s200 - day 1 - 0930 - commissioning for outcomes in specialised services

Specialised servicesPresented by: Fiona Marley and Donna Hakes

EXPO / March 2014

The history of specialised services• Before April 2013, specialised services in England were commissioned by 10 regionally

based, specialised commissioning teams and a national team, which commissioned highly specialised services

• The regional teams commissioned services for their resident populations

• The regional teams evolved and operated in different ways according to the particular agreements and arrangements with their constituent Primary Care Trusts, who collaborated together to commission specialised services

• This resulted in commissioning variation and differential access, service standards and specifications for services across regions (sometimes with the same provider)

• A Specialised Services National Definitions Set (SSNDS) provided a collection of 34 service definitions but its application was inconsistent and no region commissioned all the services in the SSNDS

The Health & Social Care Act 2012

• From April 2013/14,the Health and Social Care Act has defined specialised services as directly commissioned 'prescribed' services, based on four factors:

• The number of individuals who require provision of the service or facility

• The number of persons able to provide the service or facility

• The cost of providing the service or facility

• The financial implications for Clinical Commissioning Groups (CCGs) if they were required to arrange for the provision of the service or facility themselves

• The four factors determine whether NHS England commissions a service as a prescribed specialised service; it must also be possible to identify the prescribed activity separately to CCG-commissioned activity

How services are ‘prescribed’

• Ministers receive advice and consult with NHS England

• In 2013/14 there are 143 prescribed specialised services

• Listed in Regulations

• Described in the ‘Manual’

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How are changes made to the list? services?HMinisters take advice about:

• The services currently included on the list

• Services currently commissioned by NHS England that might more appropriately be commissioned by CCGs

• Services currently commissioned by CCGs that might more appropriately be commissioned by NHS England

• Innovative new treatments that are not part of existing services and which might be assessed by the new NICE HST Programme

It is not anticipated that there will be significant changes to the list for 2014/15

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Approach to commissioning Specialised Services

• NHS England is working with a range of stakeholders at a national level to determine the outcomes expected for specialised services

• This is being achieved through evidence based, cost effective, patient-focused commissioning, based on nationally developed clinical strategies through the five National Programmes of Care (PoC), which group together the prescribed specialised services

• The programmes span three portfolios covering acute, highly specialised and mental health services

• A national matrix team ensures a single national approach to specialised commissioning, working with the four regions and the 10 Area Teams (ATs) that have responsibility for contracting specialised services

Making it Happen: NHS England Medical and Operations Directorates

Commissioning Portfolios

3 Commissioning Portfolios

3 Commissioning Portfolios

Programmes of Care

5 Programmes

of Care

5 Programmes

of Care

Regional Oversight

4 Regional Oversight Teams

4 Regional Oversight Teams

Area Teams

10 Contracting Local Area

Teams

10 Contracting Local Area

Teams

What has been achieved in 2013 / 2014

• Single national approach

• Clinically led

• Patient focused

• Collaborative

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Goals

2000 clinicians and patients working to a common framework

All inclusive stakeholder identification and participation in service development (pathfinder groups with CCGs) Service specifications across every service we commission

A service specific innovation portfolio and commissioning through evaluation

Service specific quality measures and dashboards across every service we commission

A productivity workstream with focus on lean systems and transformational change to release money to invest

5 Year Specialised Services Strategy

Clinical Reference Groups

• Over 2000 clinicians, commissioners and patient/carer representatives working to a common framework

• All inclusive stakeholder identification and participation in service development

• Expanded to now cover 75 specialised service areas

• Internal medicine - Digestion, Renal, Hepatobiliary, Circulation system

• Cancer and Blood - Infection, Cancer, Immunity, Haematology

• Trauma - Traumatic injuries, Orthopaedics, Head and Neck, Rehabilitation

• Woman and Children - Congenital and Inherited Diseases

• Mental Health

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Medicines Optimisation CRG

• Provide support to all other CRGs

• Provide advice to other stakeholders e.g. NICE

• Products include gain share recommendations

• Close links with National Pharmacy Supply Group /Pharmaceutical Market Support Group

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What is CPAG?

• Advisory group covering all directly commissioned services, not just specialised services

• The group for difficult decision making. Health care commissioners have a statutory responsibility to ensure that care, including medicines and treatments, is commissioned within available resources (Department of Health, 2010). In order to secure the best value healthcare and the greatest health benefit for their populations, CPAG members need to make recommendations to prioritise the allocation of limited resources and balance demands for medicines and treatments against a number of considerations.

