bcbv for commissioners

Converting the potential into reality:10 steps a commissioner can take to realise the benefi ts of Better Care, Better Value indicators

NHS Institute for Innovation and ImprovementCoventry House University of Warwick Campus CV4 7ALTel: 0800 555 550

ISBN No: 978-1-907045-38-7Publication code: DQ094

© Copyright NHS Institute for Innovation and Improvement 2009

10 steps that NHS commissioners can follow to realise Better Care, Better Value benefi ts: 1 - Understand the benefi ts highlighted by the Better Care, Better Value indicators

2 - Identify your own Better Care, Better Value enthusiasts

3 - Use the indicators to understand the size of the opportunity for your organisational health system

4 - Connect with your providers

5 - Understand what your high performing peers do

6 - Decide which areas to improve

7 - Get board engagement and commitment

8 - Create an ambition for change and success

9 - Use commissioning levers to facilitate improvement

10 - Realise the benefi ts - release the cash or re-invest in the service

NHS Institute for Innovation and Improvement tools and support are available to help you with each of the ten steps and can be accessed on www.institute.nhs.uk

If every organisation (provider and commissioner) improved its performance to match that of the top quartile in each Better Care, Better Value (BCBV) indicator, NHS England could realise £2.4 billion in productivity benefi ts

This guide will show you how to continue to deliver high quality care within the challenges of the current economic environment. Commissioning and provider organisations have the opportunity to look at new ways in which all parts of the local health system benefi t from the redesign of services, so that they provide best value for money. Specifi cally, the BCBV indicators provide a starting point for your organisation to:

see how you are performing relative to your peers•

determine individual high and low performing areas•

prioritise areas of work to make improvements•

monitor your improvement on a quarterly basis.•

Each BCBV indicator has an associated ’productivity opportunity’ which is an estimate in monetary terms of what an organisation could realise if its performance matched that of the upper quartile in NHS England. The BCBV indicators in this guide focus on providers of acute care and prescribing in community care. In the future, we are planning to extend the BCBV indicators to incorporate mental health, community and primary care services.

Introduction

The Better Care, Better Value (BCBV) indicators reveal the potential to make signifi cant cash or resource savings whilst improving quality. However, the key issue is what has to be done to actually realise the benefi ts. For this reason we are introducing the ‘Converting the potential into reality’ guides - one is aimed at NHS commissioners and the other is for provider organisations. This guide contains ten steps that commissioners can take to use the BCBV indicators to maximum effect to improve quality and increase productivity.

As a commissioner, this guide will show you:

how the 10 steps can relate to the World Class • Commissioning competencies, and which commissioners can use to provide evidence as part of the assurance framework. Look for WCC logo on each page where competencies relating to that step are identified. A full list of competencies can be found in Annex 5 on page 32

where the BCBV indicators align themselves to the • quality and productivity challenge (quality, innovation, productivity and prevention)

what the current experience is from commissioners • on quality and cost, as outlined in the example that accompanies each step.

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Access the BCBV indicators quarterly via the NHS 1. Institute web site www.productivity.nhs.uk

Read your own reports and consider the following:2.

the performance value• shows the organisation level performance for each indicator. Using the NHS Indicator Explorer you can see how this value has changed over the quarters and, also, view the indicator performance at either specialty/procedure or diagnosis level

the national position• identifies where you sit when ranked against all NHS organisations included in the indicator. The SHA report data shows where you sit against the organisations in your area

the NHS Indicator Explorer• enables you to compare against a set of pre-defined peers or you can create your own groups of 3-5 peers

the BCBV indicators• should be used to stimulate the improvement discussion and to help identify areas where potential performance efficiencies could be made. The ranking can be used to identify ‘best performers’ who may have evolved practices that can be shared.

The fi ve annexes to this document provide related 3. information:

Annex 1 – Facts about the BCBV data Annex 2 – How to access and use BCBV indicators Annex 3 – How to access and use the NHS Indicator Explorer Annex 4 – Information about the Opportunity Locator Annex 5 – World Class Commissioning Competencies

1 - Understand the benefi ts highlighted by the Better Care, Better Value indicatorsThe table shows 12 Better Care, Better Value indicators. Six are aimed at providers and six at commissioners. These highlight the potential benefi ts for each in the form of a ’productivity opportunity’.

