of writing and publishing. the professionally qualified clinical The Faculty of Medical workforce. Leadership and Management â To find out more about FMLM, n Assisting the spread of innovation including the National Medical across the NHS in order to improve The Faculty of Medical Leadership Director’s Clinical Fellow Programme, quality of care. and Management (FMLM) is a go to: www.fmlm.ac.uk membership organisation established HEE holds a budget of £4.9 billion to promote the advancement of for multi-professional education and medical leadership, management and training, which it distributes to Local quality improvement for all doctors Education and Training Boards (LETBs). and dentists. It is responsible for

Understanding The New NHS Understanding The New NHS 22 Quality and innovation Quality and innovation 23

NHS IQ High-quality care for all NHS Improving Quality was established in April 2013 to help promote and drive improvement across the NHS by building capability and capacity, and improving Defining quality knowledge and skills. NHS IQ has been built upon many existing organisations, such as the NHS Institute for Innovation and Improvement and NHS Diabetes Quality has become the organising health conditions and aid recovery and Kidney Care. principle of the NHS. Quality is defined for those with ill health, or following www.nhsiq.nhs.uk as excellence in patient safety, clinical injury. All care should be delivered â effectiveness and patient experience. in a safe environment and in a way No individual or organisation is that is positive for patients and their offering high-quality care unless they families. These five principles have NICE satisfy all three of these principles. been defined in the NHS Outcomes The National Institute for Health and Care Excellence provides national guidance and An effective healthcare system Framework, which provides a process advice to improve health and social care. It achieves this by: should prevent people from dying by which performance is measured, n Producing evidence-based guidance and advice for health, public health and social prematurely, improve the quality of and acts as a catalyst to drive care practitioners; life for people living with long-term quality improvement. n Developing legally binding quality standards for those providing and commissioning health, public health and social care services; The NHS Outcomes Framework n Providing a range of informational services for commissioners, practitioners and managers across the spectrum of health and social care. Domain 1 Domain 2 Domain 3 â www.nice.org.uk

Enhancing Helping Commissioning for quality and innovation Preventing quality people to recover from Effectiveness A number of tools have been developed to encourage and incentivise quality people of life for episodes of and innovation in all areas of NHS care. from dying people with ill health or prematurely long-term following CQUIN conditions injury CQUIN stands for Commissioning for Quality and Innovation. This is a system that was introduced in 2009 to make a proportion of a healthcare provider's Ensuring people have a income conditional on demonstrating improvements in quality or innovation Domain 4 Experience positive experience of care in specified areas of care. Its value varies but is in the region of 2.5% of the total contract value for that organisation. When implemented effectively, it can lead to dramatic improvements in care for patients. Examples of CQUIN Treating and caring for people in a safe environment Domain 5 Safety goals include the Friends and Family Test and assessing for patients at risk of and protecting them from avoidable harm developing a blood clot in hospital and dementia screening. Domains one, two and three relate to the effectiveness of care; domains four and five relate to patient experience and safety. Quality Premium NHS England is able to reward CCGs to reflect the quality of services they The Health and Social Care Act 2012 promoted the healthcare quality agenda by commission and associated health outcomes. The quality premium is one of establishing new organisations or widening the remit of existing organisations the methods in which NHS England does this. Guidance is released yearly on to focus on healthcare excellence: the areas in which CCGs will be rewarded with a quality premium payment if they achieve the required improvements in quality of services. These areas can change yearly depending on clinical need; examples include improving access to psychological therapies and reducing avoidable emergency admissions.

Understanding The New NHS Understanding The New NHS 24 The NHS in the UK The NHS in the UK 25

Health and Social Care in N. Ireland The NHS in Scotland, Wales and Northern Ireland NHS Scotland The NHS in Scotland is completely devolved, meaning The NHS in Scotland, Wales that responsibility for it rests fully with the Scottish Government. The Cabinet Secretary for Health and and Northern Ireland Wellbeing and Scottish Government set national objectives and priorities for the NHS that should be delivered and monitored via NHS Boards and Special The healthcare service in Northern Ireland provides both NHS Boards. health and social care and is administered by the Department n of Health, Social Services and Public Safety. Fourteen NHS Boards – these replaced trusts in 2004 n The Health and Social Care Board holds overall and cover the whole of Scotland. They are all-purpose organisations that are expected to plan, commission responsibility for commissioning services through five Local Commissioning Groups. 5.3m and deliver NHS services for their area. They take overall n Five Local Commissioning Groups are responsible for £ 13bn responsibility for the health of their populations and

