WELCOME

Wednesday 21 January 2015

Webinar

Commissioning for Outcomes

Commissioning for Outcomes

Wednesday 21 January 2015

1pm – 1.45pm

Bob Ricketts CBEDirector of Commissioning Support Strategy

& Market Development, NHS England

&

Beverley MatthewsLTC Programme Lead, NHS Improving Quality

Bev MatthewsA nurse by background, Beverley has worked extensively throughout the NHS in a variety of clinical, managerial and strategic roles. Beverley’s current role as Programme Delivery Lead for Long Term Conditions Improvement Programmes: LTC Year of Care Commissioning Model and LTC Framework. Prior to joining NHS Improving Quality in April 2013, Beverley was Director of NHS Kidney Care and NHS Liver Care.

Passionate about service transformation through developing networks and leading complex programmes. Providing strategic leadership to partners within health communities, managing stakeholders and working across agencies.

Bob Ricketts, CBEDirector of Commissioning Support Services & Market Development for NHS England since September 2012. Focus: developing and implementing two core strategies for NHS England – developing commissioning support services (published in June) and creating autonomous NHS Commissioning Support Units (provisionally to be published in December).

Previous Director roles within the Department of Health included developing the NHS Standard Contract, competition policy, patient choice and choice of any qualified provider, the social enterprise sector, Transforming Community Services, and commissioning and demand-side reform.

Meet the Speakers

Commissioning for Outcomes

• Aligning with shared commissioning ambition.

• Sharing experience and what works.

• Using routine data to measure impact on health outcomes.

Learning Outcomes

Beverley Matthews

LTC Programme LeadNHS Improving Quality

Beverley.matthews@nhsiq.nhs.uk

www.england.nhs.uk

LTC Framework

6

Organisational &

Clinical

Processes

Informed and

engaged patients

and carers

Health & Care

Professionals

committed to

partnership

working

Commissioning

• Information and

technology

• Case finding & risk

stratification

• Care Planning

• Safety and

Experience

• Guidelines,

evidence and

national audits

• Care Delivery

• Self Management

• Information and

Technology

• Group and Peer

Support

• Care Planning

• Policies for carers

• Voluntary sector

patient & carer

support

• HSC Integration

• Multi Disciplinary

Teams

• Culture

• Workforce

• Technology

• Care Co-

ordination

• Care Planning

• Needs

Assessment and

Planning

• Joint

Commissioning

• Metrics and

Evaluation

• Service User and

Public Involvement

• Contracting and

Procurement

• Care Planning

• Tools and Levers

The table below sets out some of the key components needed to deliver the central

aim for LTC Framework - Person Centred Coordinated Care

Bespoke Support

Tools and Resources

LinksLong Term Conditions Dashboardhttp://ccgtools.england.nhs.uk/ltcdashboard/flash/atlas.html

Long Term Conditions House of Care Toolkitwww.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/house-of-care.aspx

SIMUL8: Simulation Modelhttp://www.simul8.com/viewer/download.htm

#LTCyearofcare #LTCimprovement @NHSIQ

LTC Learning Forum

“Lunch & Learn” Webinar Series

&

Bite Size Master-classes

Virtual Learning Network

“Lunch & Learn”

• 45 minute “real time” Webinar sessions

• Topics agreed and learning outcomes identified

• Faculty of Speakers identified

Open invitation

Bite Size Learning Master-Classes

• Pre-recorded 20 minute Master-classes

• Master-class either as stand alone sessions or pre-requisites for Wednesday “Lunch & Learn” Webinars

• Faculty of Speakers identified

Open invitation

To register email LTC@nhsiq.nhs.uk

LTC Lunch & Learn Series ….coming soon…

Date Webinar Hosted by Bev Matthews &

4 February 2015 The Organisation of Integrated Care: encouraging collaboration through contractual mechanisms

Dr Rachael AddicottSenior Research FellowThe Kings Fund

www.england.nhs.uk

Commissioning

for Outcomes

NHSIQ: LTC Lunch & Learn

Webinar

21st January 2015

Bob Ricketts

Director of Commissioning

Support Services Strategy

www.england.nhs.uk

1. Context:

15

The Forward View sets out unprecedented challenges:

• 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

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

• 70% of the NHS budget is now spent on long term conditions

• People’s expectations are also changing

16

www.england.nhs.uk

1. Context: New opportunities

17

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 Progr.

