Innovative commissioning for integrated out of hospital care emerging approaches
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Innovative commissioning for integrated out-of-hospital care: emerging approaches. Bob Ricketts Director of Commissioning Support Services Strategy Community Health Services Forum 20 February 2014. Innovative commissioning for integrated out-of-hospital care: emerging approaches. Topics:

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Innovative commissioning for integrated out-of-hospital care: emerging approaches

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Innovative commissioning for integrated out-of-hospital care: emerging approaches

Bob Ricketts

Director of Commissioning Support Services Strategy

Community Health Services Forum

20 February 2014


Innovative commissioning for integrated out-of-hospital care: emerging approaches

Topics:

  • Context

  • Commissioning for better outcomes & value:

    - capitation-based

    - ‘accountable lead provider’ v. ‘alliance’

    - value-based

  • Currencies & payment mechanisms

  • TCS contract expiry?


1. Context:

The NHS is facing unprecedented challenges to its sustainability – Call to Action:

  • Demographic pressures – an ageing population

  • Demand – incidence of LTCs (diabetes, dementia)

  • Rising expectations – patients, public, politicians

  • Quality – failures & gross variation

  • Outcomes – still often poor comparatively

  • Failure to deliver integrated care at-scale

  • Resource constraints - £30bn gap opening up

  • Outdated & over-stretched delivery systems – including primary care & ‘community services’

    = clear ‘burning platform’ for transformation


1. Policy context:

The new commissioning architecture provides unprecedented opportunities for innovative commissioning & provision:

  • Clinically-led commissioning

  • Strengthened partnerships with local government

  • Renewed focus on integration (Better Care Fund = 3% of total health & social care £ plus wider pooled funds )

  • Opportunity to re-design primary care

  • Growing support for ‘innovative commissioning & contracting’ – outcome-based contracts for populations, ‘lead provider’ models, risk-sharing, much longer contract durations to support investment & disinvestment to transform, review & alignment of incentives …


1. Context:

Community services key to a sustainable NHS:

  • Scale: 100m contacts pa; £9.7bn, 10.6% of NHS expenditure

  • Vehicle for at-scale service transformation & major shifts in care settings (if alternative services are available)

  • Offer wide range of opportunities for prevention, early intervention & co-production

  • Ability to engage patients, carers, communities & other agencies

  • Unmet potential – Transforming Community Services


1. Context:

Community Services: How they can transform care

Nigel Edwards, King’s Fund, Feb. 2014

  • Long-standing ambition to move care closer to home:

    - some reduction in hospital LoS, but much more to be done

    - patchy adoption of service models & limited progress to

    integration

  • Transforming Community Services (2008-), but “mostly concerned with structural change rather than how services could be changed. It is now time to correct this.”


1. Context:

Community Services: How they can transform care:

  • Develop a simple pattern of services based around primary care & natural geographies, offering 24/7 services as standard. MDTs need to work differently with specialist services, offering patients a more complete & integrated service.

  • New models should include both health (and mental health) & social care, managing the health & social care budgets for their patients

  • Services must be capable of very rapid response , to sustain independence & speed up discharges from hospital


1. Context:

Community Services: How they can transform care:

  • “New ways to contract & pay for these services are needed. This will also require changes in primary care & hospital contractual arrangements and in the infrastructure to support the model”:

  • “Eliminating obstacles in contractual and payment arrangements”:

    - block contracts

    - poor specifications

    - replicating historic commissioning patterns


2. Commissioning for better outcomes & value: the case

  • Our ambition is to deliver great outcomes, and reduce inequalities. But the current shape of the health and care delivery system is not sustainable in the medium-term given the challenges if faces.

  • Service transformation at scale and pace will be essential to secure a successful, sustainable NHS.

  • We still have a big gap in delivering the best outcomes – internationally & within England

  • We need to support & develop the NHS commissioning sector to lead the transformation of services:

  • Transformation is a key leadershiprole for CCGs & direct commissioners

  • Outcome-based population commissioning is a key vehicle to drive transformation & secure better outcomes and value


2. Commissioning for better outcomes & value: OBC & VBC

  • Outcome-based population commissioning: a key vehicle to drive transformation & secure better outcomes 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

  • Value-based commissioning: emerging approach from U.S. Potentially useful for:

    - assessing priorities

    - comparing disparate service offers

    - re-directing/re-focusing incentives to driving-up value

    within services commissioned on Tariff


2. Commissioning for better outcomes & value: OBC

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’