• Monthly meetings

• Secretariat provided by the Clinical Effectiveness Team

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CPAG Objectives

• To provide a recommendation to the Directly Commissioned Services Committee on the commissioning of services where there could be a substantial change in service provision.

• Such change will include a call on resources as defined by clinical effectiveness, cost effectiveness, appropriateness and relative priority of new and existing treatments / services.

• If treatment is of unproven effectiveness, poor cost effectiveness or of low overall priority, the group will advise under what circumstances the treatment should be made available to patients.

• The process of priority setting by CPAG is designed to be open, transparent and consistent.

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Clinical Policies

• Clinical commissioning policies set out NHS England’s position in relation to the commissioning of particular treatment, describing what will, and will not, be commissioned.

• Policies may be described as ‘interim’ for example if NICE are considering the treatment/indication under the Technology Appraisal programme and will be publishing findings within the near future, but there is a clinical urgency for a policy position in the meantime.

• 44 national clinical policies in place on 1 April 2013. 61 now published.

• Programme of over 80 policies in development, most dealing with transitional issues

• Feedback received during consultation is used by the relevant specialised services Clinical Reference Groups (CRGs) in the development of full policies for future use.

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Policy development governance flowchart

Service Specifications

• Service specifications set out what is expected from providers and define access to a service. They also set out a series of core and developmental standards. Core standards are those which any reasonable provider of a service should be able to demonstrate, whilst developmental standards are in place to improve services over a period of time.

• Pre- 1 April 2013, very few in existence.

• Now over 200 in place, including approx 70 for Highly Specialised Services

• Programme underway for CRGs to review existing documentation and update

• Derogation / compliance process completed

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Public consultation on products (1)

• Rolling programme now in place - four consultation windows per annum could include a mix of service specifications and commissioning policies

• Consultation is for 12 weeks, documents published on NHS England website

• Out to consultation currently on 14 specifications

• Given that the development of these commissioning products is continual, which will be agreed through an annual commissioning cycle, each of the consultation periods will involve NHS England consultation on both material changes to existing service specifications and policies, which may require some clarification or amendment, considered significant enough to require consultation; as well as on new specifications and/or policies.

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Public consultation on products (2)

• Any changes proposed to existing specifications and/or policies will have been tested with stakeholders registered with the relevant CRGs prior to consultation. It is this testing phase which determines whether or not a proposed amendment is significant enough to warrant public consultation. Minor amendments, such as typographical errors, do not require public consultation.

• Following 12 weeks of consultation, any feedback received will be reviewed by the Programmes of Care and CRGs as required, before CPAG recommends any new and amended documents for adoption by NHS England. Providers will then have six months’ notice for specifications of any changes due to come into effect. Policies are published with immediate effect.

• A report of the consultation process, outlining key themes from the feedback, will also be published following publication of the final documents.

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Specialised Services Innovation Portfolio (1)

• The SSIP will serve as a library of promising innovations to alert NHS England’s commissioners of the potential improved outcomes or efficiency from new innovations.

• Is an online virtual ‘library’ of new and in development innovations which have been registered by innovators, (split by invention/adoption and diffusion elements of

the end to end innovation pipeline). Launch took place 1 December 2013 of public facing view.

• NHS England’s specialised services commissioners will be able to understand the additional offer from new innovations as compared to what is already available.

• Scope:

• Now - innovations which are already on the market,

• From Summer 2014, a confidential registration option for innovations which are in development (being developed by industry, frontline staff and other innovators both at a national and international level). 24

Specialised Services Innovation Portfolio (2)

• This will have significant value for NHS England’s commissioners because as a result of this new information, commissioners will be able to:

• Understand the potential beneficial impact on patient outcomes, quality, safety, patient experience or efficiency from innovations; this may include any change over costs or related costs in future financial planning.

• Identify promising innovations for additional support where appropriate to further strengthen or speed up development plans for promising innovations as appropriate.

• Connect innovators to staff in other parts of NHS England who may have access to support or funding opportunities or working on similar/related innovations.

