Contents
Integrated Cancer Systems – Q&A ............................................................................ 4
Introduction and Contents ....................................................................................... 4
1. Background context ............................................................................................ 5
1.1 Why was there a need to review cancer services in London? ....................... 5
1.2 What is a case for change and by whom was it developed? ......................... 5
1.3 What was the scope of the review? ............................................................... 5
1.4 What were the conclusions and recommendations of the case for change? .... 6
2. Concept and Design ........................................................................................... 7
2.1 By whom and when was the model of care developed? ................................ 7
2.2 What does the model of care aim to achieve? ............................................... 7
2.3 What is the role of London Health Programmes in the process? ................... 8
2.4 What is an Integrated Cancer System? ......................................................... 8
2.5 What is the difference between a cancer network and an ICS?..................... 8
2.6 What will happen to existing cancer networks? ............................................. 9
2.7 What is outside the scope of the model of care? ........................................... 9
2.8 How have patients and non-clinical stakeholders been consulted during the
development of the model of care?...................................................................... 9
2.9 Why was there a three month engagement period and what was the
engagement strategy? ....................................................................................... 10
2.10 What are the impacts of the government’s reforms on the proposals in the
model of care? ................................................................................................... 10
2.11 Why is the focus on the acute trusts when early diagnosis is the area of
biggest concern? ............................................................................................... 10
1
2.12 One of the key recommendations of the 2010 health reform white paper
was that top down planning should not drive needs identification and service
design, how does this programme meet this aspiration? ................................... 10
3. ICS Development and Implementation ............................................................. 11
3.1 What happened after the model of care was published? ............................. 11
3.2 Who made submissions to implement the model of care and how were they
assessed? ......................................................................................................... 11
3.3 What is the scope of the integrated cancer systems? .................................. 12
3.4 What are the objectives and priority areas of each integrated cancer system?
........................................................................................................................... 12
3.5 How will ICSs be held to account? ............................................................... 13
3.6 [CHo] How much will it cost to set up and implement the systems? ............ 14
3.7 What are the financial implications of the implementation of ICSs to CCGs?
........................................................................................................................... 14
4. ICS Commissioning ........................................................................................ 14
4.1 Who will be commissioning the ICSs? ......................................................... 14
4.2 What is the pan-London Cancer Commissioning board and who will be on it?
........................................................................................................................... 14
4.3 What does this mean for the way cancer services are commissioned in the
future? ............................................................................................................... 15
4.4 What is a commissioning best practice pathway and how were they
developed? ........................................................................................................ 15
4.5 How were the output specifications developed? .......................................... 16
4.6 What are the main advantages of commissioning on a pathway basis? ...... 16
-
CQUIN payments across an integrated cancer system. .............................. 16
4.7 What will the ICSs do that was previously done by commissioners? ........... 17
4.8 What is bundle contracting?......................................................................... 17
4.9 How will tariffs be calculated? ...................................................................... 17
4.10 Is there a risk that handing over responsibility for aspects of the
commissioning cycle to ICSs will transfer too much power to providers? .......... 18
2
4.11 How will the performance of services covered by the two ICSs be monitored
and measured? .................................................................................................. 18
4.12 What is the difference between commissioning measures and other
measures clinicians will use to ensure best practice?........................................ 18
4.13 What other incentives will be used by commissioners for enhancing quality
of care? .............................................................................................................. 19
4.14 Why a system wide CQUIN? ..................................................................... 19
4.15 Will additional cancer CQUINs be developed in the future? ...................... 19
5. ICS Governance and Information Governance ............................................... 19
5.1
In the future system of governance and management, what is the remit of:
19
5.2 How does the governance structure take into account the changing nature of
the commissioning environment? ...................................................................... 20
5.3 What are the metrics by which ICS performance will be measured? ........... 20
5.4 How will data be recorded and reported? .................................................... 20
5.5 When will the systems go live? .................................................................... 21
6. Future Development ....................................................................................... 21
6.1 What will happen after 2012/13? ................................................................. 21
6.2 What is the ultimate ambition of the ICSs? .................................................. 21
Appendix 1- Pathway to system going live: Critical Milestones ............................. 22
Key Documents..................................................................................................... 22
3
Integrated Cancer Systems – Q&A
Introduction and Contents
Document Aim
To provide a cohesive overview and rationale for the case for
change of cancer services in London, and the subsequent
development and implementation of Integrated Cancer Systems
(ICSs) and revised commissioning approaches to deliver this
change.
Specifically, a clear process from concept and design to
outcomes and future development is described.
Audience
Contents
Commissioners and providers from inside and outside London
with an interest in ICSs.
