Commissioning for Value
1 key objective + 3 key phases + 5 key ingredients =
COMMISSIONING FOR VALUE
OBJECTIVE - Maximise Value (individual and population)
Five Key Ingredients:
1. Clinical Leadership
2. Indicative Data
3. Clinical Engagement
4. Evidential Data
5. Effective processes
2
Granularity
Populations
CfV Pack
Atlas
Programme
Budgets
Where to Look
3
Systems
Deep
Dive
Individuals
SDM
Care
Planning
Provider
Pathway
What to Change
Manage
care out of
hospital
How to Change
The NHS Atlases of Variation
Reducing unwarranted variation to increase
value and improve quality
Awareness is the first step
towards value –
If the existence of clinical and
financial variation is unknown,
the debate about whether it is
unwarranted cannot take place
‹#›
Clinical & Financial Variation
• When faced with variation data, don’t ask:
• How can I justify or explain away this variation?
• Instead, ask:
• Does this variation present an opportunity to
improve?
• Deep dive service reviews support this across whole
programmes & systems and deliver Phase 2:
• What to Change
6
NHS RIGHTCARE
Partners and
Stakeholders
Case
Outlines
Mechanism
Miscellaneous
Decision
(e.g. Commissioning
Annual Plan)
Process
7
Contracts
Implementation
Governing Body
Reform
Proposals
Full Business Case
Public
Engagement
Reform Ideas
GP Member
Practices
Ideas Decision
Group
Clinical Policy
Development
and
Research
Decommissioning
Clinical Executive Group
HEALTHCARE REFORM
PROCESS
Service
Reviews
Procurement
Primary
Care
Development
Service Review Pathway – Diagnostic steps
Step 1 – define:
CURRENT
SERVICE
8
Step 2 – define:
Step 3 –
Step 4 –
categorise:
recommend:
FitFit
forfor
Purpose
Purpose
Maintain
Efficiency
andand
market
market
options
options
Redesign,
Contract,
Procure
Supply
Supply
andand
capacity
capacity
options
options
Contract,
Procure,
Divest
No/ low
benefit
Divest
FUTURE
OPTIMAL
SERVICE
Galvanising Clinicians – On the right things
Number of Circulatory indicators in the bottom quintile of the practice cluster
Each coloured bar
represents a different set
of indicators e.g. dark blue
is prevalence. The specific
indicators are then shown
in the table on slides 21-27
for the 3 practices with the
highest total number of
indicators in the bottom
quintile
1
Note, some of the data are based on small numbers. Statistical significance has not been tested and should not be
inferred. The data are presented to identify potential areas of improvements rather than providing a definitive
.
comparison of performance
9
Easy answers in Secondary Care?
• Diagnostic Atlas
• %age stroke patients undergoing brain imaging
within 1 hour of arrival at hospital, by hospital
•
•
•
•
•
10
80th %ile Fairfield NMGH MRI Royal Oldham -
55%
43%
32%
7%
4%
Secondary Care
• Diagnostic Atlas
• %age stroke patients undergoing brain imaging
within 24 hours of arrival at hospital, by hospital
•
•
•
•
•
11
80th %ile Fairfield NMGH MRI Royal Oldham -
98%
96%
91%
81%
94%
Heart disease pathway
= 95% confidence intervals
Initial contact to end of treatment
NHS Bradford City CCG
Bradford’s focus on optimal system and value - CVD
Population
Prevention
Individual
Risk Factor
Management
and
Prevention
L-term RoI
S- and mterm RoI
Chest
Pain
Atrial
Fibrillation
Heart
Failure
S-term
RoI
M-term
RoI
M-term RoI
Embed and use the tools of delivery – business process,
service specifications and protocols, contract management,
monitoring, support and managing pathways
13
AID - Adopt, Improve or Defend: Clinical protocols
viability assessment and prioritisation
1. Research and collate clinical referrals protocols – start with
Vale of York CCG’s - www.valeofyorkccg.nhs.uk/rss
2. Gather impact assessment group (IAG), comprising reform
lead, clinical lead and finance lead.
3. IAG - follow initial impact assessment process (next slide)
4. Assess appropriate protocols against locally determined
criteria – e.g. use reform decision tree
5. Adopt, or Improve and adopt, dependent on prioritisation –
N.B. base the financial prioritisation on collated impact
Initial Impact Assessment process
Is the protocol
deemed clinically
appropriate for
local use?
Yes
Are new pathway
steps required to
be implemented
locally?
No
Will it reduce
demand and/ or
more complex/
costly treatment?
No
Yes
Yes
Can amendments
be made to make it
so/ optimise it for
local use?