• Identify gaps in services and encourage these to be bridged by the development of innovation

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Participate in the Innovation Portfolio:

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Specialised high cost drugs

All specialised PbR-excluded medicines and devices are:

• Prioritised nationally

• Commissioned and funded (where applicable) directly by NHS England

• Commissioned as directed by Secretary of State following NICE Technology Appraisal or in accordance with other national policy

• Potential for national procurement tenders – e.g. home Parenteral Nutrition, Pulmonary Hypertension Homecare, Anti Retro-Virus drugs

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Specialised Services Quality Dashboards

Introduction

• A programme to work with clinical reference groups to create clinical quality dashboards that are:

• Clinically meaningful

• Demonstrate service quality

• Visually intuitive

• Statistically robust

• Can be used to explore areas or excellent or poor service

• Can be near time and rapidly refreshed

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Analytical Methodology

• Spine Charts (alerts / alarms)

Used standard (Spiegelhalter) SPC methodology as per CQC /

Dr foster etc

• SPC sparklines

Increase the amount of relevant information presented contain national mean, variation and trend

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• Are you different?• Do you know why?• What does it mean?• Are you comfortable being different?

• A dashboard is the opener for a conversation, it is not a test.

• Have the conversation openly and in the spirit of appreciativeenquiry

• Don’t argue about the data andignore the message

Approach: questioning variation

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Initiation

• Programme initiated in July 2012

• 20 specialised service clinical reference groups (CRGs) engaged

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BMT Burns Cardiac Surgery Cardiology Clinical Genetics

Cystic Fibrosis Haemophilia HIV Hyperbaric Oxygen

Immunoglobulin therapy

Major TraumaMental Health NICU PICU

Paediatric Cardiac Surgery

Paediatric Neurosurgery

PET CT Radiotherapy Renal Spinal

Measures creation

• Measurement ambitions understood

• Definitions created and refined

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Measure Number

Theme Measure Name of KPI Numerator Denominator

CFS04

Domain 3: Helping people to recover from episodes of ill health or

following injury

Reduce infection risk Percentage of patients admitted who are admitted to a single room/cubicle

Number of patients who are initially

admitted to a single room/cubicle during period (admission in

period)

Number of CF patients admitted during period

CFS05


following injury

Reduce infection risk Percentage of patients admitted to a ward staffed by CF specialist staff (as defined by

national specialist service specification)

Number of patients admitted to a ward

staffed by CF specialist staff during

period

Number of CF patients admitted during period

CFS09


following injury

Physiotherapy patient contact time: outpatients

Number of routine CF appointments at multidisciplinary clinic where patient was

seen by physiotherapist

Number of routine outpatient CF

appointments at the multidisciplinary clinic

Total number of appointments in CF out

patient clinics during period

CFS10


following injury

Dietician patient contact time: outpatients

Number of routine CF appointments at multidisciplinary clinic where patient was

seen by dietician

Number of routine outpatient CF

appointments at the multidisciplinary clinic

Total number of appointments in CF out

patient clinics during period

Data collection

• Remit for Pilot – collect data from Trusts

• Data requirements and online data collection tools shared

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Q3 Pilot out turn

• First data return 20th January 2013

• Dashboards shared with providers 1st February 2013 for validation

• Dashboards shared with commissioners 8th February 2013

• 651 Dashboards populated, for 16 CRGs, 22 services

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BMT Burns Cardiac Surgery Cardiology Clinical Genetics

Cystic Fibrosis Haemophilia HIV Hyperbaric Oxygen

Immunoglobulin therapy

Major Trauma Mental Health NICU PICUPaediatric Cardiac

Surgery

Paediatric Neurosurgery

PET CT Radiotherapy Renal Spinal

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Example Trust

Example Trust

Pilot outcome

• The pilot programme has demonstrated that Specialised Service Quality Dashboards can be produced.

• They provide data on variation in a service to the national CRGs and other stakeholders that is not available through an alternative route.

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This information is now presented to the Paediatric and Neonatal Governance Committee on a quarterly basis along with the other CQUINs set to show areas of development within the Trust’s Neonatal service with actions delegated out where necessary. Issues surrounding the number of in-utero and ex-utero transfers were discussed at last Directorate Management Meeting (9th October). The reports highlight other Trusts that may be providing care in a different way where we could seek advice and support to improve our level of care.Lead Nurse for Children and Neonates and Named Nurse for Safeguarding Children

Revised Data Collection Method

• Revised submission template developed following feedback from providers on original online data collection tool.

