Public Service Agreement 19: Ensure Better Care for All

May 2008

DS25 / LB

NCT Document Summary:

Public Service Agreement 19: Ensure better care for all

The 2007 Comprehensive Spending Review (CSR) announced 30 new Public Service Agreements (PSA) for the 2008 – 2011 spending period, which are applicable to England. All PSAs have a set of indicators by which their progress will be measured. PSA 19, concerning Better Care for All1, includes an indicator on the percentage of women who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 weeks and six days of pregnancy. PSA 12 concerned Improving the Health and Wellbeing of Children and Young People2 and includes an indicator on increasing the prevalence of breastfeeding at six to eight weeks. (Please see document summary on PSA 12 for further information)

Public Service Agreements (PSA)

Introduced in the 1998 CSR, PSAs set out key priority outcomes the Government wants to achieve in the given spending period with the intention of galvanising public service delivery and driving major improvements in outcomes. Whilst the targets articulate the desired outcomes, they provide front line managers with the freedom to innovate and make decisions about the most effective and efficient means of delivery. By setting minimum standards across a range of public services, including health, education and crime, ‘floor’ targets ensure that everyone benefits from improvements.

Each PSA is underpinned by a single Delivery Agreement which is shared across all contributing departments and developed in consultation with delivery partners and frontline workers. The Delivery Agreements set out plans for delivery and the role of delivery partners. They also describe the national outcome-focussed performance indicators that will be used to measure progress towards each PSA.

PSA 19: VISION

The ‘vision’ is to ensure that people have high quality, safe and accessible care that is sensitive to their individual health and adult social care needs and their particular lifestyles and aspirations. PSA 19 (and more broadly the Department of Health’s (DH) Better Care for All strategic objective) sits alongside the DH’s other two strategic objectives; Better Health and Wellbeing for All and Better Value for All. It reflects the ambitions set out in Our health, our care, our say,3to provide more people with convenient services, in more local settings, that help them to manage their own health and improve their experience of the whole care pathway. The whole system of care delivery shifts from “central direction” to “local leadership”; a focus on outcomes rooted in what matters to public, patients, users and staff; clear accountability; and a stronger focus on prevention, safety, quality and better value.

Maternity services is one of the key areas identified as needing improvement as it is recognised that providers need to make services accessible to all women, including the vulnerable and excluded. Improved accessibility means that it is more likely that a risk assessment can be completed, women can make informed choices about their care, and appropriate care and services will be put in place to help improve life chances.

PSA 19 Indicators:

• INDICATOR 1: The self-reported experience of patients/users
• INDICATOR 2: NHS-reported referral-to-treatment times for admitted patients
• INDICATOR 3: NHS-reported referral-to-treatment times for non-admitted patients
• INDICATOR 4: The percentage of women who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy
• INDICATOR 5: Long-term conditions
• INDICATOR 6: GP Services
• INDICATOR 7: Healthcare Associated Infection rates – MRSA
• INDICATOR 8: Healthcare Associated Infection rates – Clostridium difficile

Indicator 4 – Maternity Services

Improving access to maternity care will improve outcomes for mothers and babies by providing opportunities for women to make informed choices and shared decisions about their maternity care, including where and how they give birth. This will lead to the more flexible, responsive and accessible maternity services envisaged in the National Service Framework for Children, Young People and Maternity Services.4 It is acknowledged that to have the full benefit of personalised care, women should be able to access maternity services for a full health and social care assessment of needs, risks and choices by 12 weeks and 6 days of their pregnancy. New and different types of care will be designed to meet the needs of all women and their families who need additional support such as outreach services for those who traditionally do not access maternity care early in their pregnancy. Increased choice can also improve safety, quality and family friendliness of maternity services and encourage good services to improve even further.

Delivery Strategy for PSA 19

The Delivery Strategy focuses on “transforming the whole system of care delivery”1 by using a balanced set of levers and incentives, transparency, plurality and patient choice, supported by better commissioning and a new outcomes and performance framework emphasising local leadership and accountability.

What will it deliver?

The stated priority is to provide choice of safe, high quality maternity care for all women, their partners and their babies. Specifically commissioners and providers will be able to use a number of the elements of the health reform agenda to facilitate improvements. The challenge for local commissioners is to ensure that each element is sensitive to the specific nature and requirements of their population and services provision, for example by:

• Establishing effective local commissioning frameworks;
• Ensuring tariffs support the effective commissioning of high quality services;
• Ensuring high quality and safe services are provided;
• Ensuring an appropriately skilled maternity workforce with regular continuing professional development is in place; and
• Developing monitoring frameworks for the future

Children’s centres will provide antenatal and postnatal maternity care for women, for example, providing greater access to health visitors.

