Decision Handbook
A reference guide for making effective transformation programme
decisions
This information
is confidential
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by Bainby
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Why focus on decisions?
Situation
Complication
Resolution
• Demand for health services is growing faster than funding
• There is consensus that the health service must deliver better value
• Devolved authority, matrixed accountability and divergent incentives in
the NHS produce impasses, inefficient process and sub-optimal results
• A new approach that moves beyond org structure is needed to deliver the
best possible value for patient and public
A focus on decisions
can cut through this complexity
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The purpose of the handbook is to…
Help the health service deliver
better value for patients and public
Guide effective decision making
across all organisations
Support Finance as leaders in driving
robust value-based decision making
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What the handbook is and is not
WHAT IT IS
WHAT IT IS NOT
Framework and approach for managing
and making value-based decisions
Tool to structure analysis or
build a business case
Guide on what to consider, who to
involve and the process to follow
Guide to negotiating
with stakeholders
Single source for tools, templates and
data helpful for each step
Methodology to evaluate results
after a decision has been made
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Who the handbook is for
It is useful for everyone involved in the process of making decisions that
impact value:
• For those who make and coordinate decisions it provides a rigorous
and structured end-to-end process to drive value-based decision making
• For those who have a key input role and make recommendations it
provides clarity on the big picture and helps guide the evaluation process
• For those who provide input and analysis it provides context on the
overall process and links to tools, templates and data to help them input
HELPFUL HINT
Click on the
symbols
throughout the handbook to
jump to resources and tools
related to the topic
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How to use this handbook
Most people won’t find reading the guide beginning-to-end an efficient use of
time. Depending on your role, we recommend focusing on different sections.
If you are a…
Chief Executive
CFO / Finance
Director
Commissioning /
Transformation
Director
Then you should…..
Before your decision process starts
• Study the NHS approach section closely
• Adapt the example decision set-up, roles and timeline to your situation
• Review and sense-check the high-level role of finance, use it as your guiding star
As you move through the decision process
• Reference the “how” as you start each step (x4) to ensure critical pieces aren’t missed
• Refer your direct reports and colleagues to relevant tools in the appendix
Deputy Finance
Director
Before your decision process starts
• Review and understand the NHS approach , “What is value” and big picture
• Scan the appendix for helpful tools, data sources and resources
Commissioning/
Transformation
Head
As you move through the decision process
• Focus on the role of finance to understand where you should be inputting
• Reference the “how” when starting each step for awareness of all moving parts
Finance
Manager
• Review and discuss the “What is value” with colleagues to see how you can
integrate non-finance elements of value into your analysis
• Scan the appendix for helpful tools, data sources and resources
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
DECISION HANDBOOK
APPENDIX
TIP: Click on any of the text
below to skip to that section
Contents
APPROACH
• NHS approach to effective decision making
• An holistic definition of value
DECISION HANDBOOK
• “What, who, how and when” - setting the decision up for success
• “How” - deeper look at critical elements for each step in the process
• Role of finance - key actions, analysis, data and tools for finance
APPENDIX
• Data sources and links
• Data tools and links
• Star modelling tool for value-for-money analysis
• AID model for QIPP prioritisation
• Stakeholder map and public engagement tool
• Programme budgeting marginal analysis
• Integrated Risk and Impact Assessment Tool
• Decision Trees
• Full Business Case template
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
DECISION HANDBOOK
APPENDIX
Setting up decisions for success requires focus on the “whatwho-how-when”
1
•
Define the decision we are
actually trying to make
Frame the decision in an
appropriate way
Split into sub-decisions if
necessary
•
•
4
•
•
What
When
Clarify timeline for decision and
execution, and key milestones
Consider creating a decision
calendar for on-going,
interconnected decisions
2
•
Who
Clarify upfront who will play what
role in each decision (e.g.
decision-maker, recommender)
3
How
• Install structured decision
approach
• Design and specify:
- Interactions
- Critical meetings/committees
- Closure and commitment
- Feedback loops
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
The “What”: Clear and correct definition of the decision and
its sub-decisions
Defining the decision
• Clarify exactly what decision is
under consideration:
-Make sure everyone is on the
same page regarding how to
define the decision being made
-Frame the decision correctly so
participants can make appropriate
tradeoffs
-Unbundle the decision into its
sub-decisions before working
through next steps
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
The “Who”: The RAPID® framework provides a simple
tool for allocating decision roles
WHAT THE ROLES ARE
HOW THE ROLES INTERACT
Recommend a decision or action
Recommend
Agree
Input
Input
Formally agree a recommendation
• Must be consulted
• Must work with R to resolve issues
Agree
Perform
Input
Recommend
Perform a decision once
made
Decide
Input
Decide
®
Provide input to a recommendation
• Must be consulted, may or may
not be reflected in final view
Make a final decision and commit
the organisation to action
Perform
RAPID should reflect what
will work in 90% of
situations
RAPID is a registered trademark of Bain & Company, Inc.
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
The “Who”: RAPID® roles imply a set of responsibilities
TIPS & TRICKS
Recommend
®
• Only one R – person who does 80% of the work to develop recommendation
• R has broad visibility and access to information for relevant inputs
• R has credibility with both Is and D
Agree
• Like an Input “with teeth” – must be factored into the recommendation
• Must work with R to resolve any issues
• A is on the R – D breaks a deadlock
Perform
• May be multiple Ps
• May involve P as an I to help upfront planning
Input
• Can be multiple Is, but must be consulted, may or may not be reflected in final view
• Assigned only to those with valuable information which could change the decision
Decide
• Only one D for each decision
• Locate the D at the right level in the organisation (access to information, reaction times, ability to
make tradeoffs
• If D belongs to a group, clarify how it gets exercised
RAPID is a registered trademark of Bain & Company, Inc.