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BCBV indicator description Primary target Potential benefits for provider and commissioner

Reduce costs

Improve patient experience

Reduce Health Care Associated Infections (HCAIs)

Release capacity

Reduce cancelled operations

Productivity* Opportunity range for individual organisations

Reducing length of stay Provider £2,000,000 - £21,000,000

Increasing day case surgery rates Provider £20,000 - £700,000

Reducing pre-operative stay (elective)

Provider £10,000 - £5,000,000

Reducing Did Not Attend (DNA) appointments

Provider £150,000 -£4,000,000

Reducing new to follow-up appointments ratio

Provider £350,000 -£3,500,000

Reducing emergency re-admissions at 14 days

ProviderA&E

£150,000 -£2,500,000

Managing variation in surgical thresholds

Commissioner £150,000 -£2,500,000

Managing variation in emergency admissions

CommissionerA&E

£1,000,000 - £10,000,000

Managing variation in outpatient attendances

Commissioner £150,000 - £4,000,000

Increasing low cost prescribing for lipid modification

Commissioner £0 - £2,000,000

Increasing low cost proton pump inhibitor prescribing

Commissioner £0 - £650,000

Increasing low cost prescribing for drugs affecting the renin-angiotensin system

Commissioner £0 - £650,000

* the Productivity Opportunity gives a monetary estimate of potential savings achievable if a health system improved that indicator performance by achieving top quartile performance. The figures show the range of potential savings obtainable for that indicator. Note that managing variations in emergency admissions and outpatient attendances are potential shifts in spending into primary care (rather than savings).

2 - Identify your own Better Care, Better Value enthusiasts

Practical steps you can take now

Identify potential enthusiasts to fill four key roles:• data analyst - a technical expert who will:

know what is being measured and how - –refer to annex 1,2, 3 & 4understand underlying assumptions –appreciate how this influences commissioning –understand data limitations and issues about –data quality

clinical leads - who will present the data and lead the change through the Professional Executive Committee (PEC) and practice-based commissionersexecutive lead - who will be a visible and proactive sponsorpractice-based commissioning lead - who will encourage leadership within practice-based commissioning groups to consider alternative provision of services within the community.

Avoid compartmentalising. Encourage as many of your • staff as possible to feel comfortable performing these roles and, also, develop similar enthusiasts within your providers.

Identify and understand your audience, and tailor your • delivery accordingly.

Identify and support any development your experts • need to fulfil their role.

Ensure your enthusiasts do their homework! As a • minimum they need to understand how the indicators are constructed and the assumptions used in their construction.

To make changes to realise the benefi ts highlighted by the Better Care, Better Value indicators initially, you need to mobilise and proactively support a team of enthusiasts.

2 - ExampleNHS Halton and St Helens BCBV focus: innovation strategy, energise staff

The PCT identified roles in innovation and expert • leaders to take forward programmes of activity related to the BCBV indicators.

The team aligned the BCBV indicators with their • commissioning and strategic plan, with focused activity on their biggest gains:

managing variation in accident and emergency increasing day case surgery reducing DNAs outpatients.

They have executive sign-up, support from the • performance team and dashboard reporting.

They have an innovation enabling strategy which • includes:

interventions to mobilise, energise and engage staff improving the patient experience as a way of getting into the detail of making transformational change happen.

Use this in-depth knowledge to address any data • quality issues head on. Until these are addressed, it can be difficult to move on.

Show data using simple graphs and bar charts.•

Add local data to provide context to the potential • identified in BCBV indicators.

The NHS Institute tools and resources available to help you include:

Patient and Public Engagement Toolkit for • World Class Commissioning - although not an institute tool, this provides support to commissioners and provides information and methods of engagementwww.institute.nhs.uk/engagementtoolkit

The ebd approach guide and tools• - the experience based design approach helps to design healthcare services based on patients and staff experience www.institute.nhs.uk/ebd

The Power of One, the Power of Many• - bringing social movement thinking to health and healthcare improvement www.institute.nhs.uk/powerofone

Competencies 4c and 5a- refer to annex 5

Adding life to years and years to life

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3 - Use the indicators to understand the size of the opportunity for your organisation or health system

A large productivity opportunity and/or a poor national position points to an ‘outlier’ and should be investigated further. Clicking on the indicator link in the scorecard (in the online version of this document) takes you to the SHA or foundation trust report for that indicator. This contains key steps for further analysis and suggests improvement actions, too. It shows how you relate to others and also where you might learn from others.


Use the Indicator Explorer to create a peer group and • drill down below PCT level to investigate at condition /speciality level for where your potential really is - refer to annex 3 for help on how to use Indicator Explorer.

Check that the data ascribed to your organisation • matches what your local data systems are telling you. Match it, too, against local opinions about the service or services covered and also the Opportunity Locator, if appropriate.

Use the charts as displayed within the Indicator • Explorer or use the ‘export data’ button to download the data and create your own. Keep any charts simple.

When preparing a presentation based on Better Care, • Better Value indicators, tell a story with the data. So, be selective in your use of tables and charts. Focus on the areas with the highest potential.

Find the common ground between BCBV and locally • perceived problems.