commissioning health and social care by addressing the commission all services including GP, dental, community needs of their local population. care and hospital care. These boards are expected to n Five Health and Social Care Trusts have responsibility also work together regionally and nationally so that for providing integrated health and social care in their specialist healthcare – for example, neurosurgery – is regions. The Northern Ireland Ambulance Service is correctly commissioned. At a local level the boards have designated as a sixth trust. representation or partnerships with community health n The Patient and Client Council exists to provide a powerful, 1.8m and social care teams and there is close involvement of independent voice for patients, carers and communities. £ 4.3bn local authorities, patients and public.

n The Regulation and Quality Improvement Authority is n Seven Special Boards and a Health Improvement Board an independent organisation that encourages continuous provide national services and scrutiny as well as public improvement through a programme of inspections. assurance of healthcare. n The Public Health Agency is an organisation with the remit to improve health and wellbeing, provide health â www.show.scot.nhs.uk protection and directly input into commissioning via the Health and Social Care Board. 3.2m 50 million â www.dhsspsni.gov.uk Differences between the NHS in England and the £ 6.5bn £ 100 billion other home countries n Northern Ireland has a fully integrated health and The NHS in Wales is devolved, and is the responsibility of social care service; Scotland has passed legislation to the Welsh Government. achieve this goal n Seven Local Health Boards plan, secure and deliver healthcare services for their populations; n Scotland and Wales have integrated boards as opposed n There are three National Trusts: the Welsh Ambulance to trusts that commission services at a local level Service, Velindre NHS Trust (provides specialist services in n Scotland has SIGN (Scottish Intercollegiate Guidelines cancer and other national support) and the new Public Network) and not NICE for their clinical guidance Health body for Wales. NHS Wales (Gign SevenCymru) Community Health Councils represent the health and wellbeing interests of the public in their district. Population â www.wales.nhs.uk £ Healthcare budget

- Understanding The New NHS Understanding The New NHS

26 Glossary 27

Arm's Length Body A non-departmental public body which carries out its work independent of ministers or government CCGs (Clinical Commissioning Groups) Commission health services for their local population Clinical Senates Source of independent strategic and clinical advice for commissioners Commissioning Process by which services are planned and provided effectively to meet population's needs CQC (Care Quality Commission) The independent regulator of health and social care in England CQUIN (Commissioning for Quality and Innovation) A financial incentive to improve quality of services and achieve better outcomes CSU (Commissioning Support Unit) Provide support to CCGs, NHS England, acute trusts and government DH (Department of Health) Branch of UK government responsible for health and social care policy and legislation Healthwatch Independent consumer champion; its role is to represent the views of patients HEE (Health Education England) A special health authority providing leadership for new education and training systems for healthcare professionals HWB (Health and Wellbeing Board) A forum which brings key leaders across To purchase print copies the healthcare system together to improve health and inequalities in a local population of this booklet LETB (Local Education and Training Board) 13 Local Education and Training T: 020 7111 1105 Boards are responsible for training and education of clinical and non-clinical E: [email protected] NHS staff in their area W: http://tinyurl.com/Guide2NHS Monitor NHS regulator that supports organisations which purchase and provide healthcare to make decisions in the best interest of patients NHS England A non-departmental public body of the Department of Health; oversees the budget, planning, delivery and day-to-day operations of the NHS Published and distributed by on behalf of NHS England in England © 2014 BMJ and NHS England NICE (National Institute for Health and Care Excellence) Provides national guidance and advice to improve health and social care All rights reserved. No part of this booklet may be transmitted or reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, PHE (Public Health England) An executive agency of the Department of without prior permission in writing from the publisher. Health with a mission to protect and improve the nation's health and address inequalities Published by BMJ, BMA House, Tavistock Square, London WC1H 9JR. TDA (Trust Development Authority) Responsible for providing leadership and Printed by Charlesworth Press. support to non-foundation trust sector ISBN 978-0-7279-1872-7

Understanding The New NHS Understanding The New NHS Further copies of this guide can be downloaded from www.england.nhs.uk/nhsguide/