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
Who
When
How
Pre-decision
What
DECISION HANDBOOK
APPENDIX
The “How”: Combination of the right people and information
in the right sequence to make decisions
Criteria
• We establish clear criteria for how we will evaluate options / make decision
Critical steps
• We are clear which facts and evidence need to underpin decisions; working
from one version of the truth for decision inputs
• Necessary pre-decision steps
Choices
Committees
• We ensure we consider the full range of alternatives
• We evaluate alternatives vs. agreed criteria using rigorous data and analysis
• We make effective use of committees and meetings throughout the
decision process
Post-decision
DECISION
Communication
• We clearly communicate decisions once made to all relevant stakeholders
• Once a decision is made, we move swiftly to launch execution
Closure
- Resources allocated (people and money)
- Execution plan in place (actions, accountabilities and milestones)
- Feedback loops in place to drive fast corrective action or replicate successes
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
The “When”: Clarification of the timing for the programme
and each sub-decision before the process starts
For
illustration
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APPROACH
DECISION HANDBOOK
APPENDIX
TIP: Click on any of the text
below to skip to that section
Contents
APPROACH
• NHS approach to effective decision making
• An holistic definition of value
DECISION HANDBOOK
• “What, who, how and when” - setting the decision up for success
• “How” - deeper look at critical elements for each step in the process
• Role of finance - key actions, analysis, data and tools for finance
APPENDIX
• Data sources and links
• Data tools and links
• Star modelling tool for value-for-money analysis
• AID model for QIPP prioritisation
• Stakeholder map and public engagement tool
• Programme budgeting marginal analysis
• Integrated Risk and Impact Assessment Tool
• Decision Trees
• Full Business Case template
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
DECISION HANDBOOK
APPENDIX
Making a value-based decision requires a definition of value and
its components
Outcomes
1
Clinical
outcome
e.g. population health,
survival rate, extent of
functional recovery
2
Patient
experience
e.g. comfort, treatment
by staff, waiting time,
ease of access
3
Safety
e.g. diagnostic error,
post-op complications,
infections
Value
Resources
4
Revenue costs
e.g. income, time,
salaries, system
maintenance, facilities
5
Capital costs
e.g. Investment in
infrastructure /
equipment
Value can be increased by improving outcomes for a given resource level
or by reducing the resource required to deliver a given outcome
Source: based on Michael Porter (HBR, NEJM), HFMA “Value in Health Care”, Delivery Group interviews
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APPROACH
DECISION HANDBOOK
APPENDIX
Criteria and metrics within each component of value must be
defined depending on the specific decision
COMPONENTS OF VALUE
1
Clinical
outcome
2
Outcomes
Patient
experience
3
Safety
4
Resources
5
Revenue
costs
Capital
costs
CRITERIA (EXAMPLES)
METRICS (EXAMPLES)
• Population health
• Prevalence of conditions within population
• Outcome of interventions relative to patient
expectations
• Hospital / emergency admission rate
• Degree and speed of recovery
• Mortality rate
• Sustainability of health
• Re-admittance rate
• …
• …
• Ability to access care
• Distance to care facility
• Care environment (e.g. facilities, comfort)
• Waiting time for first appointment
• Personal interactions (e.g. care and respect)
• Specialists per population
• Timeliness of interactions
• Time between referrals and number of referrals
• Availability of information
• Patient feedback on experience with interactions
• Involvement in decision-making
• Patient Net Promoter Score
• …
• …
• Diagnostic errors
• Diagnostic error rate
• Post-operative complications
• Complication rate
• Medication errors
• Medication error rate
• …
• …
• People
• Income
• Facilities
• Salaries
• Equipment
• Time
• ..
• System running costs
• Investment in facilities / equipment
• Capital requirement and rate of return
• …
• …
• Quality of recovery (e.g. visual ability post-Cataract op)
Source: based on Michael Porter (HBR, NEJM); HFMA “Value in Health Care”; Delivery Group interviews
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APPROACH
DECISION HANDBOOK
APPENDIX
An holistic value definition must be embedded in the “what-whohow-when” to achieve best possible value in decision making
1
What
Who
2
Getting the right people
engaged to ensure focus on
system-wide value
Framing your decision context,
objectives and constraints
using a value perspective
4
When
Starting at the right time,
with the right timetable and
milestones to make considering and
delivering better value possible
How
3
Taking the right steps,
through the right process
with the right analysis
for an integrated value approach
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APPROACH
DECISION HANDBOOK
APPENDIX
TIP: Click on any of the text
below to skip to that section
Contents
APPROACH
• NHS approach to effective decision making
• An holistic definition of value
DECISION HANDBOOK
• “What, who, how and when” - setting the decision up for success
• “How” - deeper look at critical elements for each step in the process
• Role of finance - key actions, analysis, data and tools for finance
APPENDIX
• Data sources and links
• Data tools and links
• Star modelling tool for value-for-money analysis
• AID model for QIPP prioritisation
• Stakeholder map and public engagement tool
• Programme budgeting marginal analysis
• Integrated Risk and Impact Assessment Tool
• Decision Trees
• Full Business Case template
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
DECISION HANDBOOK
APPENDIX
How to read the pages in this section
What
Who
When
How
“WHAT” - DECISION CHARTER
What
Who
When
How
“WHO” - DECISION ROLES
Decision roles
(R-A-P-I-D) of all
key players for
each sub-decision
Context, objectives
and constraints set
up the decision for
success
What
Who
When
How
“WHEN” – TIMELINE
What
Who
When
How
“HOW” – DECISION COMPONENTS
A reasonable
timeline for the
decision process
with key
milestones
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
A high-level
summary of
critical steps
through the
decision process
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APPROACH
DECISION HANDBOOK
APPENDIX
Decision roadmap: “what-who-how-when”
1
•
Define the decision we are
actually trying to make
Frame the decision in an
appropriate way
Split into sub-decisions if
necessary
•
•
4
•
•
What
When
Clarify timeline for decision and
execution, and key milestones
Consider creating a decision
calendar for on-going,
interconnected decisions
2
•
Who
Clarify upfront who will play what
role in each decision (e.g.
decision-maker, recommender)
3
How
• Install structured decision
approach
• Design and specify:
- Interactions
- Critical meetings/ committees
- Closure and commitment
- Feedback loops
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
The decision charter should be framed to emphasise
system-wide value, including objectives and constraints
Decision
Decide how to improve value and bridge a £4M resource gap in the health economy
Context
NHS data indicate that a CCG responsible for a small northern industrial town of
~200,000 people is underperforming relative to its demographic peer group in several
service areas. Their budget allocation will increase 5% next year to £210M, while
projected outlays with no commissioning changes are expected to increase 7% to
£214M. The CCG must decide how to improve value and bridge the £4M resource
gap in the health economy, and ensure providers implement the necessary changes.
