QIPP | Right Care
Right Care
Commissioning for Value
Outline programme for 2011/12
January 2011
Quality, Innovation, Productivity and Prevention (QIPP)
Right Care Workstream - Project Document
Programme
QIPP
Document Record ID Key
Sub Prog /
Project
Right Care
<Insert Document Record ID Key>
National
Director
Jim Easton
Status
For comment
Owner
Phil Da Silva
Version
V1.0
Version Date
31.01.2011
Document
Control
www.rightcare.nhs.uk
QIPP | Right Care
Introduction
Right Care is one of thirteen national workstreams in the DH Quality
Innovation Productivity and Prevention programme (QIPP). Right Care is an
enabling programme focussed on increasing value and improving quality
through addressing variation and in particular unwarranted variation, through
promoting the use of health investment tools such as programme budgeting,
and through sustainable systems and population planning.
During 2010/11, Right Care highlighted un-warranted variation in the NHS
Atlas of Variation (1) and published bespoke Health Investment Packs for all
PCTs, showcasing how local commissioners can use programme budgeting
techniques with a range of health investment analysis tools to highlight where
quality and value can be improved (2). Right Care led on the development of a
shared decision making programme for the NHS and further developed its
work on Interventions of Lower Clinical Value (ILCV).
This paper outlines our progress to-date and our proposed programme for the
next phase of Right Care to March 2012.
Reforming the NHS - the unique contribution of Right Care
Unlike other QIPP programmes, which are more focussed on improving
transactions in the NHS, Right Care is focussed on transformation. It acts to
stimulate clinicians and commissioners to
work together to increase the value derived
“Value in any field must be defined around the
from health investment for their populations. customer, not the supplier. Value must also be
We do this through designing and
measured by outputs, not inputs. Hence it is
promoting tools to analyse and understand
patient health results that matter, not the
volume of services delivered. But results are
variation and health spend and outcome,
achieved at some cost. Therefore, the proper
through local pilots and by promoting
objective is.. the patient health outcomes
knowledge transfer.
relative to the total cost (inputs). Efficiency,
Right Care is focussed on value but value
can be increased in two ways:


then, is subsumed in the concept of value. ”
Source: Porter ME. (2008) What is Value in Health Care?
Harvard Business School. Institute for Strategy and
Competitiveness. White Paper.
By doing things better and cheaper quality improvement improves
outcome; productivity improvement reduces resource usage
By doing the right things – that is, shifting spend from lower value
interventions to higher value interventions and ensuring that patients
receive appropriate interventions
Doing the right things – right care, right place, right time – is the unique
contribution of the Right Care programme to reforming the NHS.
1
2
http://www.rightcare.nhs.uk/atlas
http://www.rightcare.nhs.ukj/resources
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QIPP | Right Care
The table below outlines our proposed core activities and objectives for
2011/12. These are developed further in table 5 below.
Table 1: The Right Care mission for 2011/12
Workstream
Objective
Commissioning and Planning:
allocating resources optimally
Optimising allocative efficiency requires the
techniques of programme budgeting and use
of analysis tools to highlight variation and
under performance compared to similar
populations
Clinical Networks and Systems of Care
Health communities establish sustainable
systems of care, have agreed objectives,
standards and outcomes, and use health
investment tools to minimise un-warranted
variation and maximise value
Better Value clinical practice
Continuous improvement in value by clinicians
shifting activity from lower value interventions
to higher value interventions, using programme
budgeting and marginal analysis as a
framework for investment decisions
Shared Decision Making
Creating the right culture and environment for
patients to be actively engaged in the process
of decision making about their own health care
Population Medicine
Developing the culture for all clinicians to be
responsible to the whole population they
serve, not just the patients who consult them,
for the management of resources invested in
healthcare
The Right Care Approach
If value is to be increased it is essential to involve both clinicians and patient
representatives. Right Care has demonstrated the ability to bring these and
other parties together, to stimulate the discussion and seek necessary
behaviour change to increase value.
Right Care is working with colleagues at a national level through policy leads
and National Clinical Directors, at regional levels through SHAs and at a local
level through PCTs, GP pathfinders and providers. Through these networks
we are working to support and encourage clinicians, commissioners,
managers and third sector to address the challenge of reform. Right Care is
an enabling programme; it does not and cannot drive change “top down”. The
success of this programme ultimately relies on Right Care principles being put
into practice at the front line, where a clinician meets with patients to
diagnoses and decide on treatment options in discussion with the patient and
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QIPP | Right Care
where both are therefore making decisions which impact on resources and
affect the quality and value of healthcare.
A key to this approach is to design and promote tools and products and to
establish networks which will facilitate clinicians and commissioners in
understanding the existence and causes of variation in costs and outcomes in
their own health system.
Complementary to this approach is the work being led for Right Care by NHS
East of England on shared decision making. Shared decision making seeks to
shift the culture from medical opinion to patient choice. It requires the use of
decision aids, embedded in the consultation process, that allow an honest and
informed conversation between patient and clinician. The outcome should
lead to an agreed decision on the ‘highest value’ option, in that situation and
at that time for that individual.
In July 2010 the Department of Health published the white paper ‘Equity and
excellence: Liberating the NHS’. The white paper states that Shared Decision
Making will become the norm, and patients will be involved in decision made
regarding their care.” No decision about me, without me.” Recent healthcare
surveys confirm that patients want to be informed and involved in decision
making about their healthcare.(3)
Right Care will continue its lead on developing Decision Aids and will work
with EoE on national roll-out and uptake and with the National Commissioning
Board on a monitoring and evaluation framework.
Figure 1: Right Care: Bringing together patients, clinicians and national
enablers
System enablers
Clinical
Commissioning
Personal care
Enhanced
Recovery
Sh
are
d
M
ak
Clinician
in
g
Value based
care
Patient and
public
Decision
Right Care also works to co-ordinate what can only be done at a national
level. We have worked with policy leads, NCDs and Public Health
3
Do Patients want a choice and does it work?
http://www.bmj.com/content/341/bmj.c4989.full.html?ijkey=icrFYTXpKpvq5Bc&keytype=ref&si
teid=bmjjournals
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QIPP | Right Care
Observatories to publish an NHS Atlas of Variation in healthcare. We are
working with the Department of Health and the emerging Commissioning
Board to address issues with CQINN and tariffs, Programme Budget reporting
and Spend and Outcome monitoring. We are also co-ordinating a national
clinical engagement exercise, in conjunction with NCDs and professional
bodies, on interventions of lower clinical value as well as co-ordinating with
colleagues at the Regional level such as Directors of Public Health and
Medical Directors and liaising with Royal Colleges and other bodies to
promote understanding and support of Right Care objectives.
The NHS commissioning landscape is changing radically. During this period,
the challenge for Right Care is to locate and engage leading clinicians and
commissioners in the recently announced GP consortia Pathfinders, to
prepare for the new landscape and use the tools from Right Care, within a
programme budgeting framework, to assist in the design pathways of care
and sustainable systems.
Key Deliverables in 2010/11
To date Right Care has delivered some major products, on schedule, to the
service and has received some very positive feedback from the NHS to the
added value of the products.
The workstream has also undertaken to coordinate a further piece of work
around lower value healthcare and is currently working with national bodies to
understand the lists of activities, interventions and procedures that PCTs
consider to be of low value.
Table 2: Milestones Year 1
Output
Milestone
Delivered
Achieved
152 bespoke PCT packs distributed to each PCT
Oct 2010
Achieved
NHS Atlas of variation published
Nov 2010
Achieved
NHS Glossary of commissioning terms completed
Dec 2010
Achieved
Third Annual Population Value Review published
Dec 2010
Achieved
Lower Value interventions database completed and
shared with FSSA/Societies
Dec 2010
On schedule
Lower Value interventions database to transfer to
successor body
March 2011
Ongoing
“National Levers” tariff/CQINN changes et al required
Ongoing
Planning
Milestone workshop with SHAs for Year 2
Feb 2011
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QIPP | Right Care
Shared Decision Making - Right Care for Patients
NHS East of England has been asked to lead this work and Dr Steven Laitner,
Associate Medical Director for East of England has been appointed as
National Clinical Lead with Professor Robert Harris as Lead Director and
Marion Collict (EoE) as National Programme Manager.
Delivering Right Care for Patients focuses on two interdependent elements of
Shared Decision Making;
Patient Decision Aids
Patient Decision Aids are self administered informational tools that
prepare patients for making informed decisions about medical tests or
treatments. They are designed to increase a patient’s awareness of
expected outcomes and personal values. They help people understand
their options, consider the importance of possible benefits and harms
and encourage participation in decision making. They have been shown
to improve patient experience whilst reducing the cost of healthcare.
Embedding in Practice
The strongest challenge will be to ensure that once the decision aids
have been developed and hosted, they become embedded in routine
clinical practice and adopted enthusiastically by patients, clinicians and
managers. Shared Decision Making provides a new Paradigm for
Demand Management.
Benefits