Strategic Delivery Framework

Reform tools and levers, implemented and delivered locally, provide a range of incentives, centred around patients and users, to drive improvement in a more devolved system, and are the means by which the vision for Better Health and Wellbeing for all, Better Care for all and Better Value for all will be delivered. Together the reforms create an environment where local commissioners and providers deliver better services around the needs and wishes of the public and patients:

• Enabling more choice and a stronger voice for patients and service users who will be able to choose the highest quality of care appropriate for their needs, helping them to take better control of the health and care needs;
• Empowering patients, the public and staff through the provision of information and sharing of good practice;
• Strengthening commissioning, as practices, Primary Care Trusts (PCTs) and Local Authorities (LAs) use their knowledge of local communities, extensive public and patient involvement, particularly with seldom heard groups, service reviews and robust joint needs assessment to secure services within available resources;
• Supporting a richer landscape of diverse providers, including Social Enterprises and the wider third sector (including charities and the voluntary and community sector), to play an important role in providing choice, increasing quality and fostering innovation;
• Money following service users, rewarding the best and most efficient providers, giving others the incentive to improve; and
• A framework of system management, regulation and decision making which guarantees safety and quality, fairness, equity and value for money.

How will it be delivered?

The DH and Department for Communities and Local Government will work together to ensure that the whole health and adult social care system delivers improvements for service users. With a move to a more locally-led and incentive driven system, the national role in delivering the PSA will be in supporting and challenging the performance of commissioners, and Strategic Health Authorities (SHAs) in the case of health.

The indicators for this PSA, and DH’s contribution to other cross governmentPSAs are designed to align with, and be supported by, the broader the outcomesframework, and will be embedded within this to create a single coherent frameworkthat encompasses the full range of health and adult social care services.The indicators are designed in a way that:

• encourages continuous improvement across the range of health and adultsocial care services;
• supports delivery of outcomes where there is joint working between NHSand local government and other local partners (by feeding into the LocalGovernment 200 National Indicator Set to ensure alignment);
• exposes equality and inclusion issues so these can be addressed locally tomeet the needs of increasingly diverse communities, and to meet legalduties on equality (NHS organisations are required to assess the equalityimpact of their services, policy and data collection and analysis with regardto race, disability and gender, and to also ensure non-discrimination inrelation to age, sexual orientation and religion or belief); and
• supports delivery of the savings in health and adult social care identified bythe Financial Sustainability Review. A Value for Money Delivery Agreementwill be published later in 2007.

The Secretary of State for Health is the lead minister for this PSA. The relevant Cabinet Committee/s will drive performance by regularly monitoring progress, holding departments to account and resolving inter-departmental disputes when they arise.

NCT Comment

It is very useful to have important maternity objectives included in PSA targets. The PSA 19 target to improve access to maternity care for women by 12 completed weeks of pregnancy and the PSA 12 target to increase breastfeeding rates at six to eight weeks (please see document summary on PSA 12 for further information) will make these a priority for implementation by commissioners and managers in PCTs and NHS trusts. We are delighted that these two objectives have been highlighted for action.

There is a clear correlation between poorer pregnancy outcomes, including higher rates of maternal and infant deaths and morbidity in women who book later for antenatal care, attended infrequently or never attend for care5,6. Many of these women are known to be disadvantaged in terms of their socioeconomic status, ethnicity and residency status in the UK. Refugees and asylum seekers, women who experience domestic abuse, and women who have substance abuse or mental health problems and those living in the most deprived areas are most likely to be poor or non-attenders for maternity care.4,5,7 Those who face multiple disadvantages are at most risk.This PSA target will provide a strong incentive to address practical ways of welcoming these women who are least likely to access services, providing tailored care to meet their needs and follow them up if they miss appointments.

References:

1. Cabinet Office. PSA Delivery Agreement 19: ensure better care for all. Norwich: HMSO; 2007.

2. Cabinet Office. PSA Delivery Agreement 12: improve the health and wellbeing of children and young people. Norwich: HMSO; 2008.

3. Department of Health. Our health, our care, our say: making it happen. Health and social care working together in partnership. London: Department of Health; 2006.

Available from:

4. Department of Health. National Service Framework for Children, Young People and Maternity Services. London: Department of Health; Department for Education and Skills; 2004.

5. Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers' lives: reviewing maternal deaths to make motherhood safer - 2003-2005. The seventh report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007.

Available from:

6. Lavender T, Downe S, Finnlayson K et al. Access to antenatal care: a systematic review. UCLAN; 2007.

Available from:

7. Redshaw M, Rowe R, Hockley C et al. Recorded delivery: a national survey of women's experiences of maternity care 2006. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2007.

Available from:

Date for review: May 2009

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