• Improve value (cost, outcomes, safety and experience) delivered by the health system
• Deliver services more efficiently to meet population’s health needs
Objectives
• Changes are sustainable within the broader health economy
• Providers support and implement the changes
• Must reduce projected outlays by £4M
• Manage resources within the financial framework set by NHS England
Constraints
• Must align with CCG strategic plan and adhere to CCG governance rules
• Must be acceptable to public/political officials and regulators
• Should be acceptable to clinical staff, financial staff and patients
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
Example value criteria and metrics for this decision
should be adapted to match your decision context
COMPONENTS OF VALUE
CRITERIA
1
Clinical
outcome
3
5 Capital
costs
•
Prevention (e.g. ratio of hypertension v. heart failure prevalence, % of CHD
patients on aspirin)
Prevention
•
Diagnosis (e.g. % of cancers detected at an early stage)
•
Outcome of intervention relative to patient
expectations
•
% patients treated to a pre-defined care standard (e.g. 8 Key Care Processes for
Diabetics)
•
Patient recovery
•
Recovery (e.g. % of patients discharged home)
•
Sustainability of health
•
Survival rate (e.g. 1 year net cancer survival rate)
•
Re-admittance rate (e.g. emergency re-admission to hospital within 28 days (%):
stroke)
•
Distance to care (e.g. average distance for emergency admission)
•
Waiting times (e.g. TIA cases treated within 24 hrs)
•
Specialists per population (e.g. proportion of non-STEMI patients seen by member
of cardiology team)
•
Time between referrals (e.g. % of cancers receiving treatment within 2 months of
GP referral)
•
Clinical assessment incidents
•
Treatment/procedure incidents
•
Medication incidents
•
Access to care
•
Experience in care
Safety
Revenue
costs
Prevalence (e.g. hypertension prevalence relative to peer group)
•
•
4
•
Population health
2
Patient
experience
METRICS (EXAMPLES)
•
Outcomes
Resources
APPENDIX
NRLS safety incidents by type (e.g. “clinical
assessment” incidents compared to peer
group)
•
Delivery model / cost structure
•
•
Activity (total)
Activity rates (e.g. imaging frequency)
•
•
Clinician salary
Total programme spend relative to peer group (e.g. spend on primary care
prescribing for CHD)
•
Admin staff salary
•
•
System running costs
Elective/Non-elective programme spend (e.g. spend on non-elective admissions for
GI cancer)
•
Investment in facilities / equipment
•
Capital requirement and rate of return
•
…
•
…
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
This CCG transformation programme decision has four
key sub-decisions
Decision: Decide how to improve value and bridge a £4M resource gap in the health economy
Set Up
Establish
Charter
Frame
Decision
Define
Roles
Execution
Define
Key
Criteria
Key sub-decision
Where
To Look
Determine areas with greatest
opportunity for improved
outcomes/cost reduction
1
What
To Change
NHS
Right Care
Approach
Determine how to improve each
opportunity area and the preferred
option(s) for improvement
2
3
Determine
deliverability of
preferred option(s)
How
To Change
4
Closure
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
Decide whether to
proceed with preferred
option(s) and
implementation plan
Communicate
To
Stakeholders
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APPROACH
DECISION HANDBOOK
APPENDIX
Decision roadmap: “what-who-how-when”
1
•
Define the decision we are
actually trying to make
Frame the decision in an
appropriate way
Split into sub-decisions if
necessary
•
•
4
•
•
What
When
Clarify timeline for decision and
execution, and key milestones
Consider creating a decision
calendar for on-going,
interconnected decisions
2
•
Who
Clarify upfront who will play what
role in each decision (e.g.
decision-maker, recommender)
3
How
• Install structured decision
approach
• Design and specify:
- Interactions
- Critical meetings/ committees
- Closure and commitment
- Feedback loops
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
RAPID® roles for this decision are designed to maximise
decision effectiveness and can be adapted to your context
Decision: Decide how to improve value and bridge a £4M resource gap in the health economy
R
Recommend
Local
Authority
1
A
CCG
Board
CCG
chief
exec.
officer
Clinical
Senate
Council
Perform
Health &
Well-being
Board
I
Trust
Board
Input
D
Trust
Trust
clinical
finance
Consultdirectors
director or
ants
or
equivalent
equivalent
Decide
Clinical
Experts
Wider GP
Community
A
I
Regulators
R
A
I
I
Determine how to improve each opportunity area and the preferred option(s) for improvement
I
R
I
I
I
Determine deliverability of preferred option(s)
I
4
CCG
CCG
commissfinance
oning
director or
director or
equivalent
equivalent
A
D
3
P
Determine areas with greatest opportunity for improved outcomes/cost reduction
D
2
Agree
D
A
R
I
A
I
Decide whether to proceed with preferred option(s) and implementation plan
D
R
A
I
A
P
P
Key sub-decision
Ensuring stakeholders understand their RAPID® role up-front will improve
efficiency, reduce impasses and improve decision quality
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
The role of finance in this process changes across subdecisions
Key sub-decision
Sub-decision
Role of
Finance
1
Determine areas with
greatest opportunity for
improved outcomes/cost
reduction
Drive integration
of finance and
outcome/quality
analyses
2
Determine how to improve
each opportunity area and
the preferred option(s) for
improvement
3
Determine deliverability of
preferred option(s)
4
Decide whether to
proceed with preferred
option(s) and
implementation plan
Own rigorous
analysis and
insight
generation
RAPID
Intensity of
Involvement
• Generate a broad range of options for consideration
A
I
A
Lead on
delivering value
Actions
R
• Translate activity and non-financial data into financial
terms; share insights with CCG commissioning director
• Push for rigorous evidence and assumptions on financial
and non-financial benefits
• Assist integration of financial/non-financial analyses into
cohesive value assessment
• Identify, quantify and assign probabilities to resource
based limiting factors, barriers and risks
• Offer finance view on non-financial limiting factors,
barriers and risks
• Responsible for compiling full business case and
presenting recommendation to the board
• As board member, push to integrate financial/nonfinancial analyses into a unified assessment of value
Key
= High intensity
= Medium intensity
= Low intensity
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APPROACH
DECISION HANDBOOK
APPENDIX
Decision roadmap: “what-who-how-when”
1
•
Define the decision we are
actually trying to make
Frame the decision in an
appropriate way
Split into sub-decisions if
necessary
•
•
4
•
•
What
When
Clarify timeline for decision and
execution, and key milestones
Consider creating a decision
calendar for on-going,
interconnected decisions
2
•
Who
Clarify upfront who will play what
role in each decision (e.g.
decision-maker, recommender)
3
How
• Install structured decision
approach
• Design and specify:
- Interactions
- Critical meetings/committees
- Closure and commitment
- Feedback loops
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Mapping the decision process supports proper
sequencing and execution of all critical steps
Decision: Decide how to improve value and bridge a £4M resource gap in the health economy
Set Up
Establish
Charter
Frame
Decision
Define
Roles
Where
To Look
Map
resource
use by
population
group
Execution
Define
Key
Criteria
Gather
clinical
and
provider
input
What
To Change
NHS
Right Care
Approach
Key sub-decision
Review
Risk
Stratification
Assess
baseline
costs
Analyse
benchmark
data (e.g.
Commissioning for
Value pack,
SPOT, etc.)
