The Commissioning Cycle
The Commissioning Cycle
The steps:
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Needs assessment
Service provision review
Priorities
Quality outcomes
Design services / pathways
Providers/suppliers
Demand management
Clinical decision making
Manage performance and
outcomes
Underpinned by:
• Primary care involvement
• Public and Patient engagement
• Evidence based practice
Assessing Needs
Data
Prevalence
Morbidity & mortality
Risk factors & lifestyle
Clinical
Commissioning
Service access
Capabilities
Segment & trend analysis
‘Market’ Intelligence
Tools
Data collection & reporting
What is needs assessment?
Needs assessment identifies and strives to eliminate overuse, misuse and
underuse of healthcare resources
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A variety of comprehensive evidence
sources can be used that include, but are
not limited to the following:
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Local knowledge of clinicians, health care
providers, commissioners
Local Authorities
Practice based commissioning data
Prescribing data
Prevalence and incidence data
Community health profiles
Housing data
Inpatient and outpatient data
Lifestyle data
Educational attainment data
Deprivation indices
Views of patients/service users
Census and other demographic data
Referral data
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Joint Strategic needs Assessments (JSNAs)
are local assessments of current and
future health and social care needs that
could be met by the local authority, CCGs,
or the NHS CB
JSNAs and the Joint Health and Wellbeing
Strategy is produced by health and
wellbeing boards to set priorities for
future action.
Review Service Provision
Data
Current performance
Knowledge
National indicators
Clinical
Commissioning
Clinical outcome measures
Existing evidence base
Capabilities
Best practice definition
Cost effectiveness analysis
Tools
Benchmarking tools
Review current service provision
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Service reviews are undertaken to demonstrate a thorough understanding of
current services provided in relation to the identified health needs. In essence, it is
to ensure that services commissioned for the population are effective and of high
quality.
Key tasks to be considered as part of a service review include:– Understanding the operational delivery, workforce issues and clinical factors for the
service
– Developing knowledge of clinical effectiveness and evidence base
– Benchmarking service against national or other indicators to access efficiency
– Reviewing applicable performance indicators or monitoring clinical outcomes
– Reviewing user experience and satisfaction with the service
– Establish best practice clinical/public health guidelines for the service
Decide on Priorities
Data
Patient feedback
Knowledge
Patient population analysis
Clinical
Commissioning
Systematic reviews
Health economic analysis
Capabilities
Evidence synthesis
Benefits case development
Patient communications
Decide and agree Priorities
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PCTs need to ensure that both national and local priorities are considered for
inclusion in its Strategic Commissioning Plan and Annual Operating Plan, and that
appropriate and sufficient stakeholder engagement (local clinicians, GPs, patients,
public) is included in the decision making process.
Priorities are generated from insights from:–
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Public & patient engagement
Joint Strategic Needs Assessment
Clinical Evidence
Programme budgeting or equivalent.
Defined criteria for evaluation and prioritising investment and disinvestment should be
developed including:Quality
Local Needs
Impact on health outcome gains and inequalities
NICE guidance/guidelines
Costs and Productivity
Specify Quality Outcomes
Data
Current Achievement
Knowledge
Benefits case
Clinical
Commissioning
Existing outcome measures
National quality indicators
Capabilities
Outcome measure design
Audit design
Specify and agree quality outcomes
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CCGs must align their strategic plan and priorities with the key quality outcomes
which they intend to deliver for their population.
Outcomes that are chosen will need to be underpinned by quantifiable data, in
order to provide a basis against which they can be monitored.
Increasingly, national indicators which quantify health and patient reported
outcomes are being used by PCTs to measure quality improvement.
Further information on key quality outcomes agreed for NHS Milton Keynes are
outlined in the Strategic Commissioning Plan & Annual Operating Plan . For a full
list of national indicators which the PCT is measured against see NHS Milton
Keynes Care Quality Commission’s Annual Health Check.
The CCG should also take account of the NHS, Adult Social Care and Public Health
Outcomes Frameworks, the Commissioning Outcomes Framework and outcome
strategies
Design Service & Pathway
Knowledge
Existing pathways
Evidence synthesis
Clinical
Commissioning
Evidence summaries for
single interventions
HTAs
Capabilities
Pathway adaptation
Pathway development
Guideline enablement
Design services and pathways
This element of the commissioning cycle is all about PCTs being able to identify
improvement opportunities, based on national/international best practice, which
ensure that services across settings are coordinate and integrated.
1. Prioritise – rationale for the work, based
around strategic priorities
2. Start Up – preparing for the review,
establishing project team
3. Review – conducting the review, including
gap analysis and needs assessment
4. Redesign & Option Appraisal – identifying
the optimal model of care, testing of options
and option appraisal
5. Provider Development – assessing the
market, shaping supply & contract issues
6. Business Case – establish value for money &
effectiveness of the proposed new
service/pathway.