1. Background context
2. Concept and Design
3. ICS Development and Implementation
4. ICS Commissioning
5. ICS Governance and Information Governance
6. Future development
Contact
Circulation
Tom Lee – Project Officer (Cancer Commissioning), London
Health Programmes
Email: tom.lee@londonhp.nhs.uk
Phone: 020 7685 6814
Publically available on the LHP website, targeted circulation to
London Cancer Programme stakeholders.
4
1. Background context
1.1 Why was there a need to review cancer services in London?
In June 2009, NHS London and PCTs in London agreed that cancer services in
London should be reviewed. This was based on the acknowledgement that whilst
good progress has been made to improve cancer care in the capital over the last
decade, and many areas of excellence exist within the NHS in London, survival rates
still lag behind much of the UK and other European capitals. If UK cancer survival
equalled Europe’s best, there would be an estimated 11,000 fewer deaths each
year.1 In London, this could save 1,000 more lives from cancer every year. In
addition, Londoners have historically reported a poorer experience of cancer care
when compared with other regions of England.
1.2 What is a case for change and by whom was it developed?
A case for change is a piece of evidenced based clinical research that assesses care
quality outcomes and identifies priorities for improvement. Development of the case
for change was led by Commissioning Support for London (CSL) (previously
Healthcare for London), and was commissioned by NHS London together with PCTs
in London.
An expert group of 45 clinicians, selected from 144 applicants and drawn from a
range of clinical specialities, hospitals, and cancer networks across all London
geographies helped develop the case for change. Their role was to represent the
views and expertise of their peers, who deliver cancer-related services across the
capital. In addition, an external reference group was established to add valuable
perspectives from outside London and a patient and carers panel was established
(patient involvement is described in greater detail below).
1.3 What was the scope of the review?
The scope of work was determined in consultation with the Department of Health’s
national clinical director Mike Richards, NHS London’s medical director and key
stakeholders, including representatives from PCTs and sectors.
The case for change focussed on three key areas:
1. Early diagnosis.
Rationale: Early diagnosis greatly improves the chances of survival and
reduces the cost of care, yet poor public awareness levels of the signs and
symptoms of cancer, late presentation, and insufficient capacity for primary
care diagnosis have been common factors throughout London.
2. Common cancers and general care.
Rationale: Evidence suggests that treatment for common cancers is
inconsistent across London, resulting in varying quality of care and patient
1
Cancer Research UK, Tackling cancer delays will boost British survival, 2008
5
experience2. In addition, there are significant variations in post-operative
length of stay. The case for change suggested that variations could be
addressed by standardising best practice patient pathways. Furthermore, it
was suggested that elements of general care relevant to both common and
rarer cancers (such as holistic needs assessment, access to clinical nurse
specialists, and supportive and palliative care) could be better integrated into
care pathways and commissioning structures.
3. Rarer cancers and specialist care.
Rationale: Peer review indicated that treatment of some rare cancer types has
become concentrated in the hands of a smaller number of surgeons, while
others do not align with the NICE model. Fewer specialist teams managing
higher volumes will allow for better assessments of outcomes and more
sophisticated outcome measures to enable benchmarking and comparison
against international standards.
1.4 What were the conclusions and recommendations of the case for change?
The overarching conclusion in the case for change was that the quality of cancer
services in London can be improved by better integrating services and
commissioning for those services.
In addition, recognising interdependencies and patient pathway flows between care
settings would make the quality of care more consistent. This is particularly important
for tackling existing healthcare inequalities and supporting the more disadvantaged
groups in London’s diverse population.
Underpinning these there were high level recommendations for each of the three key
areas:
1. Early Diagnosis: There is a need to diagnose cancer earlier in London in order
to improve survival outcomes the most.
2. Common cancers and general care: Services should be localised where
possible and centralised where necessary. Strong clinical governance should
ensure the delivery of high quality and safe services, and the development of
recommended treatment plans through multidisciplinary teams, aligned to
NICE guidelines, should be developed
3. Rarer cancers and specialist care: Some of London’s rarer cancer services
should be further centralised, for the benefits of both patients and the services
themselves.
Specifically, the case for change recommended that an integrated approach to
commissioning cancer services was required to improve patient outcomes and
2
National Cancer Intelligence Network, One Year Cancer Survival by Cancer Network, England,
2000-2004, 2008; Office for National Statistics, London: a city of wealth or deprivation?, 25 June
2003, <http://www.statistics.gov.uk/cci/nugget.asp?id=393>
6
experience and achieve best value for money, that the delivery of these services
needed to be integrated across providers and geographies, and that providers
needed to sign up to agreed and consistently applied best practice pathways,
redesigned on the basis of the latest evidence and clinical guidance.