Input and
agreement
Review
from
JSNA
Health &
Wellbeing
Board
Align
stakeholders
on key
criteria
1
Determine areas with greatest
opportunity for improved
outcomes/cost reduction
Conduct
Service
Reviews
Input from
stakeholders
(e.g. Health &
Wellbeing
Board)
Define
optimal
Appraise
service
relative
based on
options
proven
models
Compile risk
appraisal
and
mitigants
Assess
wider
system
impact
2
Seek agreement from
Trust board and CCG
finance on
recommendation
How
To Change
Determine
deliverability
of preferred
option(s)
Develop full
business case
including impact
assessments
Closure
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
3
Determine how to improve
each opportunity area and
the preferred option(s) for
improvement
Decide whether to
proceed with
preferred option(s)
and implementation
plan
Agree terms
with providers /
market
4
Communicate
To
Stakeholders
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APPROACH
DECISION HANDBOOK
APPENDIX
Decision roadmap: “what-who-how-when”
1
•
Define the decision we are
actually trying to make
Frame the decision in an
appropriate way
Split into sub-decisions if
necessary
•
•
4
•
•
What
When
Clarify timeline for decision and
execution, and key milestones
Consider creating a decision
calendar for on-going,
interconnected decisions
2
•
Who
Clarify upfront who will play what
role in each decision (e.g.
decision-maker, recommender)
3
How
• Install structured decision
approach
• Design and specify:
- Interactions
- Critical meetings/ committees
- Closure and commitment
- Feedback loops
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Decision timeline of a ‘good case’ scenario
Where
To Look
1
Mo 10
Mo 9
Mo 8
Mo 7
Determine areas with greatest opportunity for improved
outcomes/cost reduction
Iterative process,
misaligned incentives
and behaviours can
extend this process
Announce commissioning Intentions / notice of
desired changes
2
Mo 6
Mo 5
Mo 4
Mo 3
Mo 2
Decision Calendar
Mo 1
Decision: Decide how to improve value and bridge a £4M resource gap in the health economy
Determine how to improve each opportunity area and the
preferred option(s) for improvement
What
To Change
Identify smaller quick-wins within the overall plan
Identify larger scale transformative changes
How To
Closure
Change
3
Determine deliverability of preferred option(s)
4
Decide whether to proceed with preferred option(s) and
implementation plan
Announce implementation plan
Sign new or amend existing contracts
Key sub-decision
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APPROACH
DECISION HANDBOOK
APPENDIX
TIP: Click on any of the text
below to skip to that section
Contents
APPROACH
• NHS approach to effective decision making
• An holistic definition of value
DECISION HANDBOOK
• “What, who, how and when” - setting the decision up for success
• “How” - deeper look at critical elements for each step in the process
• Role of finance - key actions, analysis, data and tools for finance
APPENDIX
• Data sources and links
• Data tools and links
• Star modelling tool for value-for-money analysis
• AID model for QIPP prioritisation
• Stakeholder map and public engagement tool
• Programme budgeting marginal analysis
• Integrated Risk and Impact Assessment Tool
• Decision Trees
• Full Business Case template
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Decision component snapshot for sub-decision one
1
2
3
4
Sub-Decision: Determine areas with greatest opportunity for improved outcomes/cost reduction
RAPID Roles
D
CCG board
Criteria
CCG
commissioning
head
R
A
CCG finance head
Critical Steps
• Focus on areas where
underperforming relative to
demographic peer group clinically
or financially
A
Health & Wellbeing
Board
I
Trust finance head
Choices Considered
I
Trust clinical
directors or
equivalent
Committees
• Map resource use by population
group
• Programme/pathway budget
allocations
• Refresh/review risk stratification
• Provider/care setting allocations
• Assess baseline costs
• Contracting frameworks (e.g.
needed
payments linked to outcomes, lead • Transformation Stakeholder
provider arrangements, capitation)
Working Group or equiv.: Joint
• Investment in self-managed care
provider / commissioner group
(e.g. web-accessible integrated
- Input mechanism for Trust finance
and Trust clinical heads
digital care records)
• Health & Wellbeing Board:
• Decommissioning services
includes local authority, public
health, Healthwatch, head of adult
and children's social services reps
• Focus on populations that consume
• Analyse peer group, patient and
the most resources
provider benchmark data
• Seek to incorporate cost, quality,
• Review Joint Strategic Needs
safety and experience
Assessment, and long-term
considerations to deliver best
strategic priorities of CCG,
possible value
stakeholders and Health &
• Alignment with CCG long-term
Wellbeing Board
strategic priorities, JSNA and other
• Gather patient input
key stakeholder priorities
• Asset / facility utilisation
• Clinical Reference Group or
equivalent: commissioning board
sub-committee of clinicians
-
commissioning head gathers Input as
-
Commissioning head seeks
Agreement. Recommendation must
reflect views, even if dissenting
DECISION
Communication
• Send “influencing paper” with high-level case for change opportunities and
forward view to commissioning, provider, patient and public stakeholders
Click these icons throughout the
Handbook for additional resources
Closure
• Commissioning director or equivalent initiates programme/pathway
review and stakeholder engagement through the Clinical Reference
Group
• CSU or internal business intelligence staff allocated for further analysis
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Decision component snapshot for sub-decision two
1
2
3
4
Sub-Decision: Determine how to improve each opportunity area and the preferred option(s) for improvement
RAPID Roles
D
CCG chief
executive
R
Criteria
CCG
commissioning
head
A
Clinical
experts
I
CCG
finance
head
Critical Steps
• Changes evaluated on their
projected effect on cost,
quality, safety and patient
experience
• Must be feasible to deliver
within the required time horizon
• Must not render other parts of
the health and social care
economy unsustainable (e.g.
impact on specialist/NHS
services, provider-level
economics, etc.)
