Oxfordshire
Clinical Commissioning Group

Oxfordshire
Clinical Commissioning Group
 Why an outcomes based contract?
 Outcomes
 Approach to procurement
 Outcomes and Indicators
 Service Scope
 Service Model
 Incentivization

Oxfordshire
Clinical Commissioning Group
 Current commissioning converts money into activity, not outcomes
 Incentives are not aligned to maximise benefit across the patient pathway
 Current approach is financially unsustainable
 If we are serious about integration we need a different approach to commissioning

Oxfordshire
Clinical Commissioning Group
 It aligns commercial arrangements to deliver outcomes for patients
 It can deliver the optimum VFM service for patients and tax payers as commissioners will seek to pay out incentives to reward excellence
 It supports integration through the inclusion of all relevant providers that jointly will need to achieve outcomes
 It supports collaborative approaches through gain share arrangements to share financial savings between providers and commissioners
 It provides a change mechanism for improvement and refinement
 It creates stability for providers (and patients) and sets the pace of change over a longer-term contract
It remains an NHS standard contract!

Oxfordshire
Clinical Commissioning Group
 Integration central to approach
 Services in scope provided by two main NHS providers
 Providers had begun to work more closely together
 Asked the two providers to work together and provide a single response
 Achieved “most capable provider” designation
 Contract negotiation to commence

Oxfordshire
Clinical Commissioning Group

Oxfordshire
Clinical Commissioning Group
Outcome Example Indicators
I want to be helped to be healthy and active
I want to be helped to be as independent as possible in the best place for me
When I am in need of care it is safe and effective
I want to have a good experience and be treated with respect and dignity
% with fragility fracture who recover to previous level of functioning; % with no on-going care after reablement
Proportion still at home 90 days after discharge; avoidable sight loss;
DTOC; admissions for ASC conditions
Effectiveness of community services; incidence of pressure ulcers
% who die in place of their wishes; experience of overall care

Oxfordshire
Clinical Commissioning Group
 Non-elective admissions
 Community hospitals
 Community assessment and admission prevention services
 Reablement services
 Intermediate care beds

9
Oxfordshire
Clinical Commissioning Group
Transforming care for Older People in Oxfordshire
Making our health and care systems fit for an ageing population. Oliver et al. Kings Fund 2013.

•
•
•
The Patient
• Frail, comorbid, vulnerable
An individual in a network
A partner in care
Therefore care must be:
• Individualised
• Comprehensive
• Coordinated
• Consistent
• Capable
• 7 day
10
Right place ‘Close to home’
We propose:
A seamless network of complex care:
•
• Community Care Hubs
– Economy of scale
– Resilience of scale
– Quality & capability of scale
• eg coprovision of physical & psychological Health
• ‘Acute site 1’
‘Community Care Hub Plus’
• Integration across multiple axes
• Virtual presence of 2
○
• Information sharing
& 3
○ capability
• Telemedicine
Evaluating integrated and community-based care. How do we know what works?
Nuffield Trust 2013
Transforming care for Older People in Oxfordshire

Patients Need:
• Prompt, effective, coordinated assessment and treatment
• Right place, right time
• Advanced decision-making with the patient
• Care to be safe and compassionate
11
We Propose:
The best care, closer to home.
• Infrastructure and teams adapted to outreaching care
• Re-balancing of the ‘care footprint’
• Universal ‘active interface’
– EMU, EAU, SEU, ED
• Distributed advanced care:
– diagnostics (PoCT & Radiology)
– complex treatment and monitoring: true ‘Hospital at Home’
Transforming care for Older People in Oxfordshire
Directory of Ambulatory Emergency Care for Adults,
3 rd edition. NHS Institute for Innovation. 2012

