World Class Commissioning Final Panel Report

1. World Class Commissioning Final Panel Report NHS Leicestershire County and Rutland March 2010

2. Overview The Panel thanks NHS Leicestershire County and Rutland for participating in this round of assessments for World Class Commissioning. The Panel asks the PCT to accept this report in the spirit in which it is intended: as a support tool on the journey to world-class commissioning and as a considered perception of the organisation’s strengths and weaknesses based on the insight the PCT itself gave the panel into its commissioning approach. During our review of NHS Leicestershire County and Rutland, the panel developed an overall impression that the PCT is making good progress but would benefit from clarifying the narrative of the Strategic Plan. The Panel noted that in some areas the PCT’s self-assessments of competencies did not match the Panel’s perceptions during the assurance process. Nationally, PCTs have tended to overstate their scores, and you are no different in this respect. The Panel identified three main recommendations that the PCT will need to consider in the drive to transform health and healthcare in Leicestershire County and Rutland.

3. Commentary The Panel saw a high performing PCT that lives up to challenges that are set with a good track record of delivery. The Panel was impressed with the progress made with partners in the Total Place programme, which it considered to be leading edge. The Panel also commends the agreement and signing of the contract with the UHL and its non- reliance on demand management in year one. The Panel acknowledges that all PCTs will face challenges in delivering continuous improvements to quality in light of the changing economic conditions and therefore makes the following recommendations to NHS Leicestershire County and Rutland. The Panel identifies three major areas for consideration by the PCT at this stage on its journey • Headline: The Strategic Plan is difficult to follow, particularly given that the link between vision, goals and initiatives is not clear. Observation: The Strategic Plan lacks clarity, which was partially gained during the Pitch on the Patch and Panel Day discussions. The Panel thought that the vision could be more ambitious given that the Strategic Plan is the cornerstone document that articulates the essence of what the PCT wants to do and how it plans to do it. As people external to the PCT will read the Strategic Plan, it is important that there is a clear articulation of the direction of travel. A crisp, clear CSP will also help to align your staff more strongly to a common vision and goals. Recommendation: As the PCT is entering a new way of working and collaborating with partners in the Local Health Economy, this provides an opportunity to revisit and refresh the Strategic Plan to better reflect this direction/purpose. • Headline: Investment and disinvestment decisions are not explicitly outlined in the Strategic Plan.Observation: The Panel commends the way in which NHS LCR in partnership with NHS Leicester City has reached financial agreement with key providers for 2010/11. Whilst the Panel was informed that a full investment and disinvestment plan is articulated in the LOP, the Panel could not see the detail in the Strategic Plan. This meant that the Panel could not clearly understand the impact of each investment and disinvestment decision on health outcomes and efficiency aspirations. Recommendation: The Strategic Plan would benefit from an explicit presentation of investment and disinvestment decisions and the Panel strongly recommends you to include them in the refreshing of the strategy suggested above. • Headline: The refreshed PBC structure and emphasis on clinical engagement is commended. Its role is so important that you should continue on this development journey.Observation: PBC and primary care are critical to the delivery of the vision. Continued nurturing and support of PBC and clinical engagement will ensure fitness for purpose and minimise risks to delivery of the vision.Recommendation: Support the PBC structure ensuring that monitoring and tracking of primary care performance is closely applied and that early variances are actively managed, whilst still ensuring that innovation and implementation are the ways of working. 2

4. Potential for Improvement Commentary PCT trajectory Commentary Areas for development • Year 1 WCC Panel Report recommended that the PCT should strengthen clinical engagement and review the narrative of its Strategic Plan. Whilst the PCT has strengthened clinical engagement and refreshed its approach to PBC, the PCT has yet to successfully refresh their Strategic Plan. • The PCT has a clear plan to move forward with partners (e.g. innovative contract with UHL for 10/11, working with NHS Leicester City and collaboration with the Local Authorities in relation to the Total Place programme) • The PCT should revisit the strategy to ensure that there is a clear Commissioning Strategic Plan for NHS Leicestershire County and Rutland, developed in accordance with best practice. • Based on mixed feedback from the PCT Stakeholder Survey, the PCT is advised to reflect on the results to ensure that the good relationships it has built are sustainable. Organisational development Commentary Areas for development • The PCT has acted on Panel Feedback from Year 1 and has appointed a Director of Public Health and has strengthened its public health team. • In a number of areas the PCT’s self-assessment did not align with the pre-Panel analytical review. • The PCT should continue to develop this new team so that it can support the organisation in achieving its vision and goals. • The PCT should review the submitted evidence that will enable it to clearly demonstrate progression through the competency framework. 3

