Commissioning for Value

Five Key Ingredients:

1. Clinical Leadership

2. Indicative Data

3. Clinical Engagement

4. Evidential Data

5. Effective processes

1 key objective + 3 key phases + 5 key ingredients = COMMISSIONING FOR VALUE

2

OBJECTIVE - Maximise Value (individual and population)

3

Granularity

Where to Look How to Change

SDMCare

PlanningManage

care out of hospital

CfV Pack

Atlas

Programme Budgets

Populations Systems

What to Change

Individuals

Deep Dive

Path-way

Provider

Reducing unwarranted variation to increase value and improve quality

The NHS Atlases of Variation

Awareness is the first step towards value –

If the existence of clinical and financial variation is unknown, the debate about whether it is unwarranted cannot take place

‹#›

6

Clinical & Financial Variation

• When faced with variation data, don’t ask:• How can I justify or explain away this variation?

• Instead, ask:• Does this variation present an opportunity to

improve?

• Deep dive service reviews support this across whole programmes & systems and deliver Phase 2:

• What to Change

7

Mechanism

Decision

Process

ServiceReviews

Clinical PolicyDevelopment

andDecommissioning

GP MemberPractices

PublicEngagement

Partners andStakeholders

Miscellaneous(e.g. Commissioning

Annual Plan)G

over

ning

Bod

y

Full

Busi

ness

Cas

e

Clin

ical

Exe

cutiv

e G

roup

CaseOutlines

ReformProposals

Contracts

PrimaryCare

Development

Procurement

Diagnostic

ResearchId

eas

Dec

isio

n

Gro

up

Ref

orm

Id

eas

Implementation

NHS RIGHTCARE

HEALTHCARE REFORM PROCESS

8

CURRENTSERVICE

FUTUREOPTIMALSERVICE

Fit forPurpose

Efficiencyandmarketoptions

Supplyandcapacityoptions

No/ lowbenefit

Step 1 – define:

Step 3 –

categorise:

Step 2 – define:

Redesign,Contract,Procure

Contract,Procure,Divest

Step 4 –

recommend:

Maintain

Divest

Service Review Pathway – Diagnostic steps

Fit forPurpose

Efficiencyand

marketoptions

Supplyand

capacityoptions

9

Number of Circulatory indicators in the bottom quintile of the practice cluster

Note, some of the data are based on small numbers. Statistical significance has not been tested and should not be inferred. The data are presented to identify potential areas of improvements rather than providing a definitive

comparison of performance.

Each coloured bar represents a different set of indicators e.g. dark blue is prevalence. The specific indicators are then shown in the table on slides 21-27 for the 3 practices with the highest total number of indicators in the bottom quintile

1

Galvanising Clinicians – On the right things

10

Easy answers in Secondary Care?

• Diagnostic Atlas

• %age stroke patients undergoing brain imaging within 1 hour of arrival at hospital, by hospital

• 80th %ile - 55%• Fairfield - 43%• NMGH - 32%• MRI - 7%• Royal Oldham - 4%

11

Secondary Care

• Diagnostic Atlas

• %age stroke patients undergoing brain imaging within 24 hours of arrival at hospital, by hospital

• 80th %ile - 98%• Fairfield - 96%• NMGH - 91%• MRI - 81%• Royal Oldham - 94%

NHS Bradford City CCG

Heart disease pathway= 95% confidence intervals

Initial contact to end of treatment

13

Bradford’s focus on optimal system and value - CVD

Population Prevention

Individual Risk Factor

Management and

Prevention

Chest Pain

Atrial Fibrillation

Heart Failure

L-term RoI S- and m-term RoI

S-term RoI

M-term RoI

M-term RoI

Embed and use the tools of delivery – business process, service specifications and protocols, contract management,

monitoring, support and managing pathways

AID - Adopt, Improve or Defend: Clinical protocols viability assessment and prioritisation

1. Research and collate clinical referrals protocols – start with Vale of York CCG’s - www.valeofyorkccg.nhs.uk/rss

2. Gather impact assessment group (IAG), comprising reform lead, clinical lead and finance lead.

3. IAG - follow initial impact assessment process (next slide)

4. Assess appropriate protocols against locally determined criteria – e.g. use reform decision tree

5. Adopt, or Improve and adopt, dependent on prioritisation – N.B. base the financial prioritisation on collated impact

Initial Impact Assessment process

Is the protocol deemed clinically appropriate for

local use?

Are new pathway steps required to be implemented

locally?

Can amendments be made to make it so/ optimise it for

local use?

Will it reduce demand and/ or more complex/

costly treatment?