I
Trust
finance
head
I
Trust
clinical
directors
I Consultants
Choices Considered
• Align stakeholders on criteria for
evaluation
• Conduct service reviews
I
Wider GP
community
Committees
• Clinical Reference Group or
• Contract Management (e.g.
reducing outpatient follow up ratios
equivalent: commissioning board
to peer averages)
sub-committee of clinicians
Policy Change: policies covering
• Appraise relative options (expected •
admissions, prescribing, etc.
outcome and benefit)
• Service or Pathway Redesign
• Assess wider system impact
Allocative (e.g. reallocate from
• Determine if public consultation is •
child to elderly care, invest in
required
prevention)
• Provider/partner arrangements
(e.g. retender)
-
Commissioning head seeks
Agreement from clinical experts
Recommendation to the CEO must
convey views of expert clinicians,
even if dissenting
• Transformation Stakeholder
Working Group or equiv.: Joint
provider / commissioner reference
group
-
• Best practice models preferred
to those which are untested
Commissioning head seeks Input
from consultants, GP, trust finance
and trust clinical directors
DECISION
Communication
Closure
• Commissioner submits clinical communication with rationale/preliminary
case for change, including population health, to all clinical stakeholders
• Commissioning and finance directors accelerate the viability assessment,
reengaging provider finance and clinicians, regulators and patient groups
• Commissioner submits a Letter of Commissioning Intention to:
• Clear competitive issues with regulators, and clinical issues with CQC
-
Trust / Provider senior management
Other commissioners if joint commissioning
• Finance / business intelligence staff are allocated for support
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Decision component snapshot for sub-decision three
1
2
3
4
Sub-Decision: Determine deliverability of preferred option(s)
CCG
RAPID Roles
D CCG Board
R commissioning
head
Criteria
CCG
finance
head
A Trust Board
I
Local Authority
• Level of political / public
support
• Availability of resources to
implement
• Ability to sustain the change
over multiple years
-
Concerns of Local Authority
Financial impact on providers
Concerns of clinicians and expert
patient groups
• Compile risk appraisal
including clinical,
commercial, operational,
implementation and timescale
risks, scores and mitigants
I Regulators
Committees
• Identify limiting factors (e.g. people, • Proposal is deliverable / not
deliverable
equipment, shortage of GP’s,
insufficient number of trainers, etc.) • Parts of the proposal are
deliverable
• Identify potential barriers including:
• Level of provider support
Health &
Wellbeing
Board
I
Choices Considered
Critical Steps
• Simplicity is preferable to
complexity
• Funding should follow
outcomes
A
• Health & Wellbeing Board:
includes local authority, public
health, Healthwatch, head of adult
and children's social services reps
• Parts are deliverable now, parts are
deliverable later
• Recommend modifications to
proposal that make it more
deliverable
-
Commissioning head seeks Input
from Health & Wellbeing Board and
Local Authority on her
Recommendation to the CCG Board
• CCG Board Decides based on
commissioning head’s
Recommendation
• Determine if programme will
need regulatory approval
DECISION
Communication
• Submit/present deliverability assessment to:
-
CCG senior management
CCG Board
Co-commissioners (e.g. NHS if potential impact on specialist services)
Health & Wellbeing Board
Provider Boards
Closure
• Commissioning finance director and non-finance staff begin assembling
final recommendation including impact assessments
• Finance staff are allocated to support the director in preparing final
documents for submission to the board
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Decision component snapshot for sub-decision four
1
2
3
4
Sub-Decision: Decide whether to proceed with preferred option(s) and implementation plan
RAPID Roles
D CCG Board
CCG
finance
head
R
Criteria
CCG
A commiss.
A P Trust Board
head
Critical Steps
• Balance implementation risk and
gain we expect to achieve
-
• Alignment with CCG long-term
strategic priorities, population
needs defined by JSNA and other
key stakeholder priorities
-
• Focus on largest opportunities
-
• Deliverability on a XX timescale
-
-
-
Local
Authority
I
Health &
Wellbeing
Board
I
Choices Considered
• Develop full business case
including:
• Seek to incorporate cost, quality,
safety and experience to deliver
best possible value
I
P
Wider GP
Community
Committees
• Health & Wellbeing Board:
includes local authority, public
health, Healthwatch, head of adult
and children's social services reps
• Do nothing
Review impact assessments
(equality & system)
Complete risk appraisal and
mitigation steps
Stress test benefits realisation
and cost assumptions
Compile implementation timescales,
resources, milestones and measures
of benefit
Develop potential exit strategy if the
benefits don’t materialise
Determine board reporting
requirements on implementation
Regulators
• Incremental change
• Radical change
• Do something
-
Commissioning finance head seeks
Input for his/her Recommendation
• Transformation Stakeholder
Working Group or equiv.: Joint
provider / commissioner group
-
Commissioning finance head seeks
Agreement from Trust Board(s) on
his/her Recommendation
• Commissioning Board (e.g. CCG
Board) Decides based on CCG
finance head’s Recommendation
DECISION
Communication
• Communicate full business case / case for change to:
-
CCG senior management
All market, regulatory and clinical stakeholders, especially trust senior management
• Launch public/patient education programme
Closure
• Memorandum of Understanding or equivalent is signed by providers and
commissioner articulating the agreed changes
• Changes to contracts made / process initiated
• Commissioner and providers make joint public announcement
• Develop plan to review and evaluate implementation
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APPROACH
DECISION HANDBOOK
APPENDIX
TIP: Click on any of the text
below to skip to that section
Contents
APPROACH
• NHS approach to effective decision making
• An holistic definition of value
DECISION HANDBOOK
• “What, who, how and when” - setting the decision up for success
• “How” - deeper look at critical elements for each step in the process
• Role of finance - key actions, analysis, data and tools for finance
APPENDIX
• Data sources and links
• Data tools and links
• Star modelling tool for value-for-money analysis
• AID model for QIPP prioritisation
• Stakeholder map and public engagement tool
• Programme budgeting marginal analysis
• Integrated Risk and Impact Assessment Tool
• Decision Trees
• Full Business Case template
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Role of finance snapshot for sub-decision one
1
2
3
• Finance’s responsibility
• Non-finance’s responsibility
4
Sub-Decision: Determine areas with greatest opportunity for improved outcomes/cost reduction
• Drive integration of financial analysis and outcome analyses (clinical, safety and experience)
Role of Finance
• Generate a broad range of options for consideration
• Translate activity and non-financial data into financial terms; share insights with CCG commissioning director
Critical Step
Actions for Finance
Pieces of Analysis
Map resource use by
population group
CCG Finance: Submit
•
request for analysis to CSU or
informatics department. If only
able to produce activity levels •
by patient population, add in
cost estimates
Refresh / review risk
stratification
CCG Finance: May overlay
cost data on models from
informatics specialists / CSU
Assess baseline costs
CCG Finance: Compile
current spend data and direct
CSU/informatics to model
future spend
Provider Finance: Identify
mismatches between tariff
rates and actual cost base
Compile comparative
benchmarking data