5. Previous Panel scorecard Previous Current Current COMPETENCIES GOVERNANCE NHS Leicestershire County and Rutland Health outcomes and quality Outcomes Selection Date: 2009/10 Level 4 PCT Rate of Change Current Time Period Level 1 Strategy A Local leader of NHS 01/01/2004 - 31/12/2008 Collaborates with partners 01/01/2005 - 31/12/2007 Patient and public engagement 01/04/2008 - 31/03/2009 Clinical leadership Finance 01/01/2005 - 31/12/2007 G Assess needs 01/04/2008 - 31/03/2009 Prioritisation N/A Stimulates provision 01/01/2005 - 31/12/2007 Innovation Board A 01/04/2008 - 31/03/2009 Procurement and contracting 01/01/2007 - 31/12/2007 Performance management Ensuring efficiency and effectiveness of spend n/a

6. Panel Assessment Last year’s rating Rationale for scoring Recommendations Governance – Panel assessment on Strategy Red Amber Green Measure Assessment • Vision and goals • Initiatives to ensure delivery of strategic goals and the PCT’s programme of change • Consistency of financial plan with the strategy • Board challenge, ownership and monitoring of strategic plan delivery • Achievement of milestones to date A • In the written submission there is no clear ‘golden thread’ that links vision and goals, initiatives and outcomes. The vision and goals do not instil full confidence that the PCT will deliver its priorities, as there is some confusion between initiatives and outcomes. However during Panel Day discussions including a compelling ‘Pitch on the Patch’ the Panel was persuaded that the ‘direction’ of travel is correct. • In the evidence submitted, some initiatives appear to be unfocused and poorly linked to the vision, and some do not have clear investment or disinvestment plans. There is a general lack of detail behind the initiatives that questions their individual deliverability (e.g. the wider implications of prioritisation decisions under different financial scenarios is not clear, and the impact of initiatives in health outcomes and inequalities is insufficiently detailed). • The evidence submitted highlighted some inconsistencies of the financial plan with the strategy. However, the Panel was persuaded that the required consistency is articulated in the LOP that had been developed after the submission of the CSP. (There has been a major LHE agreement on secondary care that was not foreseen at the time of preparation of the CSP.) • The Panel was persuaded that there is sufficient ownership of the strategy by the Board and that they challenge certain elements and initiatives (e.g. contentious decision not to increase investment in COPD). The whole Board is aligned with the strategy, and the Panel was persuaded that the Board can articulate the way the vision addresses the health needs of the population. • The Panel was persuaded that the PCT reviews past performance against milestones (e.g. root-cause analysis, applied to redesign NHS health checks). However, it was not clear that the PCT understands the impact on achieving vision and goals of missing milestones. • The Panel encourages the PCT to reflect on the following: • The Strategic Plan is confused and difficult to read, almost as if it were built on some legacy elements that no longer fit together. The presentation during Panel Day showed a much better sense of direction than the one articulated in the CSP. The PCT should take advantage of moving toward operating as part of an integrated LHE to revisit, refresh and clarify your Strategic Plan.

