In brief: what did the Operating Framework say?

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Setting the priorities

This Operating Framework for 2009/10 uses the three tiers of 'vital signs' introduced in last year's framework.

Tier 1: national 'must dos', which apply to all PCTs

The five areas remain the same as last year, with some new elements.

Health care-associated infections

  • Although overall the NHS has achieved the 50 per cent reduction in MRSA rates (compared to 2003/4 rates), not all organisations have achieved it and those who have not should make it their 'immediate goal'.
  • Those who have achieved the target should agree 'stretching ambitions' in contracts with other providers to further reduce their MRSA rates.
  • In 2009 the new National Quality Board will consult on establishing a new absolute (rather than relative) target for MRSA reduction, which will form a 'minimum standard' for all organisations, with compliance monitored by the new regulator, the Care Quality Commission.

Waiting times

  • The existing 18-week target for the time from referral to the start of hospital treatment remains.
  • Providers are expected to make the necessary outpatient slots available for patients to book their appointment online – some providers are failing to do this.
  • PCTs are urged to consider extending self-referral policies already introduced for some physiotherapy services to other services provided by allied health professionals in the community. From 2010, collecting data on referral-to-treatment times for these services will become mandatory.
  • The new GP Patient Survey will provide information not only on extended opening hours but also on care quality; this information should be used by PCTs to plan for new or improved services.

Maintaining health and reducing health inequalities

All areas should focus on improving prevention, including using the new Prevention Package for Older People, and on improving cancer and stroke services, maternity and neonatal services and child health.

Specific mentions are given to:

  • a new Child Health Strategy that will be published shortly
  • a new requirement that providers of abortion services offer contraception advice
  • a recommendation that PCTs increase radiotherapy capacity to meet the waiting time targets set in the Cancer Reform Strategy.

Experience, satisfaction and engagement

Lord Darzi's NHS Next Stage Review emphasised the need for staff empowerment and engagement, and the new regulator, the Care Quality Commission, will include a measure of staff satisfaction in their assessments of NHS organisations.

Emergency preparedness

PCTs are required to review, and if necessary improve, their existing plans for dealing with a flu pandemic and to prepare plans for dealing with major incidents such as terrorist attacks or rail crashes.

Tier 2: national and local priorities for local delivery, describing areas where PCTs are required to focus attention but can determine locally how they deliver improvements

PCTs are instructed to make improvements based on recent and forthcoming national strategies in these areas:

  • alcohol
  • dementia
  • people with learning disabilities
  • end-of-life care
  • mental health
  • services for military personnel
  • mixed-sex wards
  • people living in vulnerable circumstances.

Tier 3: a range of indicators from which PCTs can select local priorities

Progress against these indicators should be published locally, and included in Comprehensive Area Assessments, but will not be included in assessments of health organisations by the Care Quality Commission.

System Management

Lord Darzi's Next Stage Review emphasised the need for higher levels of safety, more effective care and improved patient experience. The Operating Framework states that if improvement in all three areas is to be achieved, then a new approach to change must be developed and policies put in place that support improvement.

The new quality framework, first set out in the Darzi review, includes:

  • the definition of national care standards by the National Institute for Health and Clinical Excellence
  • new measures of the quality of care
  • the publication of annual quality accounts by all providers.

The new Care Quality Commission will assess all providers against the new quality standards and a National Quality Board will provide strategic oversight of all the measures designed to improve the quality of care.

The Operating Framework states that service contracts with hospital, ambulance and community providers should link payment to the quality of care actually achieved and also, where relevant, to the rate of innovation.

The Darzi review included a commitment to make a proportion of providers' income conditional on quality and innovation, through the Commissioning for Quality and Innovation (CQUIN) payment framework, which is published alongside the Operating Framework. The content of these schemes is left to local discretion but might include data collection to provide a baseline against which improvement can be judged. The scheme will be funded from a separate allocation equivalent to 0.5 per cent of provider income, although the proportion is expected to rise over time.

Patient choice, improved commissioning, effective leadership and a better trained workforce are cited as key drivers of higher quality care. NHS Choices is to be further developed to provide the information to support choice, and a new legal right of choice will come into effect during 2009 as part of the NHS Constitution, with guidance being published to specify the services where this right will apply.

A new quality framework is to be introduced for community services.  PCTs are required both to promote diversity in provision and to introduce a clear separation between their commissioning and providing functions. Information on the form PCT provider services can take will be published, and a national call-off facility will be established for accrediting providers who can provide professional business support to PCT staff members wishing to set up social enterprises. A new approach to commissioning is to be developed organised according to areas of care, such as 'children and families' and 'end of life' as opposed to by professional group such as physiotherapist or community midwife.

New standard model NHS contracts are published alongside the Operating Framework for community services, mental health services and ambulance services and a new version of the acute contract, refined to take into account the NHS Constitution and CQUIN.


Payment by Results

  • The tariff uplift for 2009/10 is confirmed as 1.7 per cent (including the 3 per cent efficiency saving committed to in the last Spending Review). Organisations are reminded that a new way of grouping procedures for reimbursement under Payment by Results – HRG4 – will be implemented for acute services in 2009.
  • A new pricing framework for community services will be published in December 2008 and be used to ‘inform’ contracting in 2009/10.


  • £800 million of the (£1.8 billion) surplus forecast for the end of 2008/9 is to be used over the next two years 'in a planned and managed way, based on SHA and PCT planned spending to date'. In 2009/10, SHAs will be expected to carry over the remainder of the surpluses not used that year to the following year; these are expected to total £1.35 billion.

Revenue funding

  • Average growth in funding to PCTs will be 5.5 per cent in 2009/10, with a minimum growth of 5.2 per cent (before inflation). New target PCT allocations are published alongside the Operating Framework together with a report setting out changes to the resource allocation formula.

Capital funding

  • The £500 million available to PCTs to fund capital schemes in 2008/9 will be made available again in 2009/10, and £100 million which would have been spent in 2010/11 will be brought forward to upgrade 600 GP practices.


All NHS organisations will be moved to a new accounting regime – the International Reporting Standards – from April 2009. This will involve bringing PFI and LIFT assets onto the organisations' balance sheets.


  • The likely reductions in the rate of growth of the NHS budget mean there needs to be an increased emphasis on efficiency improvements.
  • As part of a cross-government Operational Efficiency Programme, savings will be sought through shared back office functions, greater use of collaborative procurement and better use of physical assets.
  • In addition, efficiency savings will be made through existing plans to link the tariff (that determines how much hospitals are paid for the operations they carry out) with best practice from 2010/11; using commissioning to increase productivity opportunities, by for example reducing pre-operative bed day; ensuring that workforce planning and training secure value for money and make the service more efficient.