the commissioning cycle. the steps: needs assessment service provision review priorities quality...
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The Commissioning Cycle
The Commissioning Cycle
The steps:
•Needs assessment•Service provision review•Priorities•Quality outcomes•Design services / pathways•Providers/suppliers•Demand management•Clinical decision making•Manage performance and outcomes
Underpinned by:
•Primary care involvement•Public and Patient engagement•Evidence based practice
Assessing Needs
Segment & trend analysis
Prevalence
Morbidity & mortality
Risk factors & lifestyle
Assessing Needs
Review
Service
Provision
Decid
e on
P
riorities
Specify
Quality
Outcom
es
Design
Services &
Pathways
Manage Quality
& Performance
Clin
ical
D
ecis
ion
Mak
ing
‘Market’ Intelligence
Data collection & reporting
Service access
Tools
Capabilities
Clinical Commissioning
Contract
providers
Man
age
Dem
and
What is needs assessment?Needs assessment identifies and strives to eliminate overuse, misuse and underuse of healthcare resources
• A variety of comprehensive evidence sources can be used that include, but are not limited to the following:
• Local knowledge of clinicians, health care providers, commissioners
• Local Authorities • Practice based commissioning data • Prescribing data • Prevalence and incidence data • Community health profiles • Housing data • Inpatient and outpatient data • Lifestyle data • Educational attainment data • Deprivation indices • Views of patients/service users • Census and other demographic data • Referral data
• Joint Strategic needs Assessments (JSNAs) are local assessments of current and future health and social care needs that could be met by the local authority, CCGs, or the NHS CB
• JSNAs and the Joint Health and Wellbeing Strategy is produced by health and wellbeing boards to set priorities for future action.
Review Service Provision
Best practice definition
Current performance
Benchmarking tools
Cost effectiveness analysis
National indicators
Clinical outcome measures
Assessing Needs
Review
Service
Provision
Decid
e on
P
riorities
Specify
Quality
Outcom
es
Design
Services &
Pathways
Manage Quality
& Performance
Clin
ical
D
ecis
ion
Mak
ing
Tools
Capabilities
Clinical Commissioning
Contract
providers
Man
age
Dem
and
Existing evidence base
Review current service provision
• Service reviews are undertaken to demonstrate a thorough understanding of current services provided in relation to the identified health needs. In essence, it is to ensure that services commissioned for the population are effective and of high quality.
• Key tasks to be considered as part of a service review include:-– Understanding the operational delivery, workforce issues and clinical factors for the
service – Developing knowledge of clinical effectiveness and evidence base – Benchmarking service against national or other indicators to access efficiency – Reviewing applicable performance indicators or monitoring clinical outcomes – Reviewing user experience and satisfaction with the service – Establish best practice clinical/public health guidelines for the service
Decide on Priorities
Assessing Needs
Review
Service
Provision
Decid
e on
P
riorities
Specify
Quality
Outcom
es
Design
Services &
Pathways
Manage Quality
& Performance
Clin
ical
D
ecis
ion
Mak
ing
Patient feedback
Capabilities
Evidence synthesis
Clinical Commissioning
Contract
providers
Patient population analysis
Systematic reviews
Health economic analysis
Man
age
Dem
and
Benefits case development
Patient communications
Decide and agree Priorities
• PCTs need to ensure that both national and local priorities are considered for inclusion in its Strategic Commissioning Plan and Annual Operating Plan, and that appropriate and sufficient stakeholder engagement (local clinicians, GPs, patients, public) is included in the decision making process.
