Improving the
local healthcare
system
Commissioning for Value
March 2015
Bob Ricketts
Director of Commissioning
Support Services Strategy
www.england.nhs.uk
1. Context:
The Forward View sets out unprecedented challenges
for the NHS nationwide & local healthcare systems:
•
•
•
•
•
Rising demand
Increasing public & political expectations
Constrained resources
Out-dated over-stretched service models (all sectors)
Persistent unacceptable variation – in outcomes,
access & VFM
www.england.nhs.uk
2
1. Context: Demand for care is growing rapidly
We are facing a rising burden of avoidable illness across England from
unhealthy lifestyles:
•
1 in 5 adults still smoke
•
1/3 of people drink too much alcohol
•
More than 6/10 men and 5/10 women are overweight or obese
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70% of the NHS budget is now spent on long term conditions
•
People’s expectations are also changing
www.england.nhs.uk
3
1. Context: New opportunities
New technologies and treatments
• Improving our ability to predict, diagnose and treat disease
• Keeping people alive longer
• But resulting in more people living with long term conditions
New ways to deliver care
• Dissolving traditional boundaries in how care is delivered
• Improving the coordination of care around patients
• Improving outcomes and quality
Support
• NHS IQ Improving Quality in Supporting CCGs to commission
personalised care for people with LTC via LTC Improvement Prog.
• Commissioning Support: Lead Provider Framework
…but the financial challenge remains, with the gap in 2020/21
previously projected at £30bn by NHS England, Monitor and
independent think-tanks
www.england.nhs.uk
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2. Commissioning for improvement:
To deliver the Forward View we need approaches which …
• Incentivise high quality integrated pathways which deliver high
quality ‘joined-up care’ – MSK: Bedfordshire
• Are place-based, with effective co-commissioning - avoiding
fragmentation from ‘multiple commissioners’
• Make the best use of resources (NHS-funded, LAs, communities,
users) – “there is only one Leeds pound”
• Reward delivery of the best outcomes for users, carers &
communities (social value)
• Address demand risk explicitly
• Catalyse new configurations/partnership of providers
• Include, not marginalise, non-NHS partners
• Are deliverable & proportionate to the problem – commissioner
and provider capacity & capability is a real issue
www.england.nhs.uk
3. We need commissioning for outcomes: What
is it?
Narrative on OBC
NHS CA Quality
Working Group
www.england.nhs.uk
3. Commissioning for outcomes = a spectrum
There is a spectrum of approaches:
Embedding outcomes in contracting:
Using outcome measures in, e.g. secondary care, to drive-up quality, linking
payment much more closely to performance.
ICHOM
Outcome-based population commissioning
a key vehicle to drive transformation & secure better outcomes, service
integration and value for specific populations or groups (e.g. frail older
people with multiple, complex problems; EoLC), or re-balance incentives by
paying for outcomes
COBIC
*International Consortium for Health Outcomes Measurement
www.england.nhs.uk
The core of ICHOM's mission is to define a
common language to measure outcomes:
"ICHOM Standard Sets"
ICHOM facilitates a process with
international physician and registry
leaders and patient representatives to
develop a global Standard Set of
outcomes that really matter to patients,
by medical condition
Physician and
registry leaders
www.england.nhs.uk
Patient representatives
Our end-product: a Standard Set, with the
domains that should be systematically
measured, and clear definitions
Treatment approaches
covered
▪
▪
▪
▪
▪
▪
Watchful waiting
Active surveillance
Prostatectomy
External beam radiation therapy
Brachytherapy
Androgen Deprivation
Treatment
▪ Other
A "reference guide"
contains all the details
to measure in a
standard way the
outcomes
recommended
(link to download)
Details
1 Recorded via the Clavien-Dindo-Classification
2 Recorded via the Common Terminology Criteria for
4.0
3 Recommended to track via the Expanded Prostate
Adverse Events (CTCAE), version
Cancer Index Composite (EPIC)-26
© 2013 ICHOM. All rights reserved. When using this set of outcomes, or quoting therefrom, in any way, we solely require that you always make a reference to ICHOM a s the source so
that this organization can continue i ts work to define more standard outcome sets.