The Opportunity Locator• - a tool to support the commissioning priorities of local health communities, refer to annex 4 www.institute.nhs.uk/opportunitylocator

BCBV methodology• - explains how indicators are constructed www.productivity.nhs.uk/definitions.aspx

The Indicator Explorer tool• - which enables analysis of some data down to specialism level www.institute.nhs.uk/explorer

The Good Indicators Guide• - a guide to help you to understand how to choose and use indicators www.institute.nhs.uk/goodindicatorguide

How to engage staff in thinking differently • shifting care closer to home - a range of tools and techniques on thinking differently to help when implementing ‘care closer to home’ projects www.institute.nhs.uk/engagestaff

The NHS indicators ‘scorecard’ for each organisation in your local health system shows the national position, any changes from the last period (rebased yearly) and the productivity opportunity.

3 - ExampleNHS HillingdonBCBV focus: care closer to home

NHS Hillingdon looked at both its BCBV indicators productivity profi le and the NHS Institute’s Opportunity Locator to identify:

a potential productivity opportunity of £10million a • year achieved by reducing emergency admissions, outpatient first attendances and follow-up appointments

how potential productivity spend could be reinvested • in primary care services that would bring greater quality and cost benefits

jointly planned services with social care, management • of long term conditions and polyclinics.

Application of the priority selector:

Competencies 5a & 8a - refer to annex 5

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4 - Connect with your providers


Talk to your providers - where are the opportunities • for realising greater benefits if you were to work together?

Understand what actions your provider is taking • forward with the BCBV indicators.

Use the Opportunity Locator to identify areas for • greater gains by ‘moving care closer to home’ - refer to annex 4.

Work in partnership with your provider to develop • patient services in the community as part of delivering care closer to home.

Identify where high impact improvements could be • made and agree how to make them. Engage with your providers in the prioritisation process.

Understand who will take the benefits and have a • straight forward conversation with your providers about it so that expectations are clear. It may be that reductions on length of stay or pre-operative assessment may benefit the health system rather than the provider organisation.

Discuss including measures based on the BCBV • indicators within contracting arrangements.

In your meetings with providers, ensure that you • are able to articulate performance differences in a way that encourages understanding and action (for example, at consultant and general practitioner level rather than at service level).

Use the BCBV indicators as part of your material for • market stimulation events with current and potential providers.


Converting the Potential into Reality: 10 steps • a provider can take to realise the benefits of Better Care, Better Value - 10 steps a provider can take in order to use the BCBV indicators to maximum effect to help improve quality and increase productivity www.institute.nhs.uk/pctportal or www.productivity.nhs.uk

Commissioning Patient Pathways Guide• - supports commissioning managers by creating a structured approach to exploring the activities required to commission planned care pathways www.institute.nhs.uk/commissioning

Project Delivery for Commissioners• - a guide which covers the whole project management process from creation of the project team right through to implementing the new pathway www.institute.nhs.uk/commissioning

Improving organisations’ performance against the Better Care, Better Value indicators requires you to work with your providers to realise the benefi ts.

The trust carried out exploratory and investigative work to understand the clinical system by:

analysing historical data which showed that for • every ten patients referred into the hospital for treatment only three went on to have further treatment. By understanding the details of referrals, the clinical staff were able to triage referral into sub-specialisation clinics earlier, avoiding possible duplication and, so, improve the patient experience

examining new to follow-up referral ratios at • consultant level and then developing specialty protocols

encouraging clinical teams working with GPs with • specialist interests and nurse practitioners to develop referral/triage systems.

By developing clinical assessment protocol for referrals it meant that:

the development of Tier 2 and CATS services • streamlined the patient pathway and increased the quality of referral to secondary care. This was evident in the increased patient conversion rate from 30% to 40% with no lowering of thresholds

quality improvements in referrals allowed secondary • care resources to be adapted accordingly and offered greater scope to meet 18 week targets

the patient experience improved as the patient • receives the right assessment at the right time, and is put on the right care pathway.

The development of consultant to consultant gateways which offers alternatives to secondary care treatment enabled:

the trust to work with NHS Manchester with • whom they are currently piloting a gateway system which offers the opportunity for patients to be treated in primary care

a pilot study to be carried out that involved the use of • a GP triage system before any consultant to consultant referral is made

a pilot study to be conducted in adult surgical and • medical specialties with a-imminent wider rollout planned

a strict criteria so that patients will automatically go • through the consultant gateway, for example if they have cardiac history.

Competencies 2b, 7b, 10b and 10c - refer to annex 5

4 - ExampleCentral Manchester University Hospitals NHS Foundation Trust and NHS ManchesterBCBV focus: referral ratios, partnership working, patient and staff benefi ts

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5 - Understand what your high performing peers do


Compare your performance against one of the • standard peer groups already defined - refer to Annex 3.