7. Panel Assessment Last year’s rating Rationale for scoring Recommendations • The Panel encourages the PCT to: • Further develop the detail that underpins the delivery of saving plans and ensure that the savings to be realised by key providers are fully aligned with the PCT’s plans. Governance – Panel assessment on Finance Red Amber Green Measure Assessment • Historical financial management • Robust financial management • Robustness of planning assumptions • Sustainable financial position as ‘base case‘ • Sustainable financial position under different financial scenarios G • The PCT has had 3 years of good financial balance. The last deficit was posted before the current management team were appointed, and they have delivered strong financial performance. • It is evident that the PCT operates robust financial management, as finances are reviewed and challenged at every Board meeting. The PCT also demonstrates good invoice auditing, asset and debt management processes. • Planning assumptions are aligned with SHA guidance and the assumptions on contingencies seem appropriate. Although the Panel was persuaded that the PCT has a good understanding of how the saving initiatives will be delivered, the PCT needs to develop more granular plans to assure delivery. • The assumptions on savings are backed up by a credible delivery plan. The PCT is projecting surplus of £1m for 09/10 and there is a credible plan in place to address major financial challenges (e.g. the PCT’s QIPP challenge in 2010/11 is £26m, of which 85% will be banked before the start of the fiscal year). The plan is not heavily dependent on the delivery of demand management initiatives in year 1 and there are several additional measures that could be brought on line in case of need (e.g. re-deploy 2% non recurrent funding, disinvestment in specialised commissioning). • The PCT achieves its surplus in both best and worst case scenarios from increased QIPP, but the PCT has not clearly articulated what additional saving are going to be used in which sequence (i.e. the additional saving programmes need to be further detailed).

8. Panel Assessment Last year’s rating Rationale for scoring Recommendations Governance – Panel assessment on Board Red Amber Green Measure Assessment • Organisation • Risk • Information • Performance • Delegation • Board interaction A • The PCT has a well-defined organisational structure, supported by a gap analysis, to become world-class commissioners. • Risk is managed effectively, as demonstrated by the monthly risk governance report. A review of the PEC was undertaken in 2009, and the PCT demonstrates clinical engagement at many levels. • The performance reports for the acute and mental health providers demonstrated that the information captured quality, finance, activity and performance. The Panel gained sufficient confidence that primary care reports are reviewed and underperformance addressed by the PEC, which led to an improvement in immunisation and smoking-cessation rates. • The PCT is not achieving the required level of delivery of its Existing, Tier 1 and Tier 2 Vital Sign commitments required to support ‘Green’ assessment (PCT achieving 81%) however the Panel gained sufficient evidence that the Board tracks progress on initiatives through its use of proxy measures for key outcomes. • Although the submitted evidence did not demonstrate governance arrangements, the Panel was persuaded that the PCT and Local Authority had outlined how joint commissioning would support delivery of the strategy. The PCT’s Scheme of Delegation however does not clearly describe points of scrutiny of commissioning arrangements and business cases (for decisions relating to Specialised Commissioning). • The Board had held a development session that demonstrated their engagement in shaping the strategy and prioritising investments. During the Panel Day, the Board provided examples of trade-offs, such as the disinvestment in COPD, as evidence showed that no further investment was deemed necessary because the PCT was already above top quartile performance in COPD. • The Panel encourages the PCT to: • Review and update the governance arrangements for all specialised/joint/collaborative commissioning arrangements, as they are crucial in the context of the Total Place pilot and to apply the skills demonstrated in understanding marginal benefit versus marginal investment, and progress this from the current application to new business cases towards all total spend.

9. Newly Selected Upper Quartile x Top quartile rate of improvement Previous Lower Quartile x Bottom quartile rate of improvement Current Outcomes NHS Leicestershire County and Rutland health outcomes and quality Outcomes Selection Date: 2009/10 • Changes in outcomes from last year • IAPT is new this year • Performance over last year : • The following metrics showed improvement: health inequalities, life expectancy, cancer mortality, alcohol related admissions, CVD mortality, diabetes controlled blood sugar, deaths at home • Aspirations: • The panel has confidence in the level of aspiration for 6 outcomes: • Male health inequalities, male life expectancy, IAPT recovery, CVD mortality, diabetes controlled BP, patient experience • The panel believes that aspirations for following outcomes might be more aggressive: • Female health inequalities, female life expectancy, smoking quitters, cancer mortality, alcohol admissions, deaths at home • Recommendations: • Reflect on which health outcomes will result in the PCT becoming the “healthiest PCT in England”. • Develop interventions that will improve outcomes such as smoking quitters and obesity 1 3 year period where available – please see appendix for variations where applicable for some indicators 4 Top decile defined as the PCTs with the largest rate of improvement SOURCE: Team analysis