• Priorities are generated from insights from:-– Public & patient engagement – Joint Strategic Needs Assessment – Clinical Evidence – Programme budgeting or equivalent. – Defined criteria for evaluation and prioritising investment and disinvestment should be
developed including:-– Quality – Local Needs – Impact on health outcome gains and inequalities – NICE guidance/guidelines – Costs and Productivity
Specify Quality Outcomes
Assessing Needs
Review
Service
Provision
Decid
e on
P
riorities
Specify
Quality
Outcom
es
Design
Services &
Pathways
Manage Quality
& Performance
Clin
ical
D
ecis
ion
Mak
ing
Existing outcome measures
Current Achievement
Outcome measure design
Capabilities
Benefits caseClinical
Commissioning
Contract
providers
Man
age
Dem
and
Audit design
National quality indicators
Specify and agree quality outcomes
• CCGs must align their strategic plan and priorities with the key quality outcomes which they intend to deliver for their population.
• Outcomes that are chosen will need to be underpinned by quantifiable data, in order to provide a basis against which they can be monitored.
• Increasingly, national indicators which quantify health and patient reported outcomes are being used by PCTs to measure quality improvement.
• Further information on key quality outcomes agreed for NHS Milton Keynes are outlined in the Strategic Commissioning Plan & Annual Operating Plan . For a full list of national indicators which the PCT is measured against see NHS Milton Keynes Care Quality Commission’s Annual Health Check.
• The CCG should also take account of the NHS, Adult Social Care and Public Health Outcomes Frameworks, the Commissioning Outcomes Framework and outcome strategies
Design Service & Pathway
Assessing Needs
Review
Service
Provision
Decid
e on
P
riorities
Specify
Quality
Outcom
es
Design
Services &
Pathways
Manage Quality
& Performance
Clin
ical
D
ecis
ion
Mak
ing Evidence synthesis
Guideline enablement
Pathway adaptation
Evidence summaries for single interventions
Capabilities
Existing pathways
Clinical Commissioning HTAs
Contract
providers
Man
age
Dem
and
Pathway development
Design services and pathwaysThis element of the commissioning cycle is all about PCTs being able to identify improvement opportunities, based on national/international best practice, which ensure that services across settings are coordinate and integrated.
1. Prioritise – rationale for the work, based around strategic priorities2. Start Up – preparing for the review, establishing project team3. Review – conducting the review, including gap analysis and needs assessment4. Redesign & Option Appraisal – identifying the optimal model of care, testing of options and option appraisal5. Provider Development – assessing the market, shaping supply & contract issues6. Business Case – establish value for money & effectiveness of the proposed new service/pathway.7. Vision – recommend and promote the ethos of new service, gain stakeholder support.
8. Specification – develop service or pathway specification, including quality outcomes desired, for the proposed change9. Approval – gain organisational approval and financial resources for progressing the new service/pathway.10.Procurement – agree process by which new service/pathway will be contracted for.11. Implement – develop a plan for implementing the new service/pathway and delivering the change12. Monitoring & Review – monitor progress in achieving the required outcomes and service specification compliance.
Contract with Providers
Assessing Needs
Review
Service
Provision
Decid
e on
P
riorities
Specify
Quality
Outcom
es
Design
Services &
Pathways
Manage Quality
& Performance
Clin
ical
D
ecis
ion
Mak
ing
KPIs, Outcomes
Contract management
Capabilities
National and local contractsClinical Commissioning
Quality Standards
Contract
providers
Man
age
Dem
and
Negotiation skills
Tools
CQUINs, PROMS
Data
Contract with Providers / Supply
• The contracting process ensures that formal agreements with all providers (acute, primary, community, mental health, voluntary sector) are in place, and that these contracts clearly set out what is expected from both the commissioning and the provider.
• Within these contracts, PCTs can• Specify quality requirements or outcomes (e.g. CQUIN, PROMs) • Incentivise the development of new service models or patient pathways • Ensure quality of care for service users • Ensure value for money
Manage Demand
Assessing Needs
Review
Service
Provision
Decid
e on
P
riorities
Specify
Quality
Outcom
es
Design
Services &
Pathways
Manage Quality
& Performance
Clin
ical
D
ecis
ion
Mak
ing
Evidence base for reducing LOS, complications and cost
Risk assessment tools
Tools
Educational resources
Existing service usage
Variation between providers
Clinical Commissioning
Man
age
Dem
and
Contract
providers
Order sets / care bundles
Referral best practice
Prescribing data
Manage demand and ensure appropriate access to care• CCGs will need to have in place a range of responsive providers that they can
commission healthcare services from. • However, they also need to be able to understand and predict current and future
demands on those services to ensure that they can accurately predict required future capacity for the population needs identified.