Create a peer group in the NHS Indicator Explorer • to benchmark your organisation against your choice of peers.

Download the peer group time series charts into Excel • to identify which of your peers are doing really well.

Talk to those organisations that are performing well • and understand what they are doing and how they got there.

Pull out the things that could work in your local health • economy and incorporate them into your operational plan and improvement projects.

Use other data sources to benchmark performance • against the NHS Institute for Innovation and Improvement High Volume Care Pathways eg the NHS Comparators.


NHS Institute networks• - access via www.institute.nhs.uk/share and network

the PCT Portal • - the PCT portal is a resource for commissioners, accessible via the NHS Institute website, it has recently been enhanced by the introduction of river diagrams, which enable PCTs to identify examples of good practice or other sources of support and information relating to the world class commissioning competences access via www.institute.nhs.uk/pctportal

see also NHS Comparators• - although not an NHS Institute tool it provides comparative data about inpatient and outpatient activity www.nhscomparators.nhs.uk/nhscomparators

BCBV and methodology• - explains how indicators are constructed www.productivity.nhs.uk/Definitions.aspx

the Indicator Explorer tool• - which enables analysis of some data down to specialism level www.institute.nhs.uk/explorer

The example of upper quartile performing organisations demonstrate the potential improvements in effi ciency that can be achieved using the Better Care, Better Value indicators. These are summarised in the NHS indicator downloads.

5 - ExamplePeer assessment of performanceBCBV focus: comparing to, and learning from, the best

“Better Care, Better Value indicators methodology provides systematic data that enables improvement leaders to ask rational questions about their own organisational performance, benchmarked against their peers. This leads to further insight gathering, which in turn leads to opportunities to learn and diffuse knowledge into local systems. To me, this is a clear example of how we can turn data into improvement.” Denis Gizzi, Director of Reform and Innovation, NHS Oldham

An example of comparing your PCT with others in the region:

The above example means that that you can establish baselines so that you can:

monitor your own performance over time•

have a common understanding of current performance • with your provider

measure any improvements•

demonstrate value for money.•

Competencies 5a & 8a- refer to annex 5

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6 - Decide which areas to improve


Sources of data:•

understand where your high spend areas are by using the BCBV indicator information prioritise BCBV into high spend, risk, patient benefit, low value adding procedures, quality of services, and consider ease of implementationuse other sources of information (for example the Opportunity Locator, NHS Comparators, local data and patient satisfaction) to get a rounded view of problems develop a marginal analysis approach to plan where BCBV areas of activity could either be:

further invested (eg shift of care into –primary or community services by using the Opportunity Locator)disinvested (eg ratio of new to follow-up ratios) –decommissioned services with low value –threshold (eg non-value surgical interventions).

Clinical involvement, prioritisation and planning:•

ensure that the resources, time and improvement skills to make changes in priority areas are in placeengage clinicians before recommending any changesdevelop a continuous improvement approach identify each benefit as an improvement that can be measured (reduction in time, reduction in number of patients being treated or numbers of patients being treated against agreed clinical criteria) develop milestone trigger points to identify if the goals are on or off track

describe a SMART (specific, measurable, agreed, realistic, timely) goal against each benefit so that you can measure improvementensure each improvement project is covered by contract management and monitoring throughout your local health system.


Prioritising Commissioning Opportunities• - provides a simple but robust planning process to help PCTs make decisions quickly and effectively www.institute.nhs.uk/commissioning

Focus On series for high volume care pathways• - a set of 16 documents supporting health communities and organisations to improve the quality of care and value for money by focusing improvement efforts on high volume HRGs www.institute.nhs.uk/qualityandvalue

10 High Impact Changes for Service • Improvement and Delivery - contains the changes that organisations in health and social care can adopt to make significant, measurable improvements in the way they deliver care www.institute.nhs.uk/10highimpactchanges

Service improvement library• - searchable library of 80+ quality and service improvement tools from the NHS Institute www.institute.nhs.uk/qualitytools

Aim to focus your improvement efforts on achieving the greatest gains for your local health system.

6 - ExampleNHS South Gloucestershire BCBV focus: demand management, prioritisation of services, best value for money

The PCT developed a collaborative partnership • with representatives from acute providers, general practitioners, general managers and clinical leads.

The collaborative partnership has ten work • streams and has agreed criteria for referrals and intervention rates.

They used the NHS Productivity procedures that • identified low value procedures for example; lumbar spine, hernia and tonsillectomies.

To reduce low value procedures they have developed • an approval method:

prior approval required while access criteria is developedconsultant gains consent for treatment using patient decision-making aids to discuss the risks and benefits of the operation.