The conclusions set out in the case for change informed the development of a new
model of care, which is described here [hyperlink].
2. Concept and Design
2.1 By whom and when was the model of care developed?
The model of care was published in August 2010.
The development of the model of care was clinically led by Professor John Toy,
appointed by the SHA’s Medical Director, along with a Senior Responsible Officer,
Bill Gillespie, Chief Executive of Sutton and Merton Primary Care Trust.
Clinical experts were invited to form three reference groups, one for each of the
project workstreams. Each group consisted of 15-18 individuals from a range of
professions and joint Chairs were appointed from among its members. The
constitution of the groups was multi-disciplinary and multi-organisational. However,
the groups were not representative of their respective organisations, but experts in
their field. The groups met formerly once a month and with the project team
intermittently, tasked with providing evidence and clinical input to the development of
the recommendations.
In addition, an overarching expert reference panel was formed, comprised of the six
co-Chairs of the expert reference groups, the clinical lead, and other representatives
with a national remit or out of London perspective, to provide objective scrutiny and
assurance to the emerging recommendations as well as ensuring synergy with
national direction.
A patient panel was formed from members of Commissioning Support for London’s
patient and public advisory group with service user representatives from London’s
five cancer networks.
2.2 What does the model of care aim to achieve?
The two main aims of the Model of Care are to reduce the number of unnecessary
deaths from cancer and to improve patient’s experience of the care that they receive.
They will be achieved through the following key objectives that are set out in the
Model of Care:




Achieve earlier diagnosis
Reduce variation and delivering best practice
Reduce inequalities in access to and uptake of services
Reduce transaction costs
7
To do this, and following on from the recommendations in the case for change, the
model of care recommends that cancer care should be reconfigured to be delivered
by integrated provider systems which will foster the sharing of best practice and drive
improvements in services. Commissioners will commission services from ‘integrated
cancer systems’ rather than individual organisations, ensuring that pathways and
best practice are standardised.
2.3 What is the role of London Health Programmes in the process?
As the project management unit, LHP’s core purpose is ensuring that the model of
care is implemented. In doing so, LHP has facilitated the authorisation and
establishment of two Integrated Cancer Systems and will then aim to facilitate the
delivery of the model of care through these systems. LHP also works with
commissioners in helping to establish how pathways will be monitored and how
tariffs will be calculated. This can involve developing metrics and benchmarks for
monitoring quality, ensuring sufficient governance arrangements, and providing
analytical support to ICSs and commissioners where necessary.
2.4 What is an Integrated Cancer System?
There are two integrated cancer systems [hyperlink], London Cancer covers North
and East London and London Cancer Alliance covers south and west.
An integrated cancer system (ICS) is defined as a group of providers (primarily acute
trusts) that come together in a formal, governed way to provide comprehensive,
seamless cancer patient pathways. Integrated cancer systems will be commissioned
to oversee the provision of cancer care based on defined care pathways to meet
patients’ needs.
They are clinically led, have responsibility for delivering best practice care pathways
[hyperlink] for different tumour sites, and have responsibility for governing and
delivering services across the system.
They are the mode of delivery for the Model of Care and are detailed in section 3
below.
2.5 What is the difference between a cancer network and an ICS?
Integrated cancer systems will be significantly different from the existing cancer
networks in that they will have stronger governance and accountability frameworks
across providers of cancer care and have a relationship with commissioners based
on agreed output specifications. Pathways, rather than the individual services
themselves, will be commissioned, and incentives tied to the overall performance of
the system, rather than only at provider level. Currently cancer services are divided
into five cancer networks across London, and patient pathways can vary depending
on the type of cancer diagnosed. By adopting a more unified approach to cancer
treatment, treatment will become more consistent across London.
8
2.6 What will happen to existing cancer networks?
The current cancer networks bring together commissioners and providers for
populations (there are 5 networks in London) and are charged with improving cancer
care and outcomes. In 2012/13 the cancer network functions will either be fulfilled
by the ICSs – being responsible for MDTs, site-specific groups, ensuring peer review
is completed etc. – or commissioners. Two cancer commissioning teams will be
formed, one to face each ICS, and they will undertake some tasks once across
London. Commissioning governance arrangements will be put in place to bring
together the commissioners for each ICS, and a London-wide cancer commissioning
group will be put in place. More detail on commissioning is found in section 4.
