Helen Lewis – Head of Acute

Provider Commissioning,

Leeds CCGs

A CCG commissioner’s

perspective – what you might

want to know about us, and what

we need to know about you!

Commissioners • Clinical commissioning groups

• NHS England specialised commissioning

• NHS England local area team

• Providers as leads for a network

• Local authority public health teams

• Public health England

Much in the national Cancer Strategy about how we can work better

together - see page 64 for proposals about who is responsible for what –

interestingly it doesn’t show public health responsibility despite the

emphasis on it earlier in the document

What do commissioners do? Try to optimise the health of the population within the allocated resources

Try to reduce inequalities of health within a population

What does our population need? How do we set priorities within a fixed resource?

How do we deliver it?

What does it cost?

What did we do this year/last year?

What impact did it have?

What should we do better next year?

In practiceWhat did we spend last year?

Can we afford it?

Is there anything we can stop doing?

Is there anything more we should be doing?

What is likely to be different next year? (Provider capacity, provider behaviour,

GP behaviour, National campaigns, public awareness)

[Ideally would also ask: Did what we do this year do any good?

What can we/should we change for next year?

Are there inequalities we could be addressing? And if so how?]

How does Cancer fit into the

overall picture for a CCG?

2014/15 NHS Leeds West CCG spend by care setting

(pop c. 367,000 – 66,000 over 60s

£191.9

£50.3

£47.1

£43.1

£15.8

£15.3

£10.0£11.4

£7.7 £3.3

NHS Leeds West CCG 2014/15 spend (£m) by care setting

Acute, IS & AQP Care

Primary Care Prescribing

Mental Health & LD

Leeds Community Healthcare

Continuing Care

Urgent Care

Other

Citywide Transformation

Running Costs

Local Primary Care

For information – Value of Primary Care Contracts - £42.485m

2014/15 Point of Delivery split of Acute,

Independent Sector & AQP/GPwSI contracts

- Total 14/15 Acute spend was £191.1m compared to £185.0m in 2013/14

£47.9

£44.5£33.5

£14.4

£10.0

£9.2

£8.9

£7.6£4.3

Point of Delivery spend split - Acute, Independent Sector & AQP/GPwSI providers

Non-Elective

Elective

Outpatient

Maternity

High Cost Drugs & Devices

A&E

Imaging/Pathology

Other (including CQUIN)

Critical Care

So what do we spend

on Cancer?

The input data we have is activity based, and specialty based; plus data

on clinical coding of inpatients/day cases and diagnostic radiology only

We do have programme budget data, but it’s for inpatient services only –

doesn’t capture information on outpatients, public health, community

services etc.

When we look at costs, often need to look at it from the ‘bottom up’ for

individual pathways

Rarely link what we spend with what we gain from that spend – tend to

look at outcomes and quality in separate forums from spend

Breast cancer spend

Leeds West CCG at LTHT

£2 million - about half inpatient and half outpatient

About 4,000 first appointments, and 2,000 MDT discussions, around 400 inpatient/day case admissions; around 400 outpatient procedures

Doesn’t include radiology, pathology or oncology spend nor any high cost drugs or drugs in primary care

We don’t commission by pathways or programme currently - just by inputs. No outpatient coding; no mapping of pathology costs to pathways that is externally visible

NB can’t really split out cancer from non-cancer but most of the work within the breast surgery treatment function relates to cancer

What data do

commissioners look

at?• Performance

• Activity

• Demand and referral variation

• Outcomes – mortality data/screening uptake,

emergency presentations

• Staging data

• Patient experience questionnaire responses

• Business cases for investment/service change

CCGs are responsible for and measured against 5 ‘domains’ –

the one most relevant to Cancer is: Domain1: Preventing

people from dying prematurely

Reducing premature mortality from major causes of death -

Measures include:

• Under 75 mortality from cancer

• One year survival for all cancers

• One year survival from breast, lung and colorectal cancers

• Cancer: diagnosis via emergency routes

• Cancer: record of stage at diagnosis

• Cancer: early detection

• Lung cancer: record of stage at diagnosis

• Breast cancer mortality

Data often only available with considerable time-lags

Overarching measure: potential years of life lost from causes considered amenable to healthcare

Generally look more at waiting

time Performance

Monthly Target Jun'15 Jul'15 Jun'15 Jul'15

2 week GP referral to 1st outpatient

(suspected cancer)93.0% 92.6% 94.7% 92.5% 94.3%

2 week GP referral to 1st outpatient (breast

symptoms)93.0% 95.1% 91.7% 96.8% 91.9%

Leeds West LTHT Total

Performance against 62 day standard overall and by tumour type

(usually well over 95% for Breast)

Breast cancer screening uptake data

But also look at the factors that are behind the performance, specifically

demand, and the level of conversion by tumour type and by GP practice,

referral rates per thousand population etc

Focus on inequality of access and outcome – do some GPs refer a lot

more/fewer patients.

304271

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278 273300 278

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372339

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50

100

150

200

250

300

350

400Breast Referrals vs Converted to Cancer

Total Converted To Cancer Not Converted to Cancer Total Referrals

Directly age-standardised rate per 100, 000 population by route

Bordered cells indicate 3 SD outliers on respective funnel plotsPercentage by Route

Female Breast Cancer

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38.4 71.2 3.9 6.0

191,120

28% 62% 5% 5%

Confidence interval 38.1 38.7 70.8 71.6 3.8 4.0 5.9 6.1

28% 29% 62% 62% 5% 5% 5% 5%

NHS Leeds West CCG

38.3 68.4 5.1 5.1

959

28% 62% 6% 4%

Confidence interval 33.7 42.9 62.9 73.9 3.8 6.4 3.5 6.7

25% 31% 59% 65% 5% 8% 3% 6%

Increasingly also looking at data

for planning

• Demand for care: impact of new guidance

• Numbers of referrals, but also understanding the resources each patient needs;

• Modelling of numbers and types of test, how many ultrasounds, mammograms,

biopsies

• What is resource required?

• Can it be organised differently?

• Resource planning for treatments

• Resource planning for aftercare

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Referral Demand for : 103 - Breast Surgery (BREA)

2014-15 Referrals

2014-15 Average

2015-16 Referrals

5646

4300

3806

3029

2747

22211989

627460

278

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210 287131

386

114 104 83 67 79

22.5%

39.6%

54.8%

66.8%

77.8%

86.6%

94.6%97.1%

98.9% 100.0%

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Skin Lower GI Breast Head and neck Urology Upper GI Gynaecology Other Lung Haematology

Leeds CCG two week wait referrals: July 14 to June 15

Number of 2ww Total cancers identified by 2ww Referral Cumulative %

Responsible for

outcomes, not inputs

but………….Rely on national guidance, NICE guidance, pathways etc

Rely on providers compliance with NICE and assurance

Peer Review

Patient feedback

We can and should do more but there is a LOT of data

How to move to commissioning for outcomes?

Achieving World-Class Cancer

Outcomes – A strategy for

England 2015-20 • Even greater emphasis on earlier referral at lower levels of

suspicion

• Specifies new dashboard

• More nationally determined and collected metrics

• Patient reported outcome measures

• More focus on aftercare

• Management of patients with comorbidities as they age

• Relationship between primary and secondary care not only

on diagnosis but also on after care, case reviews, survivorship

Resource is a big problemMultiple specialties

Within each specialty, multiple pathways

Tend to have to focus on the areas which are:

Very costly

Failing on performance

Assessed as clinically problematic by regulators/external reviewers

Areas where there is new guidance

Areas of growing demand

Don’t have service specifications for every pathway we commission – just not practical – but

we could/should do better!

How do we work with providers to provide that assurance for us; so we are confident that YOU

have systems to:

Review clinical outcomes; untoward events; complication rates; deaths within 30 days of

treatment; recurrence rates, patient feedback

Questions?

Helen.lewis5@nhs.net