7. Vision – recommend and promote the ethos
of new service, gain stakeholder support.
8. Specification – develop service or pathway
specification, including quality outcomes
desired, for the proposed change
9. Approval – gain organisational approval and
financial resources for progressing the new
service/pathway.
10.Procurement – agree process by which new
service/pathway will be contracted for.
11. Implement – develop a plan for
implementing the new service/pathway and
delivering the change
12. Monitoring & Review – monitor progress
in achieving the required outcomes and
service specification compliance.
Contract with Providers
Data
KPIs, Outcomes
Knowledge
Clinical
Commissioning
National and local contracts
Tools
Quality Standards
CQUINs, PROMS
Capabilities
Contract management
Negotiation skills
Contract with Providers / Supply
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The contracting process ensures that formal agreements with all providers (acute,
primary, community, mental health, voluntary sector) are in place, and that these
contracts clearly set out what is expected from both the commissioning and the
provider.
Within these contracts, PCTs can
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Specify quality requirements or outcomes (e.g. CQUIN, PROMs)
Incentivise the development of new service models or patient pathways
Ensure quality of care for service users
Ensure value for money
Manage Demand
Data
Existing service usage
Variation between providers
Prescribing data
Clinical
Commissioning
Knowledge
Evidence base for reducing
LOS, complications and cost
Referral best practice
Tools
Risk assessment tools
Order sets / care bundles
Educational resources
Manage demand and ensure
appropriate access to care
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CCGs will need to have in place a range of responsive providers that they can
commission healthcare services from.
However, they also need to be able to understand and predict current and future
demands on those services to ensure that they can accurately predict required
future capacity for the population needs identified.
Employing their knowledge of future priorities, needs and community aspirations
– CCGs can use their role as leader of the local NHS to influence improvement,
choice and service design in ways that can best meet future demands.
Clinical Decision Making
Knowledge
Best practice guidance
Guidelines
Pathways
Clinical
Commissioning
Tools
Referential decision support
Order sets / care bundles
Clinical prompts
Integrated decision support
‘Just in time’ learning
Clinical decision making
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The CCG must build a strong framework of clinical involvement in its decision
making to ensure that it can:•
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Develop a greater range of more integrated services in community settings
Secure great investment for upstream or preventative interventions that keep people
healthy for longer, prevent ill health and reduce inequalities
Drive continuous quality improvement and innovation across the whole system.
Quality & Performance
Data
Real time performance
Variation between providers
Knowledge
Clinical
Commissioning
Performance analysis
Best practice guidance
Tools
Decision support tools
Learning needs assessment
Performance linked
educational resources
Manage quality, performance &
outcome
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In order to assess whether their strategic goals are being achieved, CCGs need to
manage quality and performance of commissioned healthcare effectively.
This will involve monitoring and managing the performance of providers against
their contracts, including specific quality indicators or key performance indicators.
Good data and information sharing systems, plus constructive performance
discussions are crucial to this element:–
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Ensuring monthly, quarterly or annual performance reviews are in place as appropriate
Clarity as to what checking/ verification is to be done, by whom and how frequently
Agreement on what Indicators /KPIs are to be measured, by whom and how frequently.
How are the results to be communicated and to whom
Who is responsible for following up concerns and in what forums.
NHS Milton Keynes CCG Management Framework
Internal decision making structure
Clinical Programmes
& Projects Network
of member practices
NHS MK CCG
Board
NHS MK CCG
Senior
Management Team
advisory
reports to
Stakeholders
Service providers
Co-operation & Competition Panel
NHS MK CCG
Delivery Group
External resources
Health and Wellbeing Board
Clinical Networks
Clinical Senate
Acute Service Review
Commissioning Support Hub
Partner Organisations
Patient Congress
Joint Commissioning Team
Practice Participation Groups
LINk:MK
Neighbourhood
Quality &
Performance
Groups (4)
Planned Care
Programme
Urgent Care
Programme
Mental Health
Programme
Children &
Maternity
Programme
http://www.miltonkeynesccg.nhs.uk/governance_structure/
Long Term
Conditions
Commissioning in Milton Keynes
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Read about commissioning in Milton Keynes
http://www.miltonkeynesccg.nhs.uk/commissioning-in-mk/
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Read about the work of the Milton Keynes CCG Programme Boards:
http://www.miltonkeynesccg.nhs.uk/commissioning_programmes/
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See the Commissioning Toolkit of resources to support the work of
commissioners:
http://www.miltonkeynesccg.nhs.uk/commissioning_toolkit/
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Sign up for alerts to keep you abreast of the latest commissioning resources –
Anne Gray - Commissioning.librarian@miltonkeynes.nhs.uk
Compiled by Anne Gray, Knowledge Officer
NHS Milton Keynes CCG
September 2012
With acknowledgement to Dr Andrew Jones,
Clinical Specialist and Lead for Commissioning, BMJ