10. 55.0 Overview – Competencies Last year’s rating Level Panel Assessment Competency 1 2 3 4 1. Locally lead the NHS • Top line introduction • The panel agreed with 15 of the PCT’s 33 self-assessment ratings • However, the panel found it necessary to adjust the remaining ratings • The panel acknowledges that in many areas where it has adjusted self-assessment ratings, the PCT has made inroads into achieving the sub-indicators • The panel would recommend that the PCT continue to build on its acknowledged competency gaps and, where it has good approaches across some care settings, to build competencies more systematically across the PCT. More detailed recommendations are included in the following pages 2. Work with community partners 3. Engage with public and patients 4. Collaborate with clinicians 5. Manage knowledge and assess needs 6. Prioritise investment Stimulate market 7. 8. Promote improvement and innovation 9. Secure procurement skills 10 Manage the local health system 11 Ensuring efficiency and effectiveness of spend* 1 Competency added this year, hence last year’s rating not available

11. Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Continue engaging the local population to ensure they improve their perception of the local NHS. • Continue addressing staff issues to consolidate and improve the good results suggested by the Staff Survey 2009. Competency 1 – Panel assessment Panel Assessment Level Competency Measure Are recognised as the local leader of the NHS • Reputation as the local leader of the NHS • Reputation as a change leader for local organisations • Position as an employer of choice • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Insufficient evidence – The PCT scored 5.26 (above the SHA average of 5.08) on ‘local leader of the NHS’ and demonstrated examples of leading the local health agenda (e.g. community dialogue). However, the Public Perception Survey commissioned by the SHA (MORI poll) does not demonstrate that the local population yet agrees that the local NHS is improving services (the PCT scored 59% which is below the SHA average of 62%, and not sufficient for level 3). • Sufficient evidence – The PCT scored 4.94 (above the SHA average of 4.87) on ‘having a significant influence on our decisions and actions’. The PCT has led and implemented regional change (e.g. Leicester, Leicestershire and Rutland health economy on QIPP). • Insufficient evidence – There was evidence of positive commissioning staff satisfaction. However, overall staff feedback in the NHS Staff Survey 2008 was on average negative compared with peer East Midlands PCTs. The Panel was persuaded that the PCT has addressed this, as suggested by the results from the NHS Staff Survey 2009 (27 indicators have improved, 10 worsened). However, this new evidence alone is insufficient to support a level 3 score.

12. Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Review current stakeholder engagement processes to increase their agreement that the PCT engages them proactively to drive strategic decisions. • Progress further in joint collaborative initiatives, so stakeholders become progressively positive about the PCT being an effective partner in delivering health and well-being improvements for the local population. Competency 2 – Panel assessment Level Competency Measure Work collaboratively with community partners to commission services that optimise health gains and reduce health inequalities and deliver increased productivity • Creation of Local Area Agreement based on joint needs • Ability to conduct constructive partnerships • Reputation as an active and effective partner’ On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Sufficient evidence – The PCT demonstrated that it works with local strategic partners on LAA priorities and shows that LAA priorities are based on JSNA priorities. The PCT also actively involves clinicians in the process. • Insufficient evidence – Health needs were identified in the JSNA, and the PCT demonstrated ownership of the specialised commissioning agenda. However, there was no evidence of governance of shared posts. Furthermore, the PCT scored 4.32 (below the SHA average of 4.37) on the stakeholder survey which raises questions as to whether the PCT proactively engages stakeholders to inform and drive strategic plans. • Insufficient evidence – The PCT demonstrated success stories of delivery through partnership, such as smoking-cessation and the ‘Total Place’ pilot. However, these efforts have not yet fully convinced key stakeholders that the PCT is an effective partner to deliver health and well-being improvements (PCT scored 4.44, below the SHA average of 4.87) given mixed feedback to the stakeholder survey . Whilst the Panel was partially persuaded of achievement of level 3, but the positive examples were only articulated by the local authority representative whereas the competency level requires them to made explicit by many stakeholders.

13. Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Strengthen the processes by which public involvement and engagement translates into changes in commissioning decisions and improvements in health outcomes. • Make systematic use of patient feedback to influence commissioning decisions to drive quality. Competency 3 – Panel assessment Level Competency Measure Proactively build continuous and meaningful engagement with the public and patients to shape services and improve health • Influence on local health opinions and aspirations • Public and patient engagement • Improvement in patient experience • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Insufficient evidence – The PCT has demonstrated its strategies for communicating with the public, and promotes health and well-being. However, the PCT scored 3.77 (below the SHA average 4.38) on ‘proactively shaping health opinions’ and initiatives such as improving obesity do not show evidence of delivery. • Insufficient evidence – The PCT regularly involves the public in service reviews and disseminates information, and the Panel was persuaded that local engagement has driven some commissioning decisions (e.g. dentistry, walk-in centre). However, fewer than 50% of respondents agreed that the local NHS listens to the views of the local people, according to the Public Perception Survey. This score indicates that public and patients do not yet agree that the local NHS listens to their feedback. • Insufficient evidence – The PCT demonstrated that it reviews trends in patient and carer feedback. However, there was not sufficient evidence to demonstrate that the PCT has systematically driven commissioning decisions based on patient feedback, PALS and complaint queries, since the examples provided (e.g. mystery shopping in GP access) related only to primary care.

14. Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Utilise the Primary and Secondary care Interface Group to ensure that engagement is reflected across both primary and secondary care. Competency 4 – Panel assessment Level Competency Measure Lead continuous and meaningful engagement of a broad range of clinicians to inform strategy and drive quality, service design, and efficient and effective use of resources • Clinical engagement • Dissemination of information to support clinical decision making • Reputation as leader of clinical engagement • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Sufficient evidence – The PCT demonstrated engagement with clinicians from a range of backgrounds and has delegated authority to clinicians. The Panel was persuaded that the ‘clinical interface group’ creates efficient links between primary and secondary care clinicians (e.g. MSH work in UHL, pathway redesign in MH and Diabetes). • Sufficient evidence – The PCT has developed the ‘Donut’ intranet to disseminate information such as quality of care, and the PBC responded positively to the survey questions in information. Quality reports are distributed and discussed at locality level and there are clear examples of how the PCT is reducing clinical variation (e.g. Twinning process to reduce performance gap in primary care). • Insufficient evidence – The PCT demonstrated that clinicians led initiatives to redesign care. The Panel was persuaded that PBC governance has been strengthened (e.g. all decisions on business cases in less than 8 weeks and adequate mechanisms to deal with conflicts of interest through self declaration of interest to PEC. However, stakeholders do not yet agree sufficiently that ‘the PCT pro-actively engages clinicians to inform and drive strategic planning’ (PCT scored 4.34, below the SHA average of 4.60, on the stakeholder survey question, which is insufficient to support a level 3 assessment).

15. Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Expand trend analysis to all commissioning areas to identify gaps in potential to achieve targets. • Consolidate benchmarking of health needs and priority health outcomes so it takes place at least quarterly in all areas, and demonstrate that there is a clear use of the benchmark information. Competency 5 – Panel assessment Level Competency Measure Manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements • Analytical skills and insights • Understanding of health needs trends • Use of health needs benchmarks • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Sufficient evidence – The PCT has identified gaps and developed actions to address the gaps, such as in the Cancer pathway. The Panel was persuaded that stakeholders contributed significantly to the JSNA (e.g. validation work on Diabetes ended up in corrections to the JSNA). The PCT has robust segmentation (e.g. through MOSAIC groups) of population by healthcare needs. • Insufficient evidence – The PCT has identified trends in major health and well-being issues, and has a list of major health risks facing its local population. The PCT has demonstrated analysis of unmet health needs (e.g. smoking-cessation for Bangladeshi population, prison health). However, the Panel was not persuaded that there is consistent gap analysis towards achievement of all health targets (some partial examples provided in areas such as INR, Chlamydia, smoking-quitters uptake, which were not considered sufficient to support a level 3 assessment). • Insufficient evidence – The PCT has developed plans to meet health outcome aspirations and effectively disseminates reports to stakeholders. The Panel was persuaded that the PCT benchmarks itself against national targets and peer PCTs on local health needs and priority health outcomes although frequency of use was unclear from the evidence and panel day discussions (e.g. CVD, cancer mortality, smoking quitters and other WCC outcomes)