• 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

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

2. Commissioning for outcomes: Why?

www.england.nhs.uk

Narrative on OBC

NHS CA Quality

Working Group

2. Commissioning for outcomes: What is it?

www.england.nhs.uk

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

2. Commissioning for outcomes = a spectrum

www.england.nhs.uk

2. Embedding outcomes in contracting:

ICHOM Standard Set for Localised Prostate Cancer:

OutcomesTreatment approaches

covered

▪ Watchful waiting▪ Active surveillance▪ Prostatectomy▪ External beam radiation

therapy ▪ Brachytherapy▪ Androgen Deprivation

Treatment▪ Other

Details1 Recorded via the Clavien-Dindo-Classification2 Recorded via the Common Terminology Criteria for

Adverse Events (CTCAE), version 4.0 3 Recommended to track via the Expanded Prostate

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

2. 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

excellent way to ensure quality measurement and to incentivise improvement.

ICHOM conclusion: Incorporating outcomes into contracts with providers is an

excellent way to ensure quality measurement and to incentivise improvement.

www.england.nhs.uk

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

2. Outcome-based population commissioning:

www.england.nhs.uk

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

2. Outcome-based population commissioning:

www.england.nhs.uk

2. Outcome-based population commissioning:

Two main contracting models

Attribute Lead Provider Alliance

Fit local culture Requires significant trust &

effective partnering

Probably easier to implement where

relationships less mature/damaged

Shift in risk from commissioner Substantial post-

mobilisation

Significant post-mobilisation

Requirement for commissioners

to co-ordinate care & providers

Low Low for care

Low-Medium for providers –

accountability & procurement

processes

Resource intensity & lead times High High

Proof of concept in NHS Limited Very limited

Evidence base in NHS?

Evaluation?

Minimal Nil?

Fit NHS Standard Contract Can be accommodated Not currently

Deferred funding/pump-priming Major problem Major problem

www.england.nhs.uk

OBC still emerging, but examples:

• Bedfordshire (MSK)

• Cambridgeshire (range of services for older people)

• Staffordshire (cancer & EoLC for 1m+)

• Sussex x3 (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

2. Outcome-based population commissioning:

www.england.nhs.uk

Upside:

• Potential to deliver sustainable whole-system service transformation

• Better care co-ordination & planning> more ‘joined-up’ care, better outcomes & value

• Strong synergy with integration

• Can catalyse & incentivise providers to work differently

‘Urban myths’:

• Doesn’t preclude personalisation or choice – embed in requirement for ‘lead provider’

• Shouldn’t freeze-out SME & SE participation - enable through sub-contracting

2. Outcome-based population commissioning

www.england.nhs.uk

Downside:

• Resource-intensive• System capacity & capability (CSS Lead Provider Framework) • Long lead times• Clarity re desired outcomes & behaviours crucial• Requires commissioner collaboration at-scale• Effective user engagement from the outset crucial• May require substantial (and challenging) market development

– will be difficult if existing relationships are immature/tense• For most commissioners, probably one OBC project at a time• Funding double-running costs & deferred payment (SIBs?)

Is it the right approach for the problem? “Sledge-hammers & nuts”

2. Outcome-based population commissioning:

www.england.nhs.uk

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!

2. Outcome-based population commissioning: CSFs

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

2. Commissioning for outcomes:

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

2. Commissioning for outcomes:

To register email LTC@nhsiq.nhs.uk

LTC Lunch & Learn Series ….coming soon…

Date Webinar Hosted by Bev Matthews &

4 February 2015 The Organisation of Integrated Care: encouraging collaboration through contractual mechanisms

Dr Rachael AddicottSenior Research FellowThe Kings Fund