NHS
DRAFT
NHS Medway
Best practice guidance on developing service specifications
1.
Background
World Class Commissioning requires commissioners to work with local
stakeholders including clinicians and patients to develop a specification
appropriate to local circumstances. This applies equally whether the service is
being procured through a competitive process or through a process of
cooperation.
The development of service specifications in collaboration with partners and key
stakeholders must include actively seek patient/service user views and
experiences, and ensuring that existing services meet the best evidence and
their patients’ needs and preferences. Service specifications should be
developed in advance of the commencement of any competitive or negotiated
process. This ensures that commissioners are able to be completely transparent
and open about the services that they require.
This guidance paper is written in the context of the NHS Medway Procurement
Strategy and is a sub section of the NHS Commissioners Guide to Procurement.
Service Commissioners should ensure that prior to entering into developing
contract documents including service specifications that they are familiar with
both these documents.
2.
Aim
The aim of this guidance is to:



Provide a framework for service specifications.
Suggest how specification should be developed and used to ensure
high quality care is provided to local populations
Identify how to provide stretching targets for service providers and
to stimulate local debate about standards of care
3.
Who is this guidance for and how should they use it?
This paper is written for all those who could contribute to the commissioning
process. That is, firstly for commissioners, but also for the clinicians, patient and
service user groups who can contribute their expertise and local knowledge to
the process and should be an integral part of any development.
It is essential in order to secure local ownership and support that all stakeholder
groups are included in the process of specification development. Where
appropriate this may include current providers of services and the market.
Three template specifications have been developed to support commissioners to
structure requirements in a consistent and transparent way. These templates are
for:



Contracts with a value of over £96,000 over the term
Contract with a value of under £96,000 but above £19,000 over the term
and finally
Contracts with of value of less than 96,000 over the term.
These specifications are attached as Appendix 1. These templates should be
used as the basis for specification development and adapted for local use. The
templates reflect national guidance and recommendations.
The templates also provide some examples of what can be included. The
templates are intended to support those commissioners who are non-specialists.
4.
General Principles
4.1
Legislation and guidance
Specifications should reflect the key themes of Our NHS, Our Future. In
summary these are:
Care closer to home
The thrust of policy is not only to provide care closer to a person’s home (where
this provides at least equivalent quality and more conveniently than the care they
currently receive) but also “involving the local community to provide services that
meet their needs, beyond just treating them when they are ill, but also keeping
them healthy and independent”
Patient and service user engagement
Therefore development of the service specification needs to involve service
users/patients and their Carers, and should also describe how they and the
public will be engaged in the delivery of care and be supported to take
responsibility for their health and care,
– that is, in co-creation of services, and in co-production of outcomes.
Long term conditions policy
The World Class Commissioning aspiration of ‘Adding life to years and years to
life’ provides a framework that most people understand and use. These principles
should be reflected in service specifications.
Carers’ involvement
There is a new national carers’ strategy that acknowledges the important role
of carers in supporting people with health problems. Any service specification
process should engage Carers as well as patients, and the standards should
address their needs too.
4.2
Procurement Project Team
The need to involve clinicians and patients is clearly set out in World Class
commissioning (WCC) and in the process demonstrated in the Our NHS, Our
Future review.
WCC requires commissioners to:



Lead continuous and meaningful engagement with clinicians to inform
strategy, and drive quality, service design and resource utilisation
(Competence 4)
Promote and specify continuous improvements in quality and outcomes
through clinical and provider innovation and configuration (Competence 8)
Proactively seek and build continuous meaningful engagement with the
public and patients, to shape services and improve health (Competence
3).
Having established the need to develop a new specification a Procurement
Project team should be established by the Lead commissioner. The Project team
is the group of individuals that determine:
 How the procurement project will be managed
 How stakeholders will be involved, included and advised during the
procurement process
 The procurement timetable,
 The contract and specification requirements
The project team should be brought together as soon as the decision is made to
procure a service. The project team is led by the lead service commissioner. In
certain circumstances it may be appropriate to informally include service
providers in this group. The purpose of such inclusion is to ensure that the
market has the capability to respond to the specified requirements. Any such
inclusion must be carefully managed in order to ensure that providers involved in
the process are not given an unfair advantage in any subsequent procurement
exercise.
In forming this group Commissioners should seek to utilize and expand as
necessary partnerships and strategy groups to ensure that there is
representation of service users and Carers, clinicians, other commissioners upon
whom the service will have a direct impact (e.g. Public Health, Informatics), Local
authority partners and in particular social care, and other parties who have
expertise and local knowledge to contribute.
4.3
Deciding what you want.
Having prioritised attention to the service, it is most likely that whilst some
elements of an integrated service are in place further consideration will be
needed of how the service will actually work. The needs assessment process will
have suggested in broad terms how resources need to be allocates based on
geography, complexity, skill mix or balance between the levels of the relevant
care pathway but further consideration of the practicalities of what is required will
be essential.
The task of describing what you want is important. Are you describing the total
pathway of care, the missing elements, or the elements that need to be
re designed and for which you are considering a competitive procurement
process?
Will the “upstream” primary prevention functions of health promotion and public
education be commissioned separately as well as, or instead of, in the main
specification?
What about co-morbidities? For example in a study of national COPD needs
analysis data suggests that about a third of people with chronic significant
disease have depression; and 50% of those admitted to hospital have major
depression; 67% of people with severe COPD have osteoporosis and more than
60% of people with COPD die from coronary heart disease. So they have to cope
with multiple pathways, and the most important attribute of the service is
continuity of care.
Will the provision of primary care through locally enhanced service (LES)
contracts as part of the General Medical Services contract options be included?
4.4
Who should be accountable for what?
The service commissioner is ultimately responsible for the service specification
and for the procurement of a service that best meets the local specification. It is
therefore their responsibility to ensure no patient is excluded by the service, and
to ensure it is provided as equitably as possible. (Completion of an equality
impact risk assessments can support commissioners with this).
This may require monitoring of referral patterns from primary care to ensure
specialist services are available to all patients who would benefit; and monitoring
emergency admissions as a way of seeing whether any particular practice’s
patients are more likely to require unscheduled care.
In terms of clinical accountability, it is imperative that the specification addresses
this. There have been sufficient public inquiries into errors in health and social
care that have concluded that no-one was in overall charge of a person’s
care for us to know that it won’t “just happen” unless accountability is negotiated
and documented at all stages in a person’s care. It might be assumed that if a
patient is on a clinical pathway, then the accountability is defined in the pathway
and the patient is therefore safe. However, many patients have more than one
condition, and so need to be on more than one pathway, so they will only be safe
and receiving the best possible care if there is someone responsible for their
individual case. Typically, that would be the GP. However, it is best that the
specification addresses the issue. Commissioners should have a strategic view
of how the intertwining of pathways should work best.
4.5.
Training and education
The service commissioner is also responsible for ensuring the service meets
quality standards, specified outcomes and is sustainable. Service sustainability
would require the existence of an affordable strategy for continuing training and
education of primary and secondary care professionals.
The original needs assessment should be repeated regularly, and adapted to
highlight new developments or challenges. Without this, the detection and
diagnosis conditions may not be sufficient, and appropriate referrals to specialist
care may not be made at the right time.
4.5
Governance
The commissioner must establish standards and approaches for combined
governance, including financial and clinical. Any organisation awarded a service
level agreement or contract must have the competence and senior authority to be
responsible for clinical professional behaviour and standards, to have appropriate
systems to deal with risk, audit and information, appraisal, improvement and
change and collaboration and networking with other organisations.
5.
Contracting currency, incentives and penalties
Services should be commissioned in as sophisticated way as possible. What this
means is considering different and innovative options around service delivery.
For example developing a hospital at home costed package, as well as
considering options such as year of care that specify what level of support and
clinical intervention a patient could expect over a year. In addition, follow-up
telephone consultations with patients, and telephone calls between referring
professionals and their specialist colleagues also need to be contracted for in a
way that incentives the sharing of information, and encourages learning.
Contracts1 and Service Level Agreements should typically set a threshold activity
level (for example hospital spells or community contacts) above or below which
the contract value will be reviewed by the commissioner and provider together.
In order to incentivise providers by for example reducing emergency admissions
by early response and strong case management, commissioners might choose to
set a target about the numbers of admissions that is lower than the previous year
(taking into account any pre-existing trend). For example, the target might be a
20% reduction in emergency admissions.
The target could also be set in terms of financial value (that is, the numbers of
admissions multiplied by the tariff). This latter option means that providers could
choose to focus on a few individuals with multiple high-cost admissions, or on a
more widespread approach. Both require the commissioner to validate the
coding.
If managing prescribing expenditure is a priority, for example, oxygen
prescribing, then there is the possibility to set a financial target with or without a
financial incentive for achieving that target. For example, if oxygen prescribing
was contained at the budgeted level, when the trend is for an over-spend, the
commissioner might offer 50% of that underspend as a reward in the first year,
and perhaps set lower levels in subsequent years.
1
A contract is the legal agreement between two separate organisations, service level agreements
are used where a similar agreement is needed but within the same organisation for example
between NHS Medway and Medway Community Healthcare. Both legal documents should
include a detailed service specification developed in accordance with this guidance.
6.
The specification
6.1
General principles
A service specification defines what is required, when it is required and the
means of service delivery. It is essential that terms are clearly defined and set
out I order to ensure transparency. A service specification should start with a
brief description of the nature and scope of the service required, the user group
for whom the service will be provided and the overall purpose and aims of the
service. Locally agreed principles or values underpinning the service are
normally included at this point as well as relevant information about partnership
working in this area. It may also be useful to include an explanation/definition of
any technical terms used in the document as well as the recent background of
the service or client group, for example is it a new service or existing one?
It should be made clear at the outset if the service specification is based on any
national standards and related targets, or other national or local guidance as
appropriate, or a local analysis of needs.
The specification is the key way in which commissioners can satisfy themselves
that service delivery accords with the agreed levels and standards.
Specifications should be proportionate. What this means is considering if terms
and conditions for the service are appropriate to the value of the contract. For
example the expectations of a contract of £96,000 should be very different to that
of a contract for £15, 000.
6.2
Outcomes and measures
All specifications should be outcome based.
Understanding of what outcomes and measures vary. These are therefore
defined below:
An Outcome is:
The desired result or impact of the service for service users
An example of an outcome would be continuing to live independently with
improved health
An outcome is different to an output though outputs can often be a good indicator
of the outcome being achieved
Outputs are defined as:
The nature, type and volume of service required to deliver the outcomes
An example of an output would be the number of service users seen per
day/week/month.
Underpinning the delivery of good outcomes are effective processes.
Processes here are described as:
The activities put in place so that outputs can be achieved
An example of an activity would be the date for opening the new specialist unit.
6.2.1 Personal outcomes
Some examples of personal outcomes are outlined below:


I can walk at least two hundred yards further at the end of the year than
could at the start.
I can live in my own home with an end of life package that I choose
6.2.2 Strategic Outcomes
Some examples of strategic outcomes would be:




More people with dementia living in their own homes to death.
Fewer older people who have had one stroke suffering from further
strokes.
Fewer people coming into care homes through carer breakdown.
50% of service users with a mobility problem at assessment have
improved mobility six months later.
6.2.3 Linking outcomes, outputs and personal goals together
It is essential in order for outcomes to make a real contribution to the delivery of
strategic objectives that these are linked with organisational outputs and
processes as illustrated below:.
Strategic
Outcomes
Organisational
Outputs
Organisational
Processes
A higher proportion We will increase the
We will appoint
of the population
capacity of the
a specialist
aged over 80 should continence service joint service lead by
live within the community
May 09
6.2.4 Linking outcomes, outputs and personal goals together
Likewise the linking of outcomes, outputs and personal goals with ensure that the
service has a real impact of improving people’s lives. An example of this is
illustrated below:
Linking outcomes, outputs and Personal goals together
Strategic
Outcomes
A higher proportion of the population aged over 80
should live within the community
Service
Outcomes
Fewer people admitted to care homes will
have a previously undiagnosed continence problem.
Personal goals
or targets
My worry about continence and its capacity to limit
my lifestyle is no longer a problem.
6.2.5 Delivery
Achieving real outcomes require real change
It requires:
 Innovation
 Incentives
 Inclusion
 Joint commissioning
 Partnership working
 Meaningful service user engagement
These requirements should be enshrined in the specification therefore ensuring
delivery for the benefit of service users.
7.
Content
There are 3 template specifications that reflect the difference between the level
of detail expected for contracts over £96,000, contract under £96,000 and over
£20,000 and contracts under £20,000.
There are 10 sections to the template specifications:










7.1
Purpose
The Services
Service Delivery
Referral and access
End of Service
Self Care, Patient/ service and Carer Information
Performance management and Monitoring
Activity
Continuous Improvement
Costs and Pricing
Purpose
This section outlines the main purpose of the service including service aims,
background and outline of requirements.
7.2
The Services
This section should give a fuller description of the size and nature of the service
required, including information about:




The different client groups requiring services.
The differing needs of the service users.
The geographical location and spread of services.
How it is intended that service users will be referred or otherwise enter the
service.
 Any eligibility criteria for the service that will operate.
 The processes or activities to be provided under the contract and an
indication of the volume.
7.3
Service Delivery
This section should set out where and how the service will be delivered. This
section should include the model of care, details of care pathway, and how
service links to other pathways, services and strategic priorities and
arrangements for managing integrated services.
7.4
Referral, Access and Acceptance
This section sets out how service users access the service, referral
arrangements and acceptance criteria.
7.5
End of Service.
This section sets out how and where services should end, referrals onto other
services and protocols and requirements regarding service completion.
7.6
Self Care, Patient/Service User and Carer Information
This section sets out requirements regarding the providers responsibilities in
providing information and guidance to service users and their Carers including
signposting to other services and commitment to public health requirements.
7.7
Performance Management and Monitoring Arrangements
7.7.1 Setting targets
This section should detail the model of care, specific outcome and output targets
to be achieved. It will be necessary to differentiate between those that are
requirements and those that offer some flexibility for the provider. It is normally
considered good practice to get a balance between outcomes, outputs and
inputs, and, in any event, for outcomes to be restricted to three or four vital
issues, which are meaningful and measurable.
To help the provider understand how these factors fit with the overall service
requirements, it may be possible to include model care pathways for the different
client groups.
Key areas of focus in managing the performance of specific service providers are
to:

Only seek information on performance that has a clear purpose

Review volume and quality with the objective of moving to
measuring improvement in outcomes

Establish a hierarchy of KPIs which provides flexibility in the level of
scrutiny needed when providers perform well

Ensure that the KPIs are consistent with those by which NHS
Medway is measured e.g. National targets, LAA targets

Set ‘stretch targets’ and offer incentives to deliver improved quality

That for a particular service the expectation is the same for the
NHS, independent or third sector providers; proportionate to the
cost and size of the service

Seek the views of service users and Carers as an important source
of information on the patient experience
This should all be clearly reflected in the specification.
7.7.2
Working with the Information and Performance team
Before establishing measures and targets and the methods for collecting data
contact should be made with the Information and Performance team who will
support commissioners to develop frameworks and methodologies to meet the
specified requirements. There are two main possibilities in respect of data
collection. One, that commissioner systems dictate the way in which information
is recorded, collated and transmitted by the provider. Two, that the commissioner
is happy to leave the collection, collation and transmission systems to the
provider, providing it is able to meet the overall information requirements. It is
vital that the specification makes clear what is required of the provider in these
terms.
7.7.3
Collaborating with other commissioners
Commissioners should be aware of the effect that the service they will be
commissioning with have on other parts of the organisation. Ideally all functions
that will be affected through the commissioning of the service will be included in
the project team. If this is not possible then serviced specification development
should still take into account the needs of the organisation of a whole by
considering measures and specified requirements that will meet these needs for
example Medicines Management should be consulted on the development of any
specfifcation where there is a direct or indirect effect on the prescribing or use of
medicines.
7.7.4
Establishing how meeting outcomes will be measured and
monitored.
Having determined the outcomes and outputs of services required, it is important
to identify any other quality aspects that you require. Examples of minimum
practices and policy requirements in a specification are:
– Expectations/requirements in relation to staffing levels, training,
qualifications and experience.
– Expectation/requirements in relation to the management of staff,
professional supervision and HR/employment standards.
– Compliance with local or national service standards and guidance.
– Provider policies, procedures and systems ensuring a safe, consistent and
quality service.
– Involvement of users and Carers in agreeing care programmes and their
review.
– Expectation/requirements of provider involvement in the review of
services.
– Expectations of provider complaints procedures.
The specification should also make clear the expectations of the commissioner in
terms of the provider attending meetings and the sharing of information. A
schedule of meetings and the main agenda items might be included as an
appendix of the specification.
As well as the performance indicators that the provider will be expected to report
on, any other monitoring arrangements need to be outlined such as monitoring
visits, complaints or the possibility of spot checks.
7.8
Activity
This section sets out the main activities that are required in order to deliver the
service.
7.9
Continuous Improvement
This section sets out the requirements in terms of proactive continuous
improvement and business planning.
7.10
Prices and costs
This section contains the costed breakdown of this service. This section can not
be completed until completion of the competitive or cooperative process.
7.11
Appendices
Appendices (also sometimes referred to as schedules) should be cross
referenced to the main body of the specification and contract.
Appendices/schedules should add any additional detailed or requires. For
example an Appendix may show the whole patient pathways and how aspects of
this pathway are delivered. IT may also include detailed requirements such as
insurance requirements etc.