16. Competency 6 – Panel assessment Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Demonstrate predictive modelling capability in best/worst scenarios, and across key pathways. • Review all initiatives and align investment/disinvestment decisions with the financial plan. • Develop and clearly articulate investment and disinvestment plans, and agree finance responsibilities with partners. Level Competency Measure Prioritise investment of all spend in line with different financial scenarios and according to local needs, service requirements and the values of the NHS • Predictive modelling skills and insights to understand impact of changing needs on demand • Prioritisation of investment and disinvestment to improve population’s health • Incorporation of priorities into strategic invest-ment plan to reflect different financial scenarios • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Insufficient evidence – While the PCT described its predictive modelling capability, the Panel did not gain sufficient confidence that best and worst case modelling was conducted against patient quality and activity data. It was evident that predictive modelling had been conducted, such as in coronary heart disease. • Sufficient evidence – The PCT sought insight from stakeholders to inform strategic investments and disinvestment initiatives and developed criteria to prioritise the initiatives. During Panel Day the PCT showed that it has conducted a full evaluation on programme budgeting, which led to a disinvestment of £2m over 2 years in mental healthcare. • Insufficient evidence – The PCT has articulated investment and disinvestment priorities in the strategic plan on the basis of identified gaps and updated assumptions in its financial scenarios. However, it is not clear why some initiatives have been selected, as they do not align with the vision. In addition, the PCT has not defined the financing responsibilities across its partnerships. 15

17. Competency 7 – Panel assessment Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Determine the costs and benefits of changing providers in priority segments. • Forecast potential risks and mitigation plans to align provider capacity and health-needs projections. • Demonstrate changes to patient choice through public and market insight gained. Level Competency Measure Effectively stimulate the market to meet demand and secure required clinical and health and wellbeing outcomes • Knowledge of current and future provider capacity and capability • Alignment of provider capacity with health needs projections • Creation of effective choices for patients • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Insufficient evidence – PCT identified priority targets for improvement and developed provider market analysis. However, there was no evidence of specifically identifying costs and benefits by market segment and provider so as to address priority targets most effectively. • Sufficient evidence – PCT has identified specific changes in the provision for psychological therapies and dental services, and has used demand and supply scenarios to vary the level of capacity required. The PCT identified workforce shortages as a risk in their provider arm, and mitigated this with a recruitment drive. • Sufficient evidence – The PCT conducted a review of major disease areas and identified steps to create choice such as in the Diabetes pathway. The PCT has consulted patients in creating the choice offer, and this is further substantiated by the survey question, in response to which more than half the patients surveyed recalled being given a choice of acute provider. 16

18. Competency 8 – Panel assessment Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Define improvement opportunities in interventions for all pathways on the basis of international best practice. Level Competency Measure Promote and specify continuous improvements in quality (e.g., CQUIN, IQI) and outcomes through clinical and provider innovation and configuration • Identification of improvement opportunities • Implementation of improvement initiatives • Collection of quality and outcome information • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Sufficient evidence – PCT has agreed and reviewed clinical pathways such as cancer and diabetes, and pathway initiatives have specific interventions and criteria at each step of the pathway. During Panel Day the PCT stated that it uses PARR+ to conduct patient risk stratification. • Sufficient evidence – The PCT has a PMO team to drive the delivery of outcomes and has developed a quality improvement framework. In addition, improvements in the COPD pathway have decreased admissions and increased cost-effectiveness. • Sufficient evidence – The Panel gained sufficient confidence that the PCT was operating at level 3 as it has near-real-time monitoring capability with the Cassius system and demonstrated quality and efficiency metrics: BCBV length of stay, inpatient days and a CQUIN incentive on data quality. PCT has clearly identified quality and outcome metrics to monitor chosen outcomes with relevant stakeholders, and monitors outcomes at Board level. 17