Review JSNA and long
term priorities of CCG,
stakeholders and Health &
Wellbeing Board
CCG Finance: Work with
commissioning lead to identify
opportunities based on
relative performance against
benchmarks
CCG Finance: Assist the
commissioning lead in
presenting the ideas to check
if compatible with long term
strategic priorities
Data
Activity and statistical
analysis conducted by
CSU or informatics team
•
Programme activity by
population sub-group
•
Tariff rates by activity
Costing of activities
conducted by finance
•
Community, block and
other contract information
•
Outpatient, inpatient, A&E,
and GP data
•
Public Health Data
•
•
N/A
•
Assess current and
projected spend by
provider
•
Review past programme
category spend
•
Assess service line cost
•
Tools /
Resources
Data Source
•
Secondary Uses Service
•
Contract data from providers
(e.g. SLAM)
•
Hospital Episode Stats
•
Secondary Uses Service
Spend by provider
•
Existing contracts
Spend by programme
category
•
SLAM
•
Dr. Foster
•
SUS
•
Internal tracking
•
Reference costs
•
Dr. Foster PPM Module
Service line costing info
Combined
Predictive Risk
Model (Kings Fund)
N/A
•
Identify outliers of
(under)performance
•
Programme budgeting
•
•
Primary and secondary care •
Identify explanations
and consequences of
variation
•
Utilisation data
•
•
Evidence from trials in other
regions
NHS Comparators, Atlas of
Variation, Commiss. for Value
•
SLAM Data
N/A
QOF
N/A
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N/A
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N/A
N/A
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Role of finance snapshot for sub-decision two
1
2
3
• Finance’s responsibility
• Non-finance’s responsibility
4
Sub-Decision: Determine how to improve each opportunity area and the preferred option(s) for improvement
• Own activity and financial data, holding stakeholders accountable for their models and due diligence
Role of Finance
• Push for rigorous evidence and explicit assumptions on both financial and non-financial benefits
• Integrate financial/non-financial analyses into a unified assessment of value
Critical Step
Align stakeholders on
criteria for evaluation
Actions for Finance
CCG Finance: Lead process with
provider counterparts to formally
agree on metrics (incl. activity data)
underlying case for change
CCG Finance: Establish financial
baseline of maintaining current model
Conduct service reviews
Appraise relative options
Provider Finance: Model cost and
outcome implications and share with
CCG finance
CCG Finance: Lead analysis for
economic appraisal. Act as a sense
check, flag interdependencies and
barriers. Review quality impact
analysis produced by head of quality
Provider Finance: Model cost and
outcome implications and
communicate internally
CCG Finance: Gather and vet the
impact on provider resilience
Assess wider system
impact
Determine if public
consultation is required
Pieces of Analysis
Provider Finance: Work with clinical
and operations to assess impact and
share concerns with commissioner
Data
N/A
•
Cost benefit analysis of
keeping existing model
•
Vet cost modelling of
alternative models
assembled by providers
•
•
Medical Appropriateness
•
Economic appraisal
•
(e.g. financial costs and
benefits, ROI, etc.)
•
Provider level spend
STAR tool
N/A
•
Looking for Value in
Hard Times
•
QOF data
•
•
SLAM data
Diagnostic Steps of a
Service Review
•
Adopt, Improve, Defend
tool
•
CSU or provider
Clinical / trial evidence
•
Clinical Ref. Group
Cost of current service,
future baseline cost,
procurement and
mobilisation costs
•
Audit of spend
•
STAR tool
•
Reference costs
•
•
CSU/ BI activity
projections
Looking for Value in
Hard Times, The Health
Foundation
•
Program Budgeting
Marginal Analysis
Toolkit, Right Care
•
Integrated Impact
Assessment Guide,
Milton Keynes CCG
Programme budgeting
marginal analysis
•
Quality / Non-financial
benefits appraisal (e.g.
improved outcomes)
Programme category and
provider level spend
•
QOF & SLAM data
•
Patient experience data
•
HealthWatch
•
Safety data
•
Dr. Foster
•
Evidence from trials
•
Orgs running trials
•
Provider Impact
assessment (from
providers)
•
Provider finance
staff
•
•
CSU reports
Prevalence and activity data
•
Unify2 database
•
Provider financial and
operational impact
•
Equity impact assessment
Tools / Resources
•
N/A
•
•
Data Source
No Finance Role
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Role of finance snapshot for sub-decision three
1
2
3
• Finance’s responsibility
• Non-finance’s responsibility
4
Sub-Decision: Determine deliverability of preferred option(s)
• Own rigorous analysis and insight generation
Role of Finance
• Identify, quantify and assign probabilities to resource-based limiting factors, barriers and risks
• Offer finance view on non-financial limiting factors, barriers and risks
Critical Step
Identify limiting factors
(e.g. equipment, GP
shortage, shortage of
trainers, etc.)
Identify potential barriers
Actions for Finance
Pieces of Analysis
CCG Finance: Lead effort to
articulate resources needed to make
proposed changes
•
Forecast of resource
requirements and
availability under
different scenarios
CCG Finance: CFO drives process
as part of senior management team–
linking to provider counterparts.
Provides financial analysis to those
engaging clinicians
•
Assess / validate
financial risk for
providers
Data
•
Financial impact on
providers
•
Conversations w/
trust counterpart
•
Views of Local Authority
•
•
Views of clinicians
•
Views of expert patient
groups
Conversations w/
local authority
counterpart
Risk appraisal including •
clinical, commercial,
•
operational,
•
implementation and
timescale risks, scores
and mitigants
Likelihood of occurring
•
Inputs from chief
commissioning
officer, head of
quality and
provider
counterparts
Provider Finance: Express finance
concerns to internal leadership and
CCG counterpart
Compile risk appraisal
Determine if regulatory
approval will be necessary
CCG Finance: Develop financial risk
appraisal, and gather risk
assessments from trusts and inputs
from CCG departments (quality,
procurement, etc.)
No Role
•
Data Source
Potential Impact
Context
N/A
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
N/A
N/A
LON
Tools / Resources
•
Integrated Impact
Assessment Guide,
Milton Keynes CCG
N/A
141211_Allocation Decision Han ...
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APPROACH
What
Who
When
How
DECISION HANDBOOK
APPENDIX
Role of finance snapshot for sub-decision four
1
2
3
• Finance’s responsibility
• Non-finance’s responsibility
4
Sub-Decision: Decide whether to proceed with preferred option(s) and implementation plan
• Responsible for compiling full business case and presenting recommendation to the board
Role of Finance
Critical Step
• As board member, push to integrate financial/non-financial analyses into a unified assessment of value
Actions for Finance
CCG Finance: Finalise
model and estimates for
benefits realisation and
impact assessments.
Support commissioning
director in finalising risk
appraisal/ mitigation, and
rationalising implementation
timescale, milestones and
measures
Develop full business
case
Pieces of Analysis
• Stress test benefits
realisation and cost
assumptions
Data
• All inputs from
previous
analyses
• Detailed Impact
assessments (equality &
system)
Data Source
Tools / Resources
• Analyses from • Full Business Case
previous steps
Template, NHS
National Innovation
Centre
• Stakeholder Map &
Engagement Tool
• Complete risk appraisal
and mitigation steps
• Risk Appraisal &
Mitigation Tool
• Implementation
timescales, resources,
milestones and measures
of benefit
• A stakeholder map
• Communication
engagement plan
• Outline business case
(OBC)
• Service Specification and
data requirements
• Board reporting
requirements on
implementation
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141211_Allocation Decision Han ...