1
2
Model of Care
Acute medicine Complex and Interface medicine
In acute hospitals
For adult patients with the most severe illness
- General Medicine
- Geriatric Medicine
- Stroke
- General Surgery
- (non-MTC) Trauma
In both
- acute hospitals
- Community Care Hubs
Longer LoS
Complex needs
Usually (very) elderly
Dementia prevalent
Risk of Harm
‘Active Interface’ capability
Embedded in all assessment units
Outreaching support to primary care delivered from Community Hubs
Advanced relationships with clinical colleagues in the acute hospitals Generalists  integrated platform of holistic care.
Embedded Geriatric &
Psychological Medicine
Specialists  more focused (specialised) input in some settings.
Geriatricians
Generalists
Psychological Medicine
+
‘the network’
Cohort drawn and developed from
- 1 ○ & 2 ○ care
- medical & non-medical
Future hospital: Caring for medical patients. Future Hospital Commission 2013.
Transforming care for Older People in Oxfordshire

4. Universal Best Practice to deliver the best Patient-Centred Outcomes
Patients need care that is:
• Effective
• Harm-free
• Joined-up
• Delivered in partnership
• Delivered by familiar people
We Propose:
• Promotion of self-care
• Enabling care
• Tailored multi-disciplinary care – ‘CPA’
• Zero delays
• Enhanced Recovery approach
• Capable care 24-7
• ‘Care to the patient, not patient to the care’
• Care environments that are universally frail-appropriate and dementia-appropriate
13
Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011
.
Tr ansforming care for Older People in Oxfordshire

Universal Best Practice to deliver the best Patient-Centred Outcomes
An exemplar: Intermediate Care beds
Current
• Dis-integrated, isolated
• Provider-determined location
• Dated accommodation
• Weak clinical capability
• Brittle staffing
• Maximum 40 hour clinical care
• Minimal governance
• Opaque outcomes
14
Proposed:
• Integrated
• Close to home
• Purpose-built
• Scaled to optimise care
– Resilience, quality and value!
– Co-location of complementary services
• Strong clinical team
– medical, nursing, therapy, mental health
• 24-7 clinical capability
• Strong governance
• Transparent outcomes
– Benchmarked
– Quantitative and Patient-reported (PREM)
National audit of Intermediate Care 2013. NHS Benchmarking Network.
Transforming care for Older People in Oxfordshire

5. Working with Others
Primary Care needs:
• Immediate high quality advice
• Responsive outreaching home care
• Highest quality patient information
• Development of clinical capability
Social Care providers need:
• The best functional outcomes
• An accurate client prognosis
• Excellent clinical information
• Effective response to medical crises
We propose:
• Direct ‘phone access to senior clinicians
• CPA and ambulatory care
• Transformational improvement in IT
• Professional development opportunities
• CPA delivered by expert teams
• Advanced clinical network capability delivered 24-7 into the home
• Integrated Health & Social assessment
Third sector providers need:
• A meaningful role in patient care
• Support during client crisis
15
• Valuing the opportunity of their offer
• Integration into the Network of Care
• Open access to CPA and ambulatory care
Lessons from experience. Making Integrated care happen at scale and pace. Kings Fund 2013.
Transforming care for Older People in Oxfordshire

Oxfordshire
Clinical Commissioning Group

Budget c£90m
 Quantum to be at risk: TBC but 15-20%
 At (e.g.) 20% that equates to £18m per annum
 That £18m is shared across the outcomes and specific indicators. Each point (out of
100) is worth £180,000

Oxfordshire
Clinical Commissioning Group
 So-if we allocate 30% of the incentive pot to
“healthy and active”-that is worth £5.4m…
 Is that enough money to drive a more proactive and preventative service model?
 Phasing of incentives: what can be achieved in year 1, what needs 5+ years?
 Improvements on baseline, and then for review
 “bonus payment” for consistency across outcomes

Oxfordshire
Clinical Commissioning Group
 OBC Programme Lead:
 Catherine Mountford catherine.mountford@oxfordshireccg.nhs.uk
 Clinical Lead
 Dr Barbara Batty
 Barbara.batty@oxfordshireccg.nhs.uk