19. Competency 9 – Panel assessment Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Focus specifically to i) include outcome, quality, service targets and improvement of pathways in all negotiations, and ii) demonstrate sophisticated risk-sharing. Level Competency Measure Secure procurement skills that ensure robust and viable contracts • Understanding of provider economics • Negotiation of contracts around defined variables • Creation of robust contracts based on outcomes • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Insufficient evidence – The PCT has developed a basic provider fact base and has demonstrated their procurement approach. However, there was no evidence of analysis of in-house provider economics or that insight had been gained from providers. • Insufficient evidence – 3/3 contracting forms include locally defined KPIs linked to pay and a contract negotiation process. However, it was not clear whether the PCT has worked with providers to develop outcome-based service specifications and developed a sophisticated approach to risk sharing. • Insufficient evidence – The contracting forms provided demonstrated quality, service metrics, cost and activity expectations. Contracting forms quote negotiation meetings and demonstrate clinical leadership participation. The three contracts submitted had all been signed before activity commenced. However, it was not clear how the contract incentivises good patient experience and clinical quality. 18

20. Competency 10 – Panel assessment Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Consistently demonstrate how data is used to drive fact-based continuous quality and outcome improvement. • Consider how to further develop performance improvement capability through use of international best practice. Level Competency Measure Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvement in quality and outcomes and value for money • Use of performance information • Implementation of regular provider performance discussions • Resolution of ongoing contractual issues • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Sufficient evidence – Contracts define provider performance reporting, including quality and outcomes data. The data supports KPIs on quality and access, and the PCT described its workforce data requirements (working time, turnover, vacancy rates). The PCT confirmed that workforce data was available for different sectors, including primary and mental healthcare. • Sufficient evidence – The PCT demonstrated regular reviews of provider management reports and monthly provider meetings. During Panel Day the PCT described how it performs risk analysis, with examples: Midwifery staff, where the mitigating action was to increase funding. The PCT confirmed its use of root-cause analysis to address controlled drugs incidents, which led to a change in prescribing practice, and in meeting cancer targets in the urology cancer pathway. • Sufficient evidence – The three contracts forms that were submitted demonstrate compliance measures such as monitoring meetings with data requirements. Although the submitted evidence did not include improvement plans, the Panel was persuaded that the PCT uses these to drive sustainable improvement. 19

21. Competency 11 – Panel assessment Panel Assessment Last year’s rating 1 2 3 4 Rationale for scoring Recommendations • The Panel encourages the PCT to: • Demonstrate the ability to deliver sustainable efficiency and effectiveness of spend at the intervention level of pathways • Demonstrate understanding of the optimal economics of provision for major care settings Level Competency Measure Ensuring efficiency and effectiveness of spend • Measuring and understanding efficiency and effectiveness of spend • Identifying opportunities to maximise efficiency and effectiveness of spend • Delivering sustainable efficiency and effectiveness of spend • On the basis of documentary evidence and Panel Day discussions, the Panel concluded the following: • Insufficient evidence – Although output efficiency for core pathways were benchmarked against BCBV, there was no evidence of the PCT collecting and analysing financial metrics for its commissioned activity. Furthermore, there was no evidence that the PCT has a clear and detailed understanding of the optimal economics of provision for each care setting. • Sufficient evidence – Opportunities have been identified for efficiency to improve outcomes in care pathways, and the PCT provided the following examples of efficiencies in their own cost base: (1) procurement of joint IT services and (2) estates review, which would enable the community hospitals to sustain their own estates, saving £2m. • Sufficient evidence – The Panel was persuaded that the initiatives identified engaged clinicians via the Primary and Secondary interface group, and that the PCT had agreed responsibilities with its providers (UHL in the contract). The PCT also described its risks such as net growth in continuing care, which would be mitigated by the contingency. 20