Make amendments

Describe new pathways steps

Pass to reform team to work up

initial viability assessment

Collate impact and process through

decision tree

Yes No

Yes

YesYesNo

Do not proceedNo

Are there any health benefits?

Ideas & Cases

Is it a must do?

Can it be delivered?

Does it save

money?

Can it be made

deliverable?

Prioritise

Yes

Yes

Yes*

Yes

Yes

No

Do not proceedNo

Does it increase value*?

*See additional slides at end

Yes

Rate of Return <12

months

Rate of Return >12

months

High PriorityRoI* >£250k

Medium PriorityRoI* >£100k

Low PriorityRoI* <£100k

Medium PriorityRoI* >£250k

Low PriorityRoI* <£250k

Set T

imet

able

for c

ompl

etion

of c

ase

outli

ne*

Decision Tree for prioritising reform proposals

No

No No

High PriorityRoI* >£500k

17

6 steps to an optimal urgent care front end system

• 1. Operate robust Ambulatory Care protocols• 2. Care home education and training

• Manage in home, reduce admissions• 3. Advanced Paramedic Practitioner

• 1 WTE = >£1m impact on frequent callers per CCG• Supports Parity of Esteem

• 4. Commissioner/ Primary Care-led A&E triage• Only way in to A&E is via triage, unless ‘major’• Triage to MDTs and UCC/ H@H• Divert unnecessary urgent care

• 5. Multi-Disciplinary Teams for key care areas (Respiratory, CVD, Diabetes, Dementia, etc)

• Detect, divert and begin case management• 6. Urgent Care Centre/ Hospital @ Home

• Provide less complex alternative for ‘minors’

18

Bury priority: Mental Health

19

Bury priority: Mental Health

‹#›

Phase 3 – How to Change

• Behaviour, culture and leadership development• Attitude to implementation

• Delivery levers, contract and market management

- Service specifications, CQuINS, PDAs and contract clauses;

- Referrals management (reactive Vs proactive, pathway aides)

• Market management - 4 steps to buying optimal (in order of ease)

- Agreement, negotiation and persuasion (current provider improves willingly);

- Contract management (make them do it);

- Using current market options (encourage price and quality competition), and;

- Creating new market options (AQP, Tender, etc)

21

Leadership - Not for the fainthearted

• BPE for improvement is designed to:

• Make you look for problem areas (and face entrenched views)

• Make you fix them (no matter how hard)• Highlight and deal with blocks in progress

(including when important people/ stakeholders)

• Doesn’t allow you to shy away

22

Change behaviours - Change is inevitable

• Choice Whether to change

• Choice Whether to change yourselves or wait to be changed

• People and Organisations who wait to be changed lose control, become resistant and block improvement

23

Patient Decision Aids – Implementation Process

1. Identify best 6 PDAs for local impact• Use DD, CfV, AoV, PLCV, local enthusiasm, etc

2. Localise with local GP lead and add referrals criteria and protocols

• C. 50% of unwarranted activity dealt with by PDAs, 50% by protocols

3. Implement in key practices and prove impact

4. Spread across practices

5. Implement next 30 PDAs (in phases or collectively)

6. Implement International best practice

Optional (innovative):

7. Design own, use and spread

24

Leadership behaviour - Not for the fainthearted

• NHS RightCare is designed to:

• Make you look for problem areas (and face entrenched views)

• Make you fix them (no matter how hard)• Highlight and deal with blocks in progress

(including when important people/ stakeholders)

• Doesn’t allow you to shy away

25

Everyone gets to be Homer…

Which Homer are you?

Homer 1 (The Iliad) -

“Give me a place to stand and I will move the earth.”

Homer 2 (The Simpsons) -

“Trying is the first step to failure”

26

World’s 1st change management guru –

“To avoid criticism say nothing, do nothing, be nothing”

Aristotle, c.350BC

27

Typical CCG embedding process• Get buy-in and mandate from

• Key leaders (AO, GP Chair, CFO)• Wider group (Gov Body, Clinical leads, SMT, GP forums)

• Demonstrate to wider stakeholders (Provider managers and clinicians, local PH, HWBs)

• Work with senior leads – BPE, Templates, Decision criteria, DT, governance structure and local guidance to support

• Whilst also progressing Where to Look (can include “quick win pre-What to Change phase” for the financially challenged)

• Support deep dive service review, evidence-building, case for change development, decision-making

• Whilst also developing delivery skills in preparation• Build improvement capability – BI, programme office, project

management, leadership resilience, contract management knowledge-base, delivery lever identification and use