40
APPROACH
DECISION HANDBOOK
APPENDIX
TIP: Click on any of the text
below to skip to that section
Contents
APPROACH
• NHS approach to effective decision making
• An holistic definition of value
DECISION HANDBOOK
• “What, who, how and when” - setting the decision up for success
• “How” - deeper look at critical elements for each step in the process
• Role of finance - key actions, analysis, data and tools for finance
APPENDIX
• Data sources and links
• Data tools and links
• Star modelling tool for value-for-money analysis
• AID model for QIPP prioritisation
• Stakeholder map and public engagement tool
• Programme budgeting marginal analysis
• Integrated Risk and Impact Assessment Tool
• Decision Trees
• Full Business Case template
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPROACH
DECISION HANDBOOK
APPENDIX
Data sources for Best Possible Value decisions
Data source
Value categories
Description
Useful for
Quality and Outcomes
Framework (QOF)
Safety / Experience /
Outcomes
GP surgeries metrics on Clinical, Public Health, Public Health,
Patient Experience, Quality and Productivity.
Benchmarking against peer groups and
service reviews.
CCG Outcomes Indicator
Set (CCG OIS)
Safety / Experience/
Outcomes
Outcomes at CCG level to help inform priority setting and drive
local improvement.
NHS Comparators
Cost / Outcomes
Benchmarking and comparing activity and costs on a local,
regional and national level for commissioners and providers
Indicative sense of where to look deeper.
Data can be old and is not in raw format.
NRLS Organisation Patient
Safety Incident Reports
Safety
Data shows patient safety incident statistics for trusts in England
and Wales
Benchmarking against peer groups for
indication of where to look deeper.
Commissioning for Value
Packs
Cost / Experience /
Outcomes
In-depth comparative data for 13 patient conditions, within the
programmes that are most commonly identified as offering the
greatest potential improvements.
Benchmarking against peer groups for
indication of where to look deeper.
QualityWatch Indicators
Safety / Experience /
Outcomes
Independent scrutiny and data on access, experience, safety,
equity and effectiveness of services across mental, social,
primary and secondary care
Benchmarking, modelling impact on
experience, safety or clinical outcomes for
proposed changes.
Secondary Uses Service
(SUS)
Cost / Outcomes
Data can be patient identifiable or anonymised or as required for
the user's needs.
Benchmarking, consumption mapping, and
assessing cost base.
Doctor Foster Practice
Provider Module (PPM)
Cost / Outcomes / Safety
Analyse and benchmark hospital admissions data across a wide
range of outcomes, utilisation, trends and patient records across
a region.
Benchmarking, consumption mapping,
assessing cost base, and forecasting
impacts from proposed changes.
Health and Social Care
Information Centre
Population Health
Comparative benchmark data, population health, trends over
time, health risk factors, and health inequality.
Useful for benchmarking, developing a fact
base, risk stratification and service planning.
Hospital Episode Statistics
Provider Cost / Activity
HES is a data warehouse containing details of all admissions,
outpatient appointments and A&E attendances at NHS hospitals
Risk stratification
Patient Reported Outcome
Measures Tool (PROMT)
Cost / Outcomes /
Population Health
Data collected for 4 procedures: hip and knee replacements,
Risk stratification. Benchmarking against
groin hernia and varicose veins. The tool enables commissioners peer groups for indicative sense of where
to examine the relationship between a range of local factors
you could look deeper.
Service Level Agreement
Monitoring (SLAM)
Cost
Monthly dataset provided by CSUs to CCGs including detailed
breakdown of services performed by providers.
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
Useful for contract management, and
assessing current cost base.
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Data tools for Best Possible Value decisions
Tool
Description
Full Business Case Template
Detailed outline and suggested analysis for a Full Business Case from the NHS
National Innovation Centre.
Public Sector Business Cases Using
the 5 Case Model Toolkit
Template and guidance, including content outlines, for developing outline and full
business cases for specific decisions.
Useful for
Outline Business Case / Full Business Case
Health Investment Network programme Enables NHS organisations to identify: how they spend their allocation over the 23
Budgeting Benchmark Tool
diseases and their respective subcategories; how, and by how much, their
expenditure distribution pattern compares with other commissioners nationally,
locally or with similar characteristics; and how their expenditure distribution has
changed over time.
programme budgeting marginal analysis
Combined Predictive Risk Model
A model that used inpatient, outpatient, A&E and GP data to stratify populations
according to their risk of admission. In order to run this model, a software front-end
needed to be built locally. Intellectual property is owned by the Department of
Health.
Risk Stratification
Adopt Improve Defend (AID)
A Right Care process that supports both the need to generate good ideas for reform
in the priority areas needing focus and the need to engage the wider health
community in these reforms.
Evaluating and prioritising service model
options.
Socio-Technical Allocation of
Resources (STAR)
London School of Economics (LSE), the Health Foundation has developed the Star
approach that combines value for money analysis with stakeholder engagement,
where an Excel-based tool is used alongside a facilitated stakeholder workshop.
Spend and Outcomes Tool (SPOT)
Graphically illustrates where you stand, compared to similar CCG populations, on
the health outcomes you are achieving for your health spend.
Indicative sense of where you could look
deeper. Sense check on proposals under
consideration.
Inpatient Variation Expenditure Tool
(IVET)
Benchmark and compare their inpatient spending (adjusted for age, sex and needs)
on diseases and interventions with other PCTs to improve future investment
decisions.
Calculate potential savings by reducing
admissions across major disease groups and
for interventions with the highest spend.
Public Engagement Toolkit
A guide for anyone who needs to engage with the public about health care
commissioning. Designed for commissioners.
Framework for estimating / benchmarking expenditure across healthcare conditions,
also known as ‘programmes categories’, across the whole care pathway.
Practical advice on how to go about public
engagement
Benchmarking against peer groups for
indication of where to look deeper. Data can
be slightly outdated and is not in raw format.
Programme Budgeting Benchmarking
Tool
This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
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APPENDIX
STAR - a modelling tool and approach for value-for-money
analysis and stakeholder engagement
MODEL OVERVIEW
DOWNLOADABLE RESOURCES
Star (Socio-Technical Allocation of Resources) is
an innovative approach that supports
commissioners’ budget prioritisation processes.
By combining a technical value-for-money
analysis with extensive stakeholder engagement
and discussion, Star enables commissioners to
involve the wider community in the evaluation of
a range of current or potential interventions.