Competencies 4b and 4c- refer to annex 5

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7 - Create an ambition for change and success

Your health system can succeed and realise the patient and fi nancial benefi ts highlighted by the BCBV indicators, but it may involve new thinking, working differently and learning from the best.


Ask challenging questions based on what the data is • telling you:

where do we want to be? what are we good at doing? what are we not good at doing? which specialities and procedures offer the biggest opportunity for improvement?what are the incentives and barriers to change? where do we need to focus our attention? which are the most achievable changes? who should be involved?

Identify the potential benefits and how will you • measure them over time. Don’t just rely on the quarterly BCBV updates.

Identify and engage with your stakeholders and agree • how you will involve them to make it happen. Agree the best methods of communicating with them and be reliable.

Recognise the whole system of care (patient journey/• pathway) and the impact on other services. Involve these services in any discussion about changes.

Use the BCBV data as the basis of a dialogue with • clinical leaders to get the buy in to change.

Identify local clinicians who are already at, or near to, • the desired performance level and find out how they got there.


The medical leadership competency framework• - describes the leadership competences clinicians need to become more actively involved in the planning, delivery and transformation of health services www.institute.nhs.uk/leadership

Organising for Quality and Value• - a service improvement development programme which gives you the skills to roll out proven service improvement techniques that will deliver a significant return on investment. Email: [email protected]

As the key commissioner of services, take the lead in promoting changes based on BCBV indicators. Use BCBV enthusiasts to present to a wide range of clinical and managerial leaders, focusing on areas where there are high productivity opportunities or low value adding procedures.

7 - ExampleNHS Oldham BCBV focus: governance framework, clinical variation, partnership working

The PCT has incorporated BCBV indicators into its • governance frameworks to manage clinical variation.

It has developed a robust approach in setting • standards in pathways, contracting, performance monitoring and cost, and quality.

The suite of governance programmes, underpinned • by the Quality and Productivity strategy, determine an ethos of joint working (both at local and broader health economy level) to tackle their greatest quality and productivity opportunities.

It has aligned the change programmes with their • governance structure and designated responsibilities to staff and targets to teams.

NHS Oldham looked at international best practice and • developed an ‘evidence preference- based decision’ approach, so that clinical decisions take into account the use of evidence to better inform patients regarding risks, options and informed preferences.

The PCT is developing an enabling approach called • the ‘Continuous Quality Improvement Programme for Primary Care’ which is geared towards the adoption of best practice and reducing clinical variation.

Competencies 6c ,10a & 11a, - refer to annex 5

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8 - Get board engagement and commitment


Share and demonstrate the value of using BCBV • indicators:

use the first BCBV agenda item to introduce the indicators, and show where your local health system sits regionally and nationally in comparison with its peers. Be prepared to discuss the data quality issuesfocus on how the BCBV indicators impact on your highest spend areasinvolve those responsible for delivering strategic goals and overseeing the local health economy spend and quality.

Commit the board to a specific improvement project: •

choose the directors who will support improvements carefully - they will need to be visibleassign a support role to a non-executive director who sits on the board assess your local health economy’s state of readiness for change and sustainability by using the Sustainability Model and Guidelink to local clinical leaders’ networks regularly report the impact of your project. Use local data monthly and BCBV indicator data quarterly.

Create a standing board agenda item. End with • actions assigned.

Communicate progress across your local health • economy and/or embed within the board’s regular performance report so it gets mainstreamed.


The Board Development Tool• - a diagnostic leadership framework for individuals with facilitated feedback www.institute.nhs.uk/leadership

The Sustainability Model and Guide• - a diagnostic tool that is used to predict likelihood of sustainability for your improvement project www.institute.nhs.uk/sustainability

Medical Engagement Scale (MES)• - designed to assess medical engagement in management and leadership in NHS organisations www.institute.nhs.uk/mes

Your organisation will use the BCBV indicators if they are high on the board’s agenda and if they are aligned with your strategic aims for the health system.

8 - ExampleNHS Northamptonshire BCBV focus: health system partnership working, best value for money, patient pathways of care

NHS Northamptonshire has:

recognised the need to further develop and evolve • the partnership board to meet the new economic situation

established a Savings Cabinet to engage county • finance directors, clinical cabinet and clinical leaders in identifying the services/pathways for quality improvement and savings

developed the Partnership Board into the Quality, • Innovation, Prevention and Productivity Board with membership of all NHS CEOs, medical directors, nurse directors, finance director representatives and others to prioritise and ratify all proposals from the Savings Cabinet

agreed that prioritisation will be based on clinical • effectiveness, cost benefit analysis and value for money. This includes considering improvements to standards of care, innovation, prevention and productivity, encompassing those areas identified through the Better Care, Better Value indicators

identified a buddying scheme between • non-executive directors (NEDs) from NHS Northamptonshire and NEDs from its key NHS providers to ensure that all NEDs within the area are engaged with this critical agenda.