2.7 What is outside the scope of the model of care?
Children and young people’s (C&YP) cancer services are outside the scope of the
current programme. This is because these are already commissioned by the London
Specialised Commissioning Group (SCG), although providers of C&YP services are
also members of the ICSs and London Health Programmes are working with them
and the SCG to improve the way care is delivered. Within the London Cancer ICS,
children and young people’s cancer will receive an additional focus from the system
for improvement [add LCA view as well].
Public awareness initiatives are also outside the scope of the programme. This is
because they are already covered by various local and national public health
initiatives, and are being covered by separate working groups within London. Since
the development of the Model of Care, LHP has worked with existing cancer
networks,and the London Health Improvement Board on a series cancer prevention
initiatives in the public health setting. ICSs will also be involved in early diagnosis
through influencing referral rates and improving capability to recognise early
symptoms by GPs, for example. Many of these initiatives are captured in the
document “Saving 1,000 Lives: Improving outcomes – A strategy for Earlier
Diagnosis of Cancer in London”, which has been developed by existing cancer
networks, providers, PCTs, public health bodies and many other stakeholders.
2.8 How have patients and non-clinical stakeholders been consulted during the
development of the model of care?
A cancer patient panel was formed from members of Commissioning Support for
London’s patient and public advisory group and service user representatives from
London’s five cancer networks. The patient panel also met on a monthly basis and
provided invaluable feedback on and input into the two documents and supporting
papers. The two co-chairs of the patient panel also sat on the cancer project board.
A stakeholder engagement event was held in November 2009 to share and seek
feedback on the draft case for change and emerging model of care. The event was
attended by over 120 people, including patients, a range of clinicians, and third
sector organisations. The feedback received from the event was written up and fed
into the development of the project documents, including this model of care.
9
2.9 Why was there a three month engagement period and what was the
engagement strategy?
An extended, three month engagement period followed the publication of the model
of care to ensure that the wide variety of stakeholders’ views, from inside and
outside London, were reflected in the final document. This included GPs, clinical
experts in specific field, commissioning groups and patients. This approach ensured
that requirements of the revised NHS Operating Framework 2010/11 regarding
service reconfigurations had been met.
2.10 What are the impacts of the government’s reforms on the proposals in the
model of care?
The publication of the model of care coincided with the change in government, and
subsequent need to ensure that structural changes within the commissioning
environment were addressed and views adequately reflected. The ICSs will need to
respond and reflect, in line with govt policies, as the health and social care bill
proceeds through parliament [to add]
2.11 Why is the focus on the acute trusts when early diagnosis is the area of
biggest concern?
At this stage, the biggest gains to patient outcomes are to be found in improving
acute trust service provision, with a focus on a more joined up and consistent
approach between trusts across boundaries, so as to build on and further develop
existing work. A person’s cancer pathway begins when they recognise and then act
on signs and symptoms, by ensuring that the best systems and infrastructure are in
place across acute trusts, and that commissioning is based on entire care pathways,
it is expected that the interface between screening and diagnostics and ongoing care
will become more seamless. The ultimate vision in the system specification sees the
inclusion of all service providers including primary care and third sector
organisations, working with rather than duplicating existing initiatives in awareness
raising, screening, diagnosis and subsequent treatment.
In the current implementation stage, focus is necessarily being directed to the
biggest opportunities for improving patient outcomes. The early diagnosis
workstream will ensure that this work is conducted in the context of overcoming
existing barriers to, and realising the gains of, early diagnosis, by making ICSs
accountable for the quality and level of care across the entire pathway, which begins
at diagnosing symptoms at the earliest stage.
2.12 One of the key recommendations of the 2010 health reform white paper
was that top down planning should not drive needs identification and service
design, how does this programme meet this aspiration?
The establishment of ICSs empowers providers to shape their own services by
monitoring overall pathway performance and understand variation in practice and
care delivery.
10
Best practice pathways and output specification metrics have been developed
through broad clinical consultation within commissioning groups and in partnership
with locally based providers and national centres of excellence. A patient panel was
established early on and their views incorporated into the Model of Care.
The aim of the implementation programme (described in section 3) is to ensure that
planning is based around models of best practice and takes into account national
and international evidence.
Recommendations in the model of care align to the 2011/12 NHS London Business
Plan, which identifies a commitment to support the development of new
commissioning arrangements in London. In setting out these intentions, NHS London
has outlined a commissioning development programme that focuses on the
realignment of clinical networks. The ICS system can be seen as linking closely to
this aim whilst being developed to specifically address the needs of patients and
improve outcomes and experience.
3. ICS Development and Implementation
3.1 What happened after the model of care was published?
A cancer implementation programme was established, hosted by London Health
Programmes [hyperlink], with the objective of implementing the recommendations in
the Model of Care. A specification for how services would work was written and
submissions from emergent ICSs were sought and then assessed by an evaluation
panel. The programme then moved into a phase of development and engagement
leading up to the implementation phase which is scheduled for the beginning of the
2012/13 financial year when pathway and system monitoring will begin.