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Please email completed templates to : [email protected] ITEMS in GREY: please select from drop down

ITEMS in BLUE: please type value

ITEMS in YELLOW: will auto populate

Organisation Code: (please select from drop down list)

Provider Name:

Unit Name (if applicable):

Contact email (this will be used for any queries relating to your submission):

RefReporting

PeriodNumerator Denominator Value Comments

PNS04 Mean time from request for a CT scan for an urgent indication to completion time of scan Q2 1314 0

PNS10 Proportion of staff with paediatric training and neurosciences training Q2 1314 0

PNS11aProportion of patients refused admission due to lack of beds either delaying admission or requiring admission to another centre

Q2 1314 0

PNS11bProportion of patients refused admission due to lack of beds either delaying admission or requiring admission to another centre

Q2 1314 0

PNS12 Proportion of transfer delayed beyond 3 hours Q2 1314 0

PNS17Rate of patients and carers responding to experience surveys (note may be >100% with patient and carer responses)

Q2 1314 0

PNS02 Proportion of patients aged 1 - 16 years who die within 30 days of first tumour operation 2013/14 0

PNS05Number of deaths within 30 days of any paediatric neurosurgical procedure or neuroradiological interventional procedure

2013/14 0

PNS06Proportion of children dying within 30 days of a significant head injury (Codes A31 and / or A05, A06)

2013/14 0

2013/14 0

RA4

YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST

Paediatric Neurosurgery Specialised Service

Indicator Data

Please check you have completed all relevant data before submittingPlease input 'NULL' where there is no data available

Q1 2013/14 -

• 651 dashboards

• 25 CRGs or constituents

• 186 providers

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Specialised Service Submissions Q1 2013/14BMT Adults 20BMT Paediatrics 5Clinical Genetics 18CF Adults 22CF Paediatrics 22Cardiology 34Haemophilia 35Hyperbaric Oxygen 5Immunoglobulin 34Mental Health – CAMHS 41Mental Health – Deaf Services 5Mental Health – Eating Disorders 20Mental Health – Gender Identity Services 5Mental Health – Low Secure Services 91Mental Health – Medium Secure Services 40Mental Health – Perinatal Services 11NICU 78Paediatric Neurosurgery 11PET_CT 11PICU 19Radiotherapy 39Renal Dialysis 38Specialised Burn Care – Adults 10Specialised Burn Care - Paediatrics 10Spinal Cord Injury 7

Where next?

• Engaging and developing metrics with new tranche of CRGs

• Utilisation in the specialised services strategy service delivery focused plans

• Public facing – aim June 2014

• US collaboration being discussed

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Adult Critical Care

Congenital Heart Services

Hepatobiliary and Pancreas

Renal Transplant

Specialised Orthopaedic Services

Specialised Spinal

Adult Neurosurgery

Fetal Medicine Metabolic disorders

Specialised Dermatology

Specialised Pain

Specialised Urology

Cardiac Surgery

Haemoglobin-opathies

Paediatric Cancer Services

Specialised diabetes (all ages)

Specialised Respiratory

Vascular Disease

Complex Spinal Surgery

Heart and lung transplantation

Pulmonary Hypertension

Specialised Endocrinology

Specialised Rheumatology

Using outcomes to influence the commissioning of specialised services

• Pulmonary thromboendarterectomy

• Very complex surgery to remove blood clots and related material from the pulmonary artery of people with chronic pulmonary thrombo-embolic disease (repeated episodes of blood clots travelling to the lung)

• 115 patients per annum

• ?Continue with current single centre or identify second centre

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• Transplant services – heart, lung, pancreas, small bowel

• Use CUSUM plots – tool that monitors change detection

• Identify bad runs of activity in real time

• Any issues in transplantation have been shared across the service

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• Multi-systemic conditions

• Rare, often genetic conditions that affect many body systems

• Patients see numerous clinicians in an uncoordinated way

• Patient groups have influenced the development of ‘carousel’ clinics that bring together patients and all the relevant clinicians into the same room; comprehensive treatment plans are developed with the patient for local care management

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• Pseudomyxoma peritonei

• Very rare, mucus-producing tumour, which spreads to compress the abdominal organs

• ‘Sugarbaker’ technique – extensive removal of affected tissues and organs followed by heated chemotherapy

• Excellent 10-year survival in selected patients

• 200 patients per annum

• Originally single centre, now two centres

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• Adult extra corporeal membrane oxygenation (ECMO)

• Supports adults with severe potentially reversible respiratory failure by oxygenating the blood through an artificial lung machine.

• Single centre until December 2011; international trial

• Tendered and now have five expert centres

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s200 - day 1 - 0930 - commissioning for outcomes in specialised services

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