Competencies 6b and 11b- refer to annex 5

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9 - Use commissioning levers to facilitate improvement


Understand when the BCBV indicators can be used • within the commissioning cycle.

Develop evidence based service specifications which • include BCBV indicators in discussion with your providers.

Develop CQUIN (Commissioning for Quality and • Innovation) schemes utilising BCBV indicators.

Ensure business case proposals for commissioning and • contesting services include BCBV benefits.

Produce different types of performance monitoring • approaches for contracts using BCBV indicators as trigger points.

Ensure performance management of contracts contain • elements relating to price and quality.

Ensure contracts contain robust quality indicators from • a patient satisfaction perspective.

When including BCBV indicators in contracts, ensure • they are compliant with the Department of Heath NHS Contract standards, (available from the Department of Health‘s website).

Understand your provider relationship through PCT development by:

taking an active role in leadership and relationship • management between the interface of PCT and acute providers to improve BCBV indicator performance

creating innovative commissioning approaches • related to BCBV indicators through practice-based commissioning consortia

agreeing how savings accruing to providers through • the Productive Series or BCBV can be reinvested to benefit local patients

developing a business case for change in services with • your providers

agreeing joint approaches with your providers, with • collectively developed performance management interventions.


The PCT Portal• – using the CQUIN payment framework www.institute.nhs.uk/pctportal

Commissioning to make a bigger • difference – provides commissioners with insight to making a bigger difference in service and marketplace development www.institute.nhs.uk/commissioners-bigger-difference

Using the Better Care, Better Value indicators as part of the commissioning cycle provides an approach which demonstrates which productivity opportunities can be realised.

9 - ExampleNHS Knowsley BCBV focus: prescribing: value for money and patient choice

The prescribing indicators are being used to give a • value for potential savings from generic prescribing.

This has provided additional evidence for using Script-• Switch. Script-Switch is a supporting module to the GPs information module which automatically flags potential alternatives for prescriptions and asks the GPs if they are happy to change going forward.

GPs still make the decision, as cheaper generic drugs • may not always be as effective.

Competencies 7c, 8c, 9b, 9c, 10a & 10c- refer to annex 5

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10 - Realise the benefi ts - release the cash or re-invest in the service

As a commissioner, keep going until the service you are commissioning is performing as you would want it to. Remember, taking forward initiatives in transformational change takes time and commitment from staff and patients. So, be realistic in your undertaking and understand that it might take up to one year before real results are seen at system level.


Have an integrated approach that covers the whole • process from identifying opportunities and making improvements to freeing up money.

Regularly report progress and actions to clinical teams, • other stakeholders and the board, having identified the benefits to the public, patients, staff and the organisation and the fit with your strategic plan.

Bring finance leaders, clinical leaders, operational • leaders and improvement leaders together to work collectively on this agenda.

Understand at what points on the funding pathway • patient care benefits occur for providers and commissioners eg look at spells over trim-point, high quality care from alternative providers and/or in alternative settings.

Be explicit that you are releasing the cash by taking • the money out of commissioning budgets or re-investing in other services that will increase cost and quality dividends.

Use charts and graphs to display progress in offices • and clinical areas as this will:

show what progress is being made to the workforce and also to patients and their carersencourage and stimulate discussion about what needs to happen next.

Use real stories from other areas to engage, motivate • and mobilise clinical teams.

Celebrate your success - it’s a great way to say thank • you to your staff.

Share that success with others - you may be the • source of motivation for them.


The Sustainability Model and Guide• - a diagnostic tool that is used to predict likelihood of sustainability for your improvement project www.institute.nhs.uk/sustainability

Patient Safety First ‘How to measurement • for improvement’ - a good guide on how to use facts and data to drive continuous improvement for providers and commissioners www.institute.nhs.uk/safetysupport

Have you have achieved what you set out to achieve? How do you make sure that your efforts result in benefi ts and realisation of money. Many set out to improve their service but not all succeed. Make sure that yours is one of those projects that does. Remember that the Better Care, Better Value indicators have helped you pinpoint gains that can be made. So don’t give up!

10 - ExampleRealising the benefi ts - cash releasing potential for commissionersFor 2010-11 contracts:

include BCBV-inspired new to follow up ratios. • Many follow-up appointments are not necessary; for example, routine follow-up outpatient appointments after uncomplicated laparoscopic cholecystectomy. Or follow-ups can be done without the patient present (phone calls, questionnaires)

use practice-based commissioning to incentivise GPs • to manage patients with the five conditions for which patients derive little benefit from surgery in a more appropriate manner

increase the number of GPs with a special interest, • so that patients can be referred to them rather than hospital outpatients

for one of the 19 ambulatory care sensitive conditions, • fund appropriate and effective community-based support and monitor patient flows to ensure compliance.