Each stage is outlined below, and detailed in subsequent questions.
Specification
Feb
Mar
Submission
Apr
May
Jun
Assurance
Jul
2011
Aug
Development and engagement
Sep
Oct
Nov
Dec
Jan
Implementation
Feb
Mar
2012
Apr
May
3.2 Who made submissions to implement the model of care and how were they
assessed?
Two groups of cancer care providers made submissions against the integrated
cancer system specification on 30th June 2011, one covering north east and north
central London (‘London Cancer’) and the other covering north west, south west and
south east London (‘London Cancer Alliance’). The plans of these two proposed
integrated cancer systems were subject to an assurance process during July and
August 2011.
11
An evaluation panel made up of clinical experts, commissioners and patients, led this
assurance process and concluded that both proposed integrated systems should be
authorised subject to an agreed action plan and identified to each system the areas
that should be immediately addressed.
The recommendation of the evaluation panel was approved by the NHS London
Delivery Group (5th September) and the cancer implementation board (13th
September). As such, the integrated cancer system implementation programme
moved into a development and engagement phase.
3.3 What is the scope of the integrated cancer systems?
Integrated cancer systems will take ownership of and influence the whole of the
cancer care pathway (illustrated below). The performance of integrated cancer
systems will be assessed using outcome measures that span the whole care
pathway.
In the short term (i.e. by April 2012), integrated cancer systems will include all
London-based secondary and tertiary care providers in the system area. They are
responsible for:





Developing and standardising best practice pathways,
reducing local variations in access and quality of care,
improving localised services for common cancers where appropriate, and
consolidating specialist care for rarer cancers
improving patient experience.
3.4 What are the objectives and priority areas of each integrated cancer
system?
The system specification required that each ICS submission nominated priority
pathways for common and rare and specialist cancer types and/or system wide
priorities and use these priority areas to describe how they would improve working
12
across the constituent parts of the system. The below table outlines each ICSs
priority focus areas.
London Cancer
Member clusters: North East London,
North Central London
Director of Integrated Cancer: Charlotte
Williams
Chief Medical Officer: Prof. Kathy
Pritchard-Jones
Commissioning Lead: Will Huxter
Initial Priority areas:
 Common Cancers (Breast, Lung,
Colorectal and Urological)
 Rarer Cancers (Brain and Head &
Neck)
 User Engagement
 Earlier Diagnosis
 Living With & Beyond Cancer
(‘Survivorship’)
 Clinical Information
London Cancer Alliance
Member clusters: North West London,
South West London, South East London
Programme Director: Claire Dowling
Joint Clinical Directors: Prof. Arnie
Purushotham and [title] Justin Vale
Commissioning Lead: Paul Roche
Initial Priority areas:
 Acute oncology
 Breast cancer
 Lung cancer
 Oesophago-gastric cancer
 Survivorship
3.5 How will ICSs be held to account?
The two ICSs have different organisational structures so the way in which they will
be held to account, and the way in which they hold constituent providers to account,
will vary.
Commissioners will hold ICSs or their constituent hospital trusts to account through
contractual agreements. The ICSs will be given outcomes to deliver by
commissioners, who will hold the ICS and its providers to account for performance,
based on the care pathway contracts commissioned, through local contracts with
providers and ICS-wide incentives.
The development of care pathways (commissioning best practice pathways) and
relationships with the emerging ICSs will be overseen by two joint development
groups (JDGs), one for each ICS, that will allow commissioners and providers to
come together to progress in implementing the model of care and the development
of commissioning arrangements. including identifying metrics and developing
benchmarks; shadowing and subsequent planning for pathway tariffs, the
development and approval of system sanctions and incentives, the development of
service plans, and the development and implementation of consistent service
standards.
13
3.6 [CHo] How much will it cost to set up and implement the systems?
3.7 What are the financial implications of the implementation of ICSs to CCGs?
The overall financial analysis that underpins the model of care suggests that
improving earlier diagnosis – which will have the greatest impact on saving lives – is
likely to cost more than at present owing to the increase in diagnostic tests and there
may be savings related to the introduction of best practice such as enhanced
recovery and new follow up regimes. The concentration of some specialist surgical
services on to fewer sites and the localization of other services should not have a
marked impact. However the analysis is hampered by poor data; the coding, costing
and collections of cancer care is not well developed and this makes it difficult to
assess activity and costs by pathway. This will be addressed for the pilot
commissioning best practice pathways in 2012/13.