• Star comprises a technical tool and a
workshop-led process
• Online video training, demonstrations and
downloadable resources are available
User guide
Learning report
and examples
Case Study
Source: The Health Foundation, Star Online Demonstration.
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Excel modelling
tool
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Adopt, Improve, Defend - an AID for QIPP by Right Care
MODEL OVERVIEW
DOWNLOADABLE TOOLKIT
A systematic approach to achieve challenging
QIPP targets by identifying and addressing
variations in local healthcare.
The AID methodology provides commissioners
with a structured process to assess, challenge
and improve promising QIPP ideas:
- Adopt – implement the idea as presented
- Improve – adapt the idea
- Defend – reject the idea and retain the current
position
The intention is that the process is intended to
support high-value commissioning on an ongoing basis.
Source: Right Care, ‘Adopt, Improve or Defend’ – An AID for QIPP. September, 2013
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Stakeholder map and engagement toolkit
STAKEHOLDER MAP
Power
High
Satisfy
•
CQC
•
MPs
•
Health and wellbeing
board
•
Overview and scrutiny
•
Local Authority
•
NHS England
•
Competition and Markets
Authority
Manage
•
Provider boards and
governors
•
Commissioning boards
and governance
•
Partners
•
Monitor
Monitor
•
Media
Inform
•
Patients and public
•
Provider workforce
DOWNLOADABLE TOOLKIT
Low
Low
High
Influence
Note: More detailed guidance and recommendations on stakeholder engagement, tracking, and management can be found here at NHS Networks
Source: NHS Central Lancashire, Public Engagement A toolkit for health commissioners and partner organisations
Institute for Innovation and Improvement, Stakeholder Analysis
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Programme Budgeting Marginal Analysis
INPUT PROCESS OVERVIEW
Step 1
• Compile the follow data across programme budget category for the
most recent year:
-
Step 2
DOWNLOADABLE TOOLKIT
Spend per 100,000 weighted population
Average spend per 100,000 population among peer group
Average spend per 100,000 population in England
• Compile programme budget category spend by provider across all
providers
• Compiling this table will help identify relative size of each provider’s
contribution and how programme expenditure relates to provider
expenditure
Step 3
• Identify the top 10 health programmes in each of the major providers
and look at the differences.
• Discuss the differences and identify the networks and pathways these
patterns reveal.
Step 4
• Compile programme budget spend by category across age groups in
so far as local data and estimates permit.
Source: Right Care, The Third Annual Population Review: Commissioning for Health Improvement
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Integrated Risk and Impact Assessment
RISK APPRAISAL PROCESS
DOWNLOADABLE TOOLKIT
Identify
Identify risks associated with safety, patient
experience, clinical, operations, financial,
reputation, etc.
Score
An overall risk score for each element based on
the level of impact and likelihood of occurrence
Investigate
Scores above a certain threshold (e.g. above 8)
should be investigated further
Mitigate
Mitigation plans should be developed for high
risk/impact items and integrated into the Full
Business Case
SAMPLE SCORING TEMPLATE
Likelihood
Description
Very High
Will undoubtedly occur, possibly frequently
5
High
Will probably occur but not a persistent issue
Impact
Very
May occur occasionally
Low (1)
Do not expect it to happen
it is
Verybut
Low
(1)possible 1
This is unlikely to everLow
happen
(2)
2
4
Medium
Low
Very Low
Risk
Score
Probability
Low
Medium High
3
(2)
(3)
(4)
22
3
4
14
6
8
Medium (3)
3
6
9
12
High (4)
4
8
12
16
Very High (5)
5
10
15
20
Very
High (5)
5
10
Key
Low
15 Risk (1-3)
Moderate
Risk (4-9)
20
Significant
Risk (10-14)
25
High Risk (15-25)
Source: Milton Keynes CCG, Quality and Equality Integrated Impact Assessment Policy
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Example QIPP prioritisation decision tree (1/2)
KEY CRITERIA
1. Implementation cost is less than £x
2. Changes demonstrate value for
money
3. Contributes to CCG priority areas
4. Has no adverse impact on health
inequalities
5. Meets at least one of the triple aim
components (better health, best
care (clinical & patient), value for
money)
6. Net savings in the system
7. Timeline to payoff/desired benefits
Source: Matthew Cripps. Right Care, Healthcare Reform Business Process Guide. 2013.
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Example QIPP viability decision tree (2/2)
Step 1: Initial viability assessment v 1.2
Proposal
Is there evidence
that proposal could
improve health
outcomes for the
population of
Doncaster?
no
Is there evidence
that this proposal
may deliver better
value for money
(i.e. achieving the
same health
outcomes for less
money)
yes
Is this proposal achievable
within realistic timescales; i.e.
are there constraints for
example contractual delays,
financial constraints, HR
issues, training issues that
make progress inappropriate
yes
Proceed to
prioritisation
no
Can constraints be managed
within resources?
no
Do not
proceed
Do not
proceed
no
Source: Matthew Cripps. Right Care Briefing for HFMA on Option Prioritisation and Impact Assessment. May, 2013.
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APPENDIX
Full Business Case template
BUSINESS CASE TEMPLATE
DOWNLOADABLE TOOLKIT
This Business Case template provides an
outline structure and notes to describe the
content required for each section in a Business
Case document.
There are many formats for a business case,
but the information you include should be the
background of the project, the expected
business benefits, the options considered (with
reasons for rejecting or carrying forward each
option), the expected costs of the project, a gap
analysis and the expected risks.
You should also consider the other options,
including the option of doing nothing, with the
costs and risks of inactivity. This information will
help you to identify a clear justification for the
project.
Source: NHS National Innovation Centre, Full Business Case Template. 2012.
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Example deliverability dashboard for communicating to
stakeholders
Good/great
So-so
Poor
Rating
Time to Implement
Availability of
Resources Required
Provider Support
Comments / Context / Mitigants
• xxxxx
• xxxxx
• xxxxx
• xxxxx
• xxxxx
• xxxxx
Clinician Support
• xxxxx
Public/Political Support
• Xxxxx
Other…
• xxxxx
Source: Bain interviews with NHS officials, November 2014
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Key diagnostic steps in conducting a Service Review
Step 1: Define
Current
Service
Step 2: Define
Step 3:
Categorise
Step 4:
Recommend
Fit for purpose
Maintain
Efficiency and
market options
Redesign,
contract,
procure
Supply and
capacity options
Contract,
procure, divest
No/low
benefit
Divest
Future
Service
Source: NHS Right Care Case Book. Identifying “Value Opportunities” in West Cheshire: Service Reviews and Business Process Engineering. November 2013
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