Commissioning… & Practice based Commissioning Ian Ayres

1. Commissioning… & Practice based Commissioning Ian Ayres

2. Jargon • PCT – Primary Care Trust • PFI – private Finance Initiative • NSF – National Service Framework • PbC – Practice based Commissioning • PbR – Payment by Results • JSNA – Joint Strategic Needs Assessment • LDP – Local Delivery Plan • LAA – Local Area Agreement • S31 – Section 31 Agreement • SLA – Service Level Agreement • FT – Foundation Trust • nGMS – the new General Medical Services Contract • AfC – Agenda for Change • nGDS – the new General Dental Services Contract • PMS – Personal Medical Services • SPMS – Specialist PMS • APMS – Additional PMS • More detail on NHS Jargon can be found on : http://www.dh.gov.uk/en/Help/Generaltemplate/DH_075451

3. The role of a PCTDH 2006 Engaging with its local population to improve health and wellbeing Commissioning a comprehensive and equitable range of high quality responsive and efficient services, Within allocated resources Directly providing high quality responsive and efficient services where this give best value

4. Commissioning – past & future • Pre internal market • Directly Managed Service • Internal market • Internal separation of providers and purchasers • Introduction of private capital (PFI) • Systems Reform • Creation of tariff prices • Introduction of FTs • Increase in commercial providers • Creeping scope of EU tendering law • PCTs today • Need to develop commercial commissioning and procurement skills • Not yet fully fit for purpose

5. World Class Commissioning • Locally lead the NHS • Work with community Partners • Engage with Public and Patients • Collaborate with Clinicians • Manage knowledge and assess needs • Prioritise investment • Stimulate the market • Promote improvement skills • Secure procurement skills • Manage the local health systems • Make sound financial investments

6. What is PbC • Provides practices or groups of practices the freedom to develop innovative high quality services for patients by giving them the ability to move resources in the interest of patients. • However, • PCTs still hold the statutory responsibilities • PCTs bank the money • PCTs contract • PCTs must still balance the books • PCTs still commission contractor services and specialist services • PbC is required to deliver targets etc

7. 2007/08 NHS England Revenue Funding to PCTs Balance NHS Capital Ed & Train Other £92.1bn 81% 6% 5% 8% NHS Finances

8. National requirement National priority for local action Local Action Operating Framework.Vital signs All PCTs set plans For sign-off by SHA PCTs to choose - in consultation with local Partners - which of these to prioritise locally

9. Operating Framework.Vital signs • National Priorities (13) • Improving cleaniness and reducing HCAIs • Improving access (18 weeks & GP Services) • Keeping adults and children well • Improving patient experience • Preparing to respond in a state of emergency • National priority for local action (17) • Equality • Mixed sex accommodation • Learning disabilities • Diabetic retinopathy • Crisis resolution (MH) • Access to psychological therapies • Older people - dementia • End of life care • Disabled children • Local priorities (33) • Local choice

10. Expenditure profile Prescribing 13% Primary Care 14% Acute 48% (35% Covered by PbR) Provider Services 7% Administration 5% Learning Disability 4% Mental Health 9%

11. Layers of commissioning <10% • National specialist commissioning • Heart transplants • Regional (SHA) specialist commissioning • BMT, haemophilia, etc >90% • PCT strategic commissioning • ? • Practice based commissioning • ?

12. Constraints on PCTs • Big Pot - Small discretionary spend • One year funding • Politics (National and Local) and election cycles • Constraints on Management Costs • Dual focus on provision and commissioning • Close relationship with Primary Care/GPs • Top down targets and priorities

13. Stakeholders Design Specifications & Manage Demand PbC Providers & Other Commissioners Stakeholders Assess Need Shape Market PCT Contract & Performance Manage Providers Commissioning Cycles

14. Stakeholders DH / NHS PCTs Practice based Commissioners Politicians Local Authorities Patients Public Third sector Not for Profit Voluntary sector Social Enterprise Clinicians Clinical Networks Providers Foundation Trusts NHS Trusts PCTs Local Authorities GPs and other Independent Contractors Private Sector Third sector Not for Profit Voluntary sector Social Enterprise Clinicians Stakeholders & Providers

15. Stakeholders Assess Need Commissioning Cycle

16. Assess Need • Outcome specification for individuals and populations (key PCT document is a JSNA): Based on • Needs assessments • Epidemiology • Actuarial analysis • Evidence based Medicine • Inequalities, unmet need, program budget information, analysis of unwarranted variation • Health impact assessments • Public Health • Stakeholder opinion (Voice)

17. Stakeholders Design Specifications & Manage Demand Stakeholders Assess Need Commissioning Cycle

18. Design Specifications and Manage demand • Service Specification and activity estimate (key PCT documents Operating Plan & LAA): Based on • Multi-professional teams • Best practice & Benchmarking • Modernisation and process mapping • Specification specification • Activity modelling • Referral management • Prior approval & utilisation review • Case management • Risk stratification • Outcomes Measures / KPIs / Quality Standards

19. Stakeholders Design Specifications & Manage Demand Stakeholders Assess Need Commissioning Cycle Providers & Other Commissioners Shape Market

20. Shape Market • Influence market development Includes • Market entrants & exits • New service offerings • Service redesign & reconfiguration Based on • Service strategies and reviews • Tendering (whole service or Specifications) • Changes to referral Specifications • Local Area Agreements • S31, Pooled budgets and partnership commissioning • Incentives (including Payment for Performance, and use of PbC efficiency savings)

21. Stakeholders Design Specifications & Manage Demand Providers & Other Commissioners Stakeholders Assess Need Shape Market Commissioning Cycle Contract & Performance Manage Providers

22. Contract and Performance Manage (1) • Setting and monitoring SLAs / Contracts & performance management • Template contracts • Performance Review • Comparison with plans • Achievement of targets • Compliance with contract terms • Compliance checks • Quality Review • Auditing patient experience & Patient reported outcomes • Peer review of quality • Clinical quality audit & review against standards

23. Contract and Performance Manage (2) • Setting and monitoring SLAs / Contracts & performance management • Information review • Data quality and completeness • Clinical coding challenge • Specification Review • Prior approval • Compliance with contract terms • Compliance with specifications & Specifications • Pay for Performance • Efficiency standards • Payments decreased or increased based on these reviews

24. Practice based Commissioning One part of the jigsaw of reforms New Strategy • White Paper – “Our Health, Our Care, Our Say…” • SHIFT (“central direction to local leadership” & “hospital” to “community”) • Sir Ara’s review (London and now National) • Market reforms • PbC • Payment by results (PbR) & Framework contract • Foundation Trust status (FT) • Plurality in provision • Commercial commissioning/procurement • Choice • Organisational Reforms • New Structure - SHAs and PCTs • New IM&T - Connecting for Health • New Staff Contracts - nGMS / Consultants / AfC / nGDS / Pharmacy

25. Provider Provider Contracts Provider Provider PCT PCT PCT PCT Cmcl Local Cmcl Local Cmcl Local Cmcl Local Commercial Commissioner Ltd Agree Plans Practices PbC Agree Plans Cmcl HQ clinical & contracting Draft reports, plans etc. Information Cmcl Data Centre data & transactions Data

26. Corporate Primary Care PCT • Provides Services • Commissions • Sub contracts Primary Care LLP/ltd Co GP practice Private Co GP practice GP practice GP practice GP practice

27. Lessons • Clinically led • Evidence based • Critical mass and localisation • Robust Processes • Clear partnerships - seek win/win • Pathways not interventions • Data, analytics & KPI Driven • Quality first • Empower Users & understand their experience

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