4. ICS Commissioning
4.1 Who will be commissioning the ICSs?
As the commissioning landscape changes and functions of existing clusters are
transferred to emerging clinical commissioning groups, it is proposed that local
commissioning groups, covering the same areas as ICSs are established as a forum
for delivering the local engagement, discussion and decision making required.
Consistency in commissioning will be ensured via a pan-London cancer
commissioning board. There will be a single lead commissioner for each ICS, who
will chair the Joint Development Group to oversee the relationship with the system.
4.2 What is the pan-London Cancer Commissioning board and who will be on
it?
The model of care recommended a London-wide governance board for cancer
services, which would set standards and monitor performance, including identifying
issues of concern regarding investment decisions, quality, performance and
outcomes.
To do this, a pan-London Commissioning Board will be established to replace the
programme implementation board and provide an overview across London. It is
proposed that this board will draw its membership from Clinical Commissioning
Groups, Specialised Commissioning Groups and Local Authorities as well as the
various working groups (Patient Panel, Early Diagnosis, Commissioning,
Radiotherapy Advisory and Survivorship) and will be supported by London Health
Programmes in 2012/13.
14
It is proposed that the pan-London Commissioning Board will report to NHS London
Delivery Group.
4.3 What does this mean for the way cancer services are commissioned in the
future?
A key model of care recommendation is that cancer services will be commissioned
on best practice pathways rather than individual services from individual providers. A
pathway approach to commissioning is characterised by aligning to best practice the
description, quality measures, activity levels and income; and for funding to be
directed on the basis of overall pathway activity rather than individual interventions.
Funds are transferred through a mixture of payment by results, penalties for missing
key performance indicators and additional funds (through CQUINs) for achieving
exceptional performance in agreed priority areas
4.4 What is a commissioning best practice pathway and how were they
developed?
A ‘commissioning best practice pathway’ is a clinically developed specification and
map of cancer care, which charts a patient’s journey from initial presentation to
recovery or end of life care.
The development of commissioning best practice pathways was clinically led through
pathway specific specialist groups comprised of clinical experts in their fields,
commissioners and commissioning support organisations, service providers and the
ICSs themselves. Commissioning best practice pathways are approved at the Joint
Development Groups which bring together lead commissioning, clinical and ICS
management staff. The below schematic outlines the governance arrangement for
agreeing best practice pathways.
Governance
ICS
Lead commissioner
Pathway Group
Clinical commissioners
Acute
Primary Community
Commissioning Support
Organisation
Evidence base - NICE / PROMS / PREMS / Other
Each pathway is accompanied by a detailed description (output specification) which
clearly states the expected type and frequency of services provided and will be used
by commissioners to mandate providers and hold them to account.
15
4.5 How were the output specifications developed?
Output specifications are the clinical narrative behind the best practice pathways and
clearly outline the expected types and levels of service patients can expect along the
care pathway. They will be included in provider contracts and be used to hold
providers to account. They were based on initial work by cancer networks in London
and have been developed in collaboration with clinicians working in the relevant
specialties, including surgeons and oncologists from London and beyond. They are
consistent with the Map of Medicine and NICE guidance and will form part of the
contracts between the lead commissioner and each Integrated Cancer System’s
(ICS) constituent providers. They will be monitored at ICS level and sit alongside the
agreed quality metrics, CQUIN, and plan for the delivery of the model of care.
The outcome specifications are intended to:
 Support the best practice pathways with a written description of best practice –
moving away from detailed service specifications, towards a focus on key
outcomes.
 Provide closer alignment between pathway descriptions, quality standards,
outcome measures and the way that services are monitored.
 Provide a common format across the two systems for commissioning cancer
pathways
4.6 What are the main advantages of commissioning on a pathway basis?
For patients:
Commissioning pathways will ensure patients receive the best care available in
across providers in London, and experience a seamless transition between
organisations in the provider system, leading to better care experience and
outcomes. For example, when care transfers from a specialist centre to their local
hospital or primary care, their assigned key workers (a Clinical Nurse Specialist, for
example) ensure continuity of care for that patient.
For commissioners:
Contract currencies to support the contracted pathway are a significant lever for
change. These incentives will be used to drive the behaviours and outcomes
expected of an integrated cancer system.
These, along with other levers, are currently in development and include:
– Best practice type tariff arrangements for bundled activity along the care
pathway.
-
CQUIN payments across an integrated cancer system.