www.england.nhs.uk
ICHOM have already developed 12 Standard
Sets, covering 35% of the disease burden
www.england.nhs.uk
3. Embedding outcomes in contracting:
Bedfordshire CC Group developed an outcomes based contract using
ICHOM Lower Back Pain outcomes Set
Bedfordshire CCG has
constructed a
musculoskeletal care
contract with Circle
ICHOM Lower Back Pain
Set incorporated into the
contract and Circle
expected to report on
these outcomes
A baseline will be
measured in Year 1 and
then annual
improvements in the
outcome Set will result in a
financial reward.
ICHOM conclusion: Incorporating outcomes into contracts with providers is an
ICHOM conclusion: Incorporating outcomes into contracts with providers is an
excellent way to ensure quality measurement and to incentivise improvement.
excellent way to ensure quality measurement and to incentivise improvement.
www.england.nhs.uk
3. Outcome-based population commissioning:
Integral to core OBC’ /COBIC model are:
• Identifiable & measurable outcomes
• That those outcomes can be linked to desired behaviours
• That those behaviours can be incentivised through payment
systems
• Spans primary, community & secondary care
• At-scale for populations (but can be done on a smaller scale,
introducing a % payment for specific outcomes)
• More mature & long-term relationship with providers (7+
year contracts)
• ‘Lead provider’ or ’Alliance’ contracting
www.england.nhs.uk
3. Outcome-based population commissioning:
Key components of fully-developed OBC:
• Population-based (frail older people, multiple complex
problems; EoLC) or major pathway(s) (MSK)
• Outcome-focused capitation payment*
• ‘Lead provider’ or ‘alliance’
• Provider(s) co-ordinates care planning & delivery
• Provider(s) takes on much of the demand risk
*LTC Year of Care Commissioning EI sites – testing
population capitated budget for LTC cohorts, new contracting
& delivery models
www.england.nhs.uk
3. Outcome-based population commissioning:
OBC still emerging, but examples:
• Bedfordshire (MSK)
• Cambridgeshire (range of services for older people)
• Staffordshire (cancer & EoLC for 1m+)
• Sussex (MSK)
• Greater Huddersfield & Kirklees CCGs (community
services lead provider)
• Smaller-scale: Oxfordshire & Milton Keynes (sexual
health; substance abuse)
EI sites for Year of Care commissioning: Southend,
Leeds, Kent, West Hampshire, Barking, Dagenham &
Havering and Redbridge
www.england.nhs.uk
3. Outcome-based population commissioning: CSFs
Critical Success Factors:
• Know what problem you’re trying to solve
• Commission the underpinning analysis – e.g. RightCare ‘deep
dive’; CfV packs
• Be clear what you’re trying to achieve
• Set identifiable & measurable outcomes
• Link outcomes to desired behaviours
• Think about how to incentivise the right behaviours – not just
through payment systems
• Engage systematically, consistently & early – users, communities,
clinicians, providers, ‘politicians’
• Budget for resources - capability & capacity
• Start small!
www.england.nhs.uk
Useful sources:
General overview:
NHS CA Quality Working Group
King’s Fund: How to measure for improving outcomes: a guide for
commissioners
Embedding outcomes:
ICHOM International Consortium for Health Outcomes
Measurement
www.ichom.org
www.ichom.org/project/cataracts
www.ichom.org/project/low-back-pain
www.england.nhs.uk
Useful sources:
Outcome-based population commissioning:
COBIC & Cobic Club www.cobic.co. uk
Right Care Casebook series : Paul Corrigan & Nick Hicks
“What organisation is necessary for commissioners to develop
outcomes-based contracts?”
COBIC Explained – NHS Change Model
www.changemodel.nhs.uk/dl/cv
Contracting models:
King’s Fund: Contractual models for commissioning integrated
care Nov. 2014
www.england.nhs.uk