  • Provider co-ordinates care planning & delivery

  • Provider takes on much of the demand risk

    Still emerging, but examples: Bedfordshire (MSK), Cambridgeshire (older people services), Staffordshire (cancer & EoLCfor 1m+), Oxfordshire & Milton Keynes (sexual health; substance abuse), Oxfordshire (adult mental health, maternity & older people – on hold)


2. Commissioning for better outcomes & value: OBC

To be transformational, OBC should …

  • be genuinely patient-centred & outcome-led ; aim high

  • focus on local priorities for improving outcomes & quality more widely AND reducing inequalities

  • build on sound analysis & prioritisation – RightCare & STAR

  • address prevention, not just treatment & care

  • span primary, community & secondary health care – see King’s Fund Top 10 Priorities for Commissioners

  • consider & involve other relevant services – social care but also other agencies influencing outcomes


2. Commissioning for better outcomes & value: OBC

Staffordshire - at the leading-edge …

  • Collaborative: 5 CCGs + Macmillan Cancer Support (strategic partner) + NHS England + CSU

  • Outcome-focused & integrated services:

  • At scale: key services for 1m people across the footprints of people3 acute provider trusts. Will be the biggest contracts yet tendered for integrated NHS care

  • Transformational: patient-centred re-design; joined-up care

  • Innovative contracting: lead provider; 10 year duration


2. Commissioning for better outcomes & value: OBC

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. Commissioning for better outcomes & value: OBC

Downside:

  • Resource-intensive

  • 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

    Is it the right approach for the problem? Value-based?


2. Commissioning for better outcomes & value: Value Based Commissioning:


2. Commissioning for better outcomes & value: Value Based Commissioning:

Assessing priorities:

1. Patient Value – value from the perspective of an individual patient

2. Public Value – value from the perspective

of the public considering health care as a whole

3. Allocation Value – economic benefits within a

fixed annual commissioning allocation

4. Economic Value – economic benefit across the

whole of the health and social care system

Select service proposals


3. Currencies & payment mechanisms:

  • Still very difficult for commissioners to compare providers, performance & value

  • Information systems & measurement = key barriers

  • Limited progress from block contracts

  • Compounded by often unsophisticated approaches to commissioning & prioritisation

    But …

  • Increasing support commissioners to prioritise & assess value systematically – Right Care & STAR

  • CFTTN work on indicators

    Indicators > Currencies > Fairer Payment Systems

  • Wheelchair tariff?


3. Currencies & payment mechanisms:

Indicators:

  • Foundations laid in Initial work led by the CFTN to develop indicators of performance & value

  • Indicators based around 3 domains: performance; quality; social value, equity & inclusion

  • Signalled support from Monitor, NHS England, CQC, NHS TDA, HSCIC & Commissioning Assembly

  • Long lead time (2 years for indicators?), but great start

  • Should enable value-based commissioning for those services not included in capitation OBC


3. Currencies & payment mechanisms:

Deferred payment – Social Impact Bonds?

  • Need for upfront investment prior to social impact & financial return

  • Applications? Frail older people – admission avoidance & promoting independence; reducing use of anti-psychotic drugs in residential care; challenged families

  • Examples? GLA & St. Mungo’s – homelessness; Essex County Council & Action for Children – children at the edge of care; Sandwell & West Midlands CCG with Marie Curie – EoLC; Age UK in Cornwall – admission avoidance (under development)


3. Currencies & payment mechanisms: SIBs

SOCIAL INVESTOR

(Investment contract

for financial return)

COMMISSIONER ↔ SPECIAL PURPOSE

(OBC contract for VEHICLE

cashable savings & (Sub-contract for activity)

better outcomes) ↕

SERVICE PROVIDERS

(Acknowledgement to Bevan Brittan)


4. TCS contract expiry?

Poses real dilemmas for commissioners & regulators …

  • PCT divestment of community services under ‘TCS’ 2011

  • Contracts 2-3-5 years

  • Uncontested contracts to social enterprise spin-outs, on condition open competition on expiry

  • Decisions subject to procurement law, public law (Gloucs. TCS judicial review) & s.75 regulations – caveat emptor!

  • We now have a diverse non-NHS market (SEs & corporates


4. TCS contract expiry?

What to do?

  • Roll-over for another full term (but not for TCS Social Enterprises)

  • Extend pending disaggregation and/or OBC

  • Re-procure for service transformation and/or better value(Bath & NE Somerset CCG; Hambleton, Richmondshire & Whitby – terminating contract with York Teaching FT & re-procuring)


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