– Possible sanctions where services do not achieve the standards or goals set
out in the model of care
16
For service providers
Transferring certain functions that have traditionally been managed by
commissioning organisations will empower ICSs to shape their own services. Further
information is provided in the next question
4.7 What will the ICSs do that was previously done by commissioners?
ICSs will take on responsibility for shaping the structure of services and managing
capacity and demand. By shaping services across the entire pathway rather than at
provider level, opportunities to innovate and improvement quality, as well as better
supporting patient choices will be fostered. In turn, commissioners can focus on
broader issues of population needs and priorities, whilst ensuring the best available
care is accessible to all through system commissioning.
The diagrams below demonstrate this transition within the commissioning cycle.
Current
2012/13
4.8 What is bundle contracting?
The term bundle contracting refers to those elements of a care pathway that will be
brought together in a contract between a commissioner and provider(s). For
example, treatment (chemotherapy, radiotherapy, surgery etc.) and follow up
(rehabilitation, psycho-social care, follow up assessments etc) may be purchased
together to provide a single integrated package of care for a patient.
4.9 How will tariffs be calculated?
In the first year of operation, the London wide best practice tariff bundles will be
monitored across four tumours (breast, brain, lung and colorectal) to assess what
17
are the best financial mechanisms to support pathway commissioning. In
determining this, the difference between current practice and the new best practice
pathways will be assessed, alongside the extent to which the type of care varies
between providers. The extent of the variance will determine the likely costs of
reconfiguring services to make them consistent across London, and will therefore
impact on the final tariffs.
Commissioners will review shadow arrangements in July 2012 to assess risk and
identify future cost pressures. The assessment will inform 2013/14 commissioning
intentions and the decision whether the roll out of other pathways will be shadowed
in 2013/14 or go live without shadowing over a 2 year period. The expectation is that
all pathways are in place from 1 April 2015, and those shadowed in 2012/13 will go
live in 2013/14.
The total cost for the shadow pathways will be reviewed by commissioners on an
annual basis.
4.10 Is there a risk that handing over responsibility for aspects of the
commissioning cycle to ICSs will transfer too much power to providers?
The transfer of the power to innovate and improve quality and efficiency of services
across the pathway to providers is one of the key objectives of this project. With this
in mind, once established ICSs will inherit the responsibility for shaping the structure
of service provision and plan for capacity and demand within the system. Patient
choice is central to the development of these services. Once in place, commissioning
groups will focus on reviewing service provision against population needs and
priorities, the process for which is detailed below.
4.11 How will the performance of services covered by the two ICSs be
monitored and measured?
Close monitoring of the ICSs and constituent providers will be ensured through the
incorporation of a series of benchmarked metrics into service contracts, jointly
identified by commissioners and ICSs. Performance will primarily be monitored by
tumour type and not by organisation, and away from monitoring inputs and
processes (such as quantity and frequency of treatments) and towards monitoring
outcomes (such as the experience of patients and the impact on 5 year survival
rates). .
The process for reporting and monitoring is explained further in here.
4.12 What is the difference between commissioning measures and other
measures clinicians will use to ensure best practice?
Commissioner measures are a limited set of high level, predominantly system wide
measures such as referral to treatment times, access to specialist carers and
survival rates, and are tagged to payments. Clinicians in pathway groups will use a
broader set of pathway specific measures to measure effectiveness and identify
opportunities for change and improvement.
18
4.13 What other incentives will be used by commissioners for enhancing
quality of care?
Commissioning for Quality and Innovation (CQUIN) incentives are currently being
developed by commissioners. Options include system wide CQUINs for improving
staging data collection (as a proxy for measuring early diagnosis) or the provision of
holistic needs assessments and discharge summaries (as a proxy for improved
patient experience).
4.14 Why a system wide CQUIN?
The London Cancer Programme Implementation Board signed off the proposal that a
CQUIN is used to incentivise Integrated Cancer Systems (ICSs) to improve cancer
services. In doing so, this will encourage collaborative working across all trusts in an
ICS, using a financial incentive as an appropriate lever to encourage collaboration
and change.
4.15 Will additional cancer CQUINs be developed in the future?
Yes. As specific elements of service provision are improved, and new areas for
improvement are identified, it is envisaged that new CQUINs will be developed each
year, parallel to the yearly review of pathway effectiveness and pressures, to
encourage continual reflection and improvement. These may replace existing
incentives or be in addition to them.
5. ICS Governance and Information Governance
5.1 In the future system of governance and management, what is the remit of:
(a) Commissioners
Commissioners will be responsible for assessing population needs, commissioning
and reviewing quality of services provided by the ICSs
(b) ICSs
The ICSs are designed to support providers working together to deliver less
fragmented and more consistent care. They will take responsibility for driving up
quality and outcomes across the whole care pathway. The ICSs will also take over
and reform the site specific tumour groups run by the current networks.