Increased knowledge and understanding of the treatments and
interventions causes patients to feel more empowered and able to
actively participate in shared decision making.
Lowers the use of aggressive surgical procedures in favour of more
conservative ones.
Improved patient experience.
Table 3: Shared Decision Making Milestones Year 1
Output
Milestone
Delivered
Achieved
First set of decision aids available on national platform
Nov 2010
Achieved
Agree Phase 4 Decision Aids to be Commissioned
Dec 2010
Achieved
Produce a national patient and clinical engagement
programme
Dec 2010
Achieved
Agree the membership and Terms of Reference for
design group.
Oct 2010
Achieved
National Conference to Launch Programme
Sept 2010
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QIPP | Right Care
Outline Mission – Year 2
In year 2 the focus on addressing un-warranted variation and shifting from
lower to higher value interventions will continue through further work on a
second Atlas of Variation and promoting the use of health investment analysis
tools and in rolling out shared decision making tools (see table 4 and 5
below).
The next challenge for the Right Care Programme is to roll out the early
learning and concepts of the Right Care workstream to larger numbers of
health care professionals and patients and to the public.
It will be important to develop the narrative further to inspire clinicians and
commissioners to use a systems and pathways approach to managing the
care for given conditions, together with programme budgeting, as a
mechanism to reduce waste and increase value.
Using the principle of “Do Once and Share”, Right Care will work with local
commissioners in a number of health economies, or “population labs”, to
develop and road test a “best value systems template” for one or more
disease groups. These templates will provide the framework to analyse spend
and plan care for their whole population, not just those who attend as patients.
A best value template essentially provides a specification for a service
including objectives, standards for care and measures. Together with a
national care pathway as expressed in the Map of Medicine, they are a tool for
local health economies to localise them to their population requirements.
The table below summarises the proposed workstreams, objectives and
deliverables for Right Care in 2011/12.
Table 4: Workstreams and projects for 2011/12
Workstream and objectives
Proposed projects
Commissioning and Planning:
allocating resources optimally

Developing the use of programme budgeting to
increase value from spend

Promoting the use of the Spending and Outcome
Tool (SPOT) and other tools to examine
commissioner’s outcomes and expenditures
compare with other commissioners and identify
improvement opportunities

Developing the public health profession to support
commissioners and clinicians in understanding
population health and epidemiology skills

Highlighting un-warranted variation through
products such as the NHS Atlas of Variation and
encouraging annual reporting on un-warranted
variation
Optimising allocative efficiency
requires the techniques of
programme budgeting and use of
analysis tools to highlight variation
and under performance compared
to similar populations
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QIPP | Right Care

Identify individual health economies (population
labs) to lead on one major common condition e.g.
arthritis, diabetes, bipolar disorder, and develop
“best value system templates”. These will be
shared with all Consortia as a model of
improvement

Population labs localising national Map of Medicine
pathways

Knowledge management project to establish a
Chief Knowledge Officers network and facilitate
knowledge transfer from population labs to
commissioners across the NHS

Work with Quality and Public Health Observatories
to create the specification for a health outcome
and value intelligence service to support new GP
consortia

Develop a “2040” network of future clinical and
managerial leaders in training, working with them
to produce “QIPP Improvement Casebooks” for
specific services
Better Value clinical practice
Continuous improvement in value
by shifting investment from lower
value interventions to higher value
interventions, using programme
budgeting and marginal analysis
as a framework for investment
decisions

To establish a NHS Commissioning Board led
framework for local work on interventions of lower
clinical value

To work with patient organisations and specialist
societies to ensure full engagement in the
evolution of clinical practice
Shared Decision Making

Work with East of England to lead the
development of Shared Decision Making tools and
their roll-out to GP Consortia across England

Work with the DH Information Standard and NHS
Choices to encourage all NHS organisations to
adopt the Information Standard for health
information services
Population Medicine

