Annex A > Chapter 5 - Regional, District and Trust Management > Management structures throughout the period in question > The relationship between district health authorities and the UBH and UBHT

The relationship between district health authorities and the UBH and UBHT

142 Prior to the separation of the purchaser and provider functions in the period up to 1991, the B&WDHA imposed obligations by way of resource allocation mechanisms, planning processes and contracts of employment. In the two years prior to the creation of trusts, the necessary changes to systems and structures that were being implemented in shadow form included the development of contracts as part of an ongoing process. These were not legally binding contracts, but took the form of service agreements which were created and refined `so that by the time the Trust was created there was considerable experience and expertise in the development of continuation budgets'. [166] The changes in management had also been introduced in advance, `so that when the Trust was created there was a very smooth transition with no immediate impact on the provision of healthcare'. [167]

143 In areas other than those funded as a supra regional service, the obligations between any of the DHA purchaser units (such as the B&DHA) and the NHS trust provider units (such as the UBHT) after the purchaser-provider split were imposed by the contract system of service provision. According to Pamela Charlwood, Chief Executive of Avon HA from October 1994 [168] and Regional General Manager of SWRHA from 1993 to 1994, in initially drafting these contracts, the B&WDHA took advice from three main sources: [169]

• The DoH issued a paper in 1990 which gave initial advice on formulating service specifications, which included reference to quality requirements.
• The NHS Management Executive (NHSME) issued a paper, `Contracts for Health Services: Operating Contracts', in February 1990. [170]
• The SWRHA set up a Service Contracts Working Party, which presented to the DHAs a report on service contracts, and which mentioned the need to assess outcomes of treatment. [171]

The SWRHA also produced draft contracts for use by the districts.

144 In preparing these contracts, which included those to be used for the provision of cardiac surgical services, B&WDHA received input from its Purchaser Committee, which later divided to create the specialised Contracts, Quality and Monitoring
Sub-Committee.

145 The B&WDHA produced the form of contract for cardiac surgery, [172] for use as the service agreement between the purchaser authority and the provider department. [173] This contract included quality criteria and targets in terms of referral rates for different classes of patient and for different procedures, and aimed to provide feedback to the District. It provided for systems of quality assurance to be put in place to `include elements of quality control, identification of service deficiencies, and mechanisms for correcting and reviewing problems'. [174] Specific sections dealt with the process of medical audit, to include audit of outcome, the medical process and the management process. Separate sections detailed nursing audit and audit of support services, together with monitoring provisions and obligations to report back to the DHA. [175]

146 The contract provided that:

`15.1 The audit will include audit of outcome, the medical process and the management process. In addition to the statements in this document, the Cardiac Surgery Unit will set up an audit group to meet regularly and to provide the Bristol & Weston Health Authority with sufficient information for it to ensure that adequate audit is taking place.

`15.2 The audit of outcome will include measures of 30 day mortality, one year mortality and one year symptomatic state. Symptom relief assessments to be agreed with the referring cardiologists.

`15.3 The audit of process will include days spent in intensive care, days on a ventilator, units of blood and oxygen used.

`15.4 Audit information will be made available to the Director of Public Health Medicine as the Purchaser's representative. ...' [176]

147 The responsibility for the purchaser-provider contracts passed to the B&DHA in 1991, specifically to the Director of Contracting [177] and the Finance and Contracting Committee. Further service specifications were produced as was a quality/monitoring manual.

148 The reviewing and updating of contracting requirements was an ongoing process during the life of the B&DHA. This included feedback to the Finance and Contracting Committee from the provider units and purchaser-driven reviews of services, which in turn fed back into B&DHA's future purchasing intentions. [178]

149 In January 1992 UBHT and B&DHA had a contract-negotiating meeting to assess contract requirements against performance. [179] A paper was tabled, listing topics for outcomes to be monitored and reported in 1993/94.

150 From May 1992 a report on contract monitoring was given to each board meeting of the B&DHA, where actual activity levels provided would be measured against the contracted activity levels purchased. Any shortfalls would then be reviewed with the SWRHA and addressed with the provider units. [180]

151 The situation by 1995 is summarised by Ms Charlwood:

`... By 1995 the NHS Management Executive had moved from a policy which required contracts to be monitored for activity, to an approach which required contracts to be monitored for outcomes. In May 1995 the NHSME commended "Clinical Involvement in Contracting, A Handbook of Good Practice". [181] This included checklists, one item of which asked purchasers whether contracting had been informed by clinical audit, and whether that could be demonstrated. It also included a reminder [182] ... that EL(94)20 on clinical audit in 1994/95 and beyond outlined a number of approaches to developing contracts for audit, "but whatever approach is taken it is clear that clinicians have the leading role in developing audit proposals and ensuring that the outcomes of clinical audit are used to inform future contracts". Providers [183] ... should "ensure that there is a shift from the activity and financial focus of existing contracting so that the contracting process is increasingly informed by the clinical audit process; covering issues around good practice, clinical effectiveness and quality of service delivery". Authorities needed to demonstrate that clinical audit had informed the contracting process.' [184]

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Footnotes

[166] WIT 0108 0016 Dr Roylance

[167] WIT 0108 0016 Dr Roylance

[168] Then Avon Health Commission - the shadow form of Avon HA

[169] WIT 0038 0027 Ms Charlwood

[170] Executive Letter EL(90)MB24 `Contracts for Health Services: Operating Contracts'

[171] HAA 0037 0021; report of the service contracts working party of the South Western Regional Public Health Medicine Sub-Committee dated 4 January 1989

[172] For application to cardiac services other than those designated as supra regional, i.e. for adults and children over 1 year of age

[173] HAA 0011 0245 - 0252 ; service agreement dated 14 March 1991

[174] HAA 0011 0248; service agreement dated 14 March 1991

[175] For details of the audit provisions of these contracts, see Chapter 18

[176] HAA 0011 0249; service agreement dated 14 March 1991

[177] Ms Deborah Evans was Associate Director, latterly Director, of Contracting for B&WDHA from April 1991, and Director of Contracting for B&DHA from October 1991

[178] WIT 0038 0029 Ms Charlwood

[179] WIT 0038 0029 Ms Charlwood; HAA 0003 0021

[180] WIT 0038 0029 Ms Charlwood

[181] See HAA 0163 0155; `Clinical Involvement in Contracting, A Handbook of Good Practice'

[182] See HAA 0163 0166; `Clinical Involvement in Contracting, A Handbook of Good Practice'

[183] See HAA 0163 0171; `Clinical Involvement in Contracting, A Handbook of Good Practice'

[184] WIT 0038 0030 Ms Charlwood