(c) Providers
Providers will be responsible for delivering care services, to the specifications of
agreed best practice pathways. They will also be required to gather data on the
system and outcome measures to feed to ICSs.
19
5.2 How does the governance structure take into account the changing nature
of the commissioning environment?
The shift from five cancer networks to two commissioning support organisations is
significant, given the amount of knowledge and expertise contained within the
current structures.
Joint Development Groups have been established to ensure that expertise within the
London cancer community is not lost during this time of transition. The groups bring
together commissioners and the ICSs, along with patients and clinical and
managerial staff throughout London, to ensure coherence and timely decisionmaking on issues relating to the development of the ICS, implementation of the
cancer strategy, the commissioning arrangements, and other appropriate cancer
related business.
The Joint Development Groups will also serve as a forum in which to agree revisions
to best practice pathways along with the local descriptors and benchmarks, which
will then be used by the lead commissioner in the contractual process with the ICS.
5.3 What are the metrics by which ICS performance will be measured?
In the first instance there will be a broad selection of generic and tumour specific
measures tracking all aspects of quality and effectiveness of the systems, and fewer
measures over time as systems become more established.
A series of initial priority metrics have been selected by commissioners and agreed
with ICSs. These have been selected to ensure system effectiveness can be
assessed. As such, they focus primarily on generic measures such as waiting times,
ease of access to treatment centres, access to specialist carers, rates of
readmission and survival rates.
Each of the metrics will be benchmarked and stretch targets agreed upon to reflect
improved services. In some cases, existing national benchmarks exist and will be
monitored from 1 April 2012, for others data will need to be monitored over the first
year and benchmarks developed in partnership with commissioners and ICSs.
The metrics and expected targets will be included in provider contracts through
which providers will be held to account.
5.4 How will data be recorded and reported?
Where possible, existing reporting mechanisms will be used.
The key difference is that, in the future, reporting may supplied to commissioners
from providers via a system lead who will have responsibility for delivering both
Quality Reports and ensuring data collection requirements are being met. It is also
envisaged that data registries will be used where possible and new ways of
capturing and interpreting data (e.g. East of England’s Encore cancer registry) will
incorporated into the reporting system.
20
The below schematics outline the high level proposals for potential informatics
systems structures and reporting flows from provider to commissioner. Into the
future, data gathering tools such as Encore (developed by East of England) may
simplify the data collection process and allow commissioners to draw directly from
providers.
Integrated Cancer System
Provider
Provider
Commissioning
Group
TCR
5.5 When will the pathways go live?
The four initial best practice pathways (breast, brain, lung, and colorectal) will go live
from April 2013 after one year of monitoring, with pathways for other tumour types
going live in April 2014. Once this happens, commissioning groups will no longer pay
for individual services offered by providers but for the entire pathway of treatment a
patient will be provided with across providers, presented as a holistic package by
ICSs.
6. Future Development
6.1 What will happen after 2012/13?
Monitoring of the four commissioning best practice pathways will begin on 1 April
2012....
6.2 What is the ultimate ambition of the ICSs?
The ultimate ambition of the ICSs aligns to that of the Model of Care and is to
improve the standard of cancer care in London to improve clinical outcomes (such as
survival rates), improve prevalence rates, and improve the experience of patients
who are diagnosed with cancer
In achieving this, the ultimate vision in the system specification sees the inclusion of
all service providers including primary care and third sector organisations, working
with rather than duplicating existing initiatives in awareness raising, screening,
diagnosis and subsequent treatment....
21
Appendix 1- Pathway to system going live: Critical Milestones
Completed
1
2
Critical Milestone
Project Initiation Document
Case for Change
3
Model of Care
August 2010
4
Service Specification
May 2011
5
ICS Service Plan submissions received
June 2011
6
Completion of commissioner assurance
process
ICS project plans developed
September
2011
November
2011 to
February 2012
Critical Milestone
Formal assessment of ICS service plans
for 2012/13
Identifying Pathway Directors for each ICS
Due
March 2012
Pathway scorecards and minimum data
quality measures by pathway agreed.
Output specifications and CQUINs placed
in trust and ICS contracts
Annual plans agreed. ICS commissioning
starts
Governance arrangements for 2012/13 in
place.
Review of initial (breast, colorectal, brain,
lung) pathway performance/currencies
All pathways go live
March 2012
7
8
9
10
11
12
13
14
15
March 2010
March 2012
March 2012
April 2012
April 2012
May 2012-April
2013
April 2014
Key Documents
Case for Change
Model of Care
System Specification
Implementation Support documents
22