• Employing their knowledge of future priorities, needs and community aspirations – CCGs can use their role as leader of the local NHS to influence improvement, choice and service design in ways that can best meet future demands.
Clinical Decision Making
Assessing Needs
Review
Service
Provision
Decid
e on
P
riorities
Specify
Quality
Outcom
es
Design
Services &
Pathways
Manage Quality
& Performance
Clin
ical
D
ecis
ion
Mak
ing
Clinical Commissioning
Contract
providers
Man
age
Dem
and
Best practice guidance
Tools
‘Just in time’ learning
Guidelines
Pathways
Clinical prompts
Referential decision support
Integrated decision support
Order sets / care bundles
Clinical decision making
• The CCG must build a strong framework of clinical involvement in its decision making to ensure that it can:-
• Develop a greater range of more integrated services in community settings • Secure great investment for upstream or preventative interventions that keep people
healthy for longer, prevent ill health and reduce inequalities • Drive continuous quality improvement and innovation across the whole system.
Quality & Performance
Assessing Needs
Review
Service
Provision
Decid
e on
P
riorities
Specify
Quality
Outcom
es
Design
Services &
Pathways
Manage Quality
& Performance
Clin
ical
D
ecis
ion
Mak
ing
Performance analysis
Decision support tools
Tools
Real time performance
Variation between providers
Learning needs assessment
Clinical Commissioning
Contract
providers
Man
age
Dem
and
Performance linked educational resources
Best practice guidance
Manage quality, performance & outcome• In order to assess whether their strategic goals are being achieved, CCGs need to
manage quality and performance of commissioned healthcare effectively. • This will involve monitoring and managing the performance of providers against
their contracts, including specific quality indicators or key performance indicators.• Good data and information sharing systems, plus constructive performance
discussions are crucial to this element:-– Ensuring monthly, quarterly or annual performance reviews are in place as appropriate – Clarity as to what checking/ verification is to be done, by whom and how frequently – Agreement on what Indicators /KPIs are to be measured, by whom and how frequently. – How are the results to be communicated and to whom – Who is responsible for following up concerns and in what forums.
NHS MK CCGBoard
NHS MK CCG Senior
Management Team
NHS MK CCGDelivery Group
Stakeholders
Service providers
Health and Wellbeing Board
Clinical Networks
Clinical Senate
Acute Service Review
Partner Organisations
Patient Congress
Practice Participation Groups
LINk:MK
Commissioning Support Hub
Joint Commissioning Team
External resources
Neighbourhood Quality &
Performance Groups (4)
Planned Care Programme
Urgent Care Programme
Mental Health Programme
Children & Maternity
Programme
Long Term Conditions
reports to
Co-operation & Competition Panel
Clinical Programmes& Projects Network of member practices
advisory
NHS Milton Keynes CCG Management FrameworkInternal decision making structure
http://www.miltonkeynesccg.nhs.uk/governance_structure/
Commissioning in Milton Keynes• Read about commissioning in Milton Keynes
http://www.miltonkeynesccg.nhs.uk/commissioning-in-mk/
• Read about the work of the Milton Keynes CCG Programme Boards:http://www.miltonkeynesccg.nhs.uk/commissioning_programmes/
• See the Commissioning Toolkit of resources to support the work of commissioners:
http://www.miltonkeynesccg.nhs.uk/commissioning_toolkit/
• Sign up for alerts to keep you abreast of the latest commissioning resources – Anne Gray - [email protected]
Compiled by Anne Gray, Knowledge OfficerNHS Milton Keynes CCGSeptember 2012
With acknowledgement to Dr Andrew Jones, Clinical Specialist and Lead for Commissioning, BMJ