Developing the culture for all
clinicians to be responsible to the
whole population they serve, not
just the patients who consult
them, for the management of
resources invested in healthcare
Developing the role of a ‘clinical lead for the
population’ within a single care system for e.g.
Diabetes or Rheumatology and define their role

Develop Communities of Practice for individual
conditions and services, which unite generalist and
specialist care clinicians with patient
representatives - to assess population healthcare
needs and improvement opportunities

Work with professional clinical bodies to embed
skills development in population medicine as part
of on-going professional development
Clinical Networks and Systems
of Care
Health communities establish
sustainable systems of care,
have agreed objectives,
standards and outcomes, and use
health investment tools and best
value pathways to minimise unwarranted variation and maximise
value
Creating the right culture and
environment for patients to be
actively engaged in the process of
decision making about their own
health care
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QIPP | Right Care
The table below outlines the deliverables which Right Care will deliver in
2011/12.
Table 5: Right Care Milestones Year 2
Workstream
Output
Delivery
Commissioning
and Planning
A series of training sessions in use of PBMA and Health
Investment tools including SPOT to GP Consortia in
collaboration with an academic unit (tbc)
Start April
2011 –
End Mar
2012
Delivery of six public health colloquia across regions to GP
commissioners and Public Health professionals
June 2011
Delivery of “Atlas 2.0 series”; second printed Atlas
incorporating new topics and presentations, together with a
series of online atlases in collaborations with NHS and third
sector organisations
Sept 2011
New Health Investment packs and “how to” guides focussed
on GP Consortia geographies
Sept 2011
First tranche of local health economies tasked with producing
system templates for one or more conditions
June 2010
Second Tranche of local health economies tasked with
producing system templates for one or more conditions
September
2011
Knowledge Management framework and Chief Knowledge O
network established to facilitate knowledge transfer on
commissioning for value, systems of care, SDM and population
medicine - across all commissioners
May 2011
Launch online tools to support knowledge transfer and current
awareness
June 2011
Publication of systems improvement templates to GP
Consortia, together with Map of Medicine Care Pathways
Oct 2011
Publish specification for Health Outcomes and Value
Intelligence Service with APHO
Aug 2011
Lower Value interventions database to transfer to successor
body
April 2011
10 SHA Clinical Directors ILCV network established to lead on
local and specialist engagement – each SHA taking lead on
one or more professional specialties – national sponsorship
and reporting structure established
April 2011
Interventions of Lower Clinical Value – Hand over Report
April 2011
Clinical
Networks and
Systems of
Care
Better Value
clinical practice
Shared
Decision
Making
A suite of decision aids available on a national platform (NHS
Direct)
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QIPP | Right Care
A national Patient Decision Support Service provided by NHS
Direct with opportunities for other providers such as BUPA
Health Dialogue, other independent organisations and the
voluntary sector to provide patient decision support
A national “Shared Decision Making” engagement programme
for the public, patients, carers, managers and clinicians
Means of embedding Shared Decision Making in
commissioning such as via a commissioning “contract variation
for Shared Decision Making” relating to newly developed
decision aids
Means of embedding Shared Decision Making and Patient
Decision Aids in routine NHS care, such as via prompts in GP
systems (e.g. EMIS), links from Map of Medicine, links for
clinicians and patients from Choose and Book and changes to
Informed Consent procedures
Population
Medicine
“clinical population leads” identified for 10 health communities
covering 10-20 conditions
April 2011
Publish “Job Description” for a population lead
April 2011
Publish a specification of population medicine skill set and a
framework for incorporation into CPD for clinical professions
July 2011
10 Population Medicine Communities of Practice established
June 2011
Population Health Needs Assessment published for the above
communities
Mar 2012
Next Steps
Right Care will further develop this programme in the coming weeks through
discussions with the QIPP programme leads and the relevant partners and
stakeholders across the NHS and in the third sector.
The team are very happy to receive comments on any aspects of Right Care
and are pleased to discuss opportunities for involvement in the roll out of the
programme.
If you want to contact the team you can do so on our website at
www.rightcare.nhs.uk/meettheteam/
Phil DaSilva
Sir Muir Gray
Dr Steve Laitner
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QIPP | Right Care
Joint National Lead for
Right Care
Joint National Lead for
Right Care
Right Care Lead for
Shared Decision Making
January 2011
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