Competencies 3c, 8b, 11a & 11c- refer to annex 5

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Annex 1 Facts about the Better Care, Better Value dataThe BCBV indicators are published quarterly in:1.

January •

April •

July •

October. •

The BCBV indicators are published on the website 2. www.productivity.nhs.uk where NHS staff can access the information.

The clinical indicators are compiled by Dr Foster 3. Intelligence using an extract of the data submitted to the Secondary Uses Service (SUS) by provider trusts. The prescribing indicators are compiled by the NHS Information Centre using ePACT.net data. The workforce indicators were originally compiled from WIMS data by the workforce team at the Department of Health (DH). However, this data source is no longer available and we are looking to use the NHS Workforce dataset through the NHS Information Centre.

The indicators are published as soon as possible after 4. the quarter end date. We need to ensure that we have meaningful data, but we don’t wait for the fi nal ‘quality’ cut off dates. The SUS dates are:

quarter one data submitted to SUS up to 31 July•

quarter two data submitted to SUS up to 31 October•

quarter three data submitted to SUS up to 31 January•

quarter four data submitted to SUS up to 30 April.•

The BCBV indicators are published as a ‘snap shot’ at that time and are not re-published to include any changes.

The NHS Indicator Explorer is updated within a day 5. or so of the publication of this data on the website. It should be used in conjunction with the PDF documents. Access to use the tool is free and if you work in an acute trust or PCT you can register for your own account at www.nhsindicatorexplorer.productivity.nhs.uk You will then receive an email with the fi nal registration details. After you have registered you can start to use the tool. SHA users need to request an account by emailing [email protected]

When looking at the data, if there is a fl uctuation 6. in the trend that is outside what would normally be expected, fi rst check the SUS submission to rule out any data quality problems in the SUS data extract.

If you would like help, please contact us by emailing 7. [email protected]

Annex 2 How to access and use Better Care, Better Value indicators

To view Better Care, Better Value indicators1. Figure 1 shows each lettered step described here:

fi rst select the SHA that you belong to, either by A. selecting from the drop down list or by clicking the SHA area on the map

select the BCBV indicator that you want to view and B. the period from the lists (the most recent data is the default period). Click the ‘Get PCT Indicator’ button

select ‘Get Scorecard’ to view all the indicators that C. apply to your PCT for a selected quarter

the blue navigation pane can be used to view other D. areas of the website. These include:

Indicator Definitions•

Publication Schedule•

Case Studies•

NHS Indicator Explorer.•

Productivity web site navigationVisit www.productivity.nhs.uk to view the most recently published Better Care, Better Value (BCBV) indicators, together with all indicators published since 2006. Also available on the website are indicator defi nitions, a selection of case studies and access to an online analytical tool. Registration to use the tool is free.

D

CAB

A

Figure 1 www.productivity.nhs.uk Entry Screen

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The selected indicator data will be shown as a 2. table in a PDF document (see fi gure 2). The tables contain the selected quarter results for the PCTs within the SHA, or all indicators for your particular PCT.

National Position• - this is the position of the PCT relative to others (the PCT with the best value is given the rank of one).

The Indicator Rate• - this is the actual value for the PCT for the selected indicator.

Productivity Opportunity• - this is the potential financial gain to be made if the PCT were to move to the upper quartile performance.

Change from Last Period• - this is the difference in the rate from the previous quarter. The arrows indicate if performance has improved (green) or worsened (red).

Figure 2 PDF Documents

Features provided by the system

Breakdown of the Clinical Indicators •

Trend Analysis•

Peer Group Comparison• - within the trend analysis you can select from a number of pre-defined peer groups to display and compare performance. Alternatively, you can create any number of your own peer groups containing three to five organisations.

Data Export•

Reports• - use the ‘printable view’ to create images for local reporting.

Commissioning Group• - you can create a group of acute trusts that you have a commissioning relationship with and, then, use the NHS Indicator Explorer to view in more detail their Better Care, Better Value indicator performances.

To access the 1. NHS Indicator Explorer tool, select the ‘NHS Indicator Explorer login’ from the blue navigation panel on the right hand side of any of the website pages shown at A, fi gure 1.

If you are using the 2. NHS Indicator Explorer for the fi rst time, you need to register your user account which can be done by selecting ‘Click here to Register’, shown at A, fi gure 2 and following the instructions on the login screen. Once you have submitted your details, you will be sent a confi rmation email with the fi nal details for activating your account.

User name and password are entered in to the fi elds 3. shown at B, fi gure 2 and then you click the Login button to enter the system.