Describe new
pathways steps
Collate impact and
process through
decision tree
Yes
Make amendments
Pass to reform
team to work up
initial viability
assessment
Ideas &
Cases
Are there
any health
benefits?
No
Do not
proceed
Rate of
Return <12
months
High Priority
RoI* >£250k
Medium Priority
RoI* >£100k
Yes
Low Priority
RoI* <£100k
Is it a
must do?
Yes*
No
Does it
save
money?
No
High Priority
RoI* >£500k
Rate of
Return >12
months
No
Does it
increase
value*?
Yes
Prioritise
Yes
Yes
Can it be
delivered?
No
Yes
Can it be
made
deliverable?
Medium Priority
RoI* >£250k
Low Priority
RoI* <£250k
*See additional
slides at end
No
Do not
proceed
Set Timetable for completion of case outline*
Decision Tree for prioritising
reform proposals
6 steps to an optimal urgent care front end system
• 1. Operate robust Ambulatory Care protocols
• 2. Care home education and training
• Manage in home, reduce admissions
• 3. Advanced Paramedic Practitioner
• 1 WTE = >£1m impact on frequent callers per CCG
• Supports Parity of Esteem
• 4. Commissioner/ Primary Care-led A&E triage
• Only way in to A&E is via triage, unless ‘major’
• Triage to MDTs and UCC/ H@H
• Divert unnecessary urgent care
• 5. Multi-Disciplinary Teams for key care areas (Respiratory, CVD,
Diabetes, Dementia, etc)
• Detect, divert and begin case management
• 6. Urgent Care Centre/ Hospital @ Home
• Provide less complex alternative for ‘minors’
17
Bury priority: Mental Health
18
Bury priority: Mental Health
19
Phase 3 – How to Change
• Behaviour, culture and leadership development
• Attitude to implementation
• Delivery levers, contract and market management
Service specifications, CQuINS, PDAs and contract clauses;
Referrals management (reactive Vs proactive, pathway aides)
• Market management - 4 steps to buying optimal (in order of ease)
Agreement, negotiation and persuasion (current provider improves
willingly);
Contract management (make them do it);
Using current market options (encourage price and quality
competition), and;
Creating new market options (AQP, Tender, etc)
‹#›
Leadership - Not for the fainthearted
• BPE for improvement is designed to:
• Make you look for problem areas (and face
entrenched views)
• Make you fix them (no matter how hard)
• Highlight and deal with blocks in progress
(including when important people/
stakeholders)
• Doesn’t allow you to shy away
21
Change behaviours - Change is inevitable
• Choice ≠ Whether to change
• Choice = Whether to change yourselves or wait to be
changed
• People and Organisations who wait to be changed
lose control, become resistant and block
improvement
22
Patient Decision Aids – Implementation Process
1. Identify best 6 PDAs for local impact
• Use DD, CfV, AoV, PLCV, local enthusiasm, etc
2. Localise with local GP lead and add referrals criteria
and protocols
• C. 50% of unwarranted activity dealt with by
PDAs, 50% by protocols
3. Implement in key practices and prove impact
4. Spread across practices
5. Implement next 30 PDAs (in phases or collectively)
6. Implement International best practice
Optional (innovative):
7. Design own, use and spread
23
Leadership behaviour - Not for the fainthearted
• NHS RightCare is designed to:
• Make you look for problem areas (and face
entrenched views)
• Make you fix them (no matter how hard)
• Highlight and deal with blocks in progress
(including when important people/
stakeholders)
• Doesn’t allow you to shy away
24
Everyone gets to be Homer…
Which Homer are you?
Homer 1 (The Iliad) “Give me a place to stand and I will move the earth.”
Homer 2 (The Simpsons) “Trying is the first step to failure”
25
World’s 1st change management guru –
“To avoid criticism say nothing, do nothing, be
nothing”
Aristotle, c.350BC
26
Typical CCG embedding process
•
•
•
•
•
•
•
27
Get buy-in and mandate from
• Key leaders (AO, GP Chair, CFO)
• Wider group (Gov Body, Clinical leads, SMT, GP forums)
Demonstrate to wider stakeholders (Provider managers and clinicians,
local PH, HWBs)
Work with senior leads – BPE, Templates, Decision criteria, DT,
governance structure and local guidance to support
Whilst also progressing Where to Look (can include “quick win pre-What
to Change phase” for the financially challenged)
Support deep dive service review, evidence-building, case for change
development, decision-making
Whilst also developing delivery skills in preparation
Build improvement capability – BI, programme office, project
management, leadership resilience, contract management knowledgebase, delivery lever identification and use