Annex 3 How to access and use the NHS Indicator ExplorerThe NHS Indicator Explorer offers one simple system for commissioners and providers to view and monitor their performance and it is available free via the website www.productivity.nhs.uk

A

A

B

Figure 2 NHS Indicator Explorer Login Screen

Figure 1 www.productivity.nhs.uk Entry Screen

26 27

DThe 4. NHS Indicator Explorer Entry Screen allows you to select any of the dashboard links shown at A, fi gure 3 to view the BCBV indicators.

Select the dashboard link shown at B, figure 3 to view acute trust BCBV indicators for your selected trusts.

The links shown at C, figure 3 can be used to create your own peer groups and the acute trust list can be used to ‘tailor’ the views in the system to suit your own requirements. Follow the instructions shown on the screens to create the groups.

Figure 3 NHS Indicator Explorer Entry Screen

The 5. Clinical Effectiveness Dashboard is accessed through the NHS Indicator Explorer. It shows the top specialty, diagnosis or procedures and displays the greatest opportunities for improvement. The full list is displayed in a ‘scorecard’ view if you click within a selected indicator dial face.

The tables shown at B, figure 4 display the top opportunity from the lower level information for the particular indicator. Click in any of the dial faces shown at A, figure 4 to ‘drill down’ to the next level of detailed information (see figure 5).

You can use the ‘Export Data’ button shown at C, figure four to produce an Excel spreadsheet with all the data displayed for the selected indicator.

To look at how the performance has changed over time use the link ‘Trend Analysis’ shown at D, figure four (figure 6 shows how trend analysis information is displayed).

The export data feature is available on all screens. You can export the data shown by clicking the “export data” button available from each screen.

Figure 4 Clinical Effectiveness Dashboard

Figure 3 NHS Indicator Explorer Entry Screen

A

C

The 6. Indicator Breakdown Scorecard - by clicking within any of the indicator dial faces you can view the detailed information based on specialty, diagnosis or procedure, as appropriate (see fi gure 5).

Figure 5 Indicator Breakdown Scorecard

Trend Analysis7. - by selecting the trend analysis hyperlink (or icon for the specialty/procedure view) you can view the performance/rank trend for your organisation for a particular indicator.

In fi gure 6 - the graph displays the performance A. ‘trend’ for the selected indicator. If you select a peer group comparison (shown as C, fi gure 6), these values are shown as dotted lines on the graph.

In fi gure 6 - the bar graph charts the national B. ranking trend for your PCT for the selected indicator.

Figure 6 Trend Analysis and Peer Group Comparison

Figure 5 Indicator Breakdown Scorecard

Figure 6 Trend Analysis and Peer Group Comparison

A

B

C

28 29

B

Figure 4 Clinical Effectiveness Dashboard

A A A

B B B

C C C

D DD

Annex 4 Opportunity Locator for CommissionersIntroduction

The Opportunity Locator is an online data tool that supports commissioning priorities and stimulates thought as to where commissioners should focus their attention. It has been designed to give you and your community relevant and useful data in an easily accessible format to support the ‘care closer to home’ agenda.

The Opportunity Locator helps you explore the potential and opportunities for shifting services. It should prompt you to start thinking about how and why your organisation might differ from others and to support commissioning priorities for health communities.

The shift potential is indicative and local health communities should interpret it taking into account local knowledge. The Opportunity Locator might help you to:

highlight services that could potentially be shifted • from a hospital setting to a community setting

identify situations where transferring services into the • community might give better value

improve planning for cost and quality benefits.•

Values are calculated differently in the Opportunity Locator than in the Better Care, Better Value indicators. The difference in the calculation means that the monetary values will be different but the figures are still an important indicator of potential efficiency improvements. In neither case should the figures be taken as an absolute achievable saving; they are more of an indication of the scale of potential savings.

The differences in the calculation are caused by the following factors:

both use the same data source. However, the timing • of the extracts differ, which may result in some differences due to the data submission process

the Opportunity Locator shift potential is calculated • for the quarter, whereas Better Care, Better Value indicators are annualised.

Data from the Opportunity Locator web site

The first thing to do with this data, and with any • other from the Opportunity Locator, is to check that these results make sense locally. There may be understandable reasons why performance appears as it is, or there may not.

The Opportunity Locator tool provides a means to • analyse the shift potential that can be gained from moving care closer to the community. PCTs can examine their shift potential through a range of comparative PCT datasets. You can measure your shift potential against the top 10%, 25% and 50%. You can also compare yourself to similar organisations outside your SHA area which have been pre-selected. You can also reorganise the data to be presented to individual GP practices or clusters that can be adjusted by yourself to reflect local arrangements.

Charts can be downloaded from the Opportunity • Locator to identify where individual PCTs may wish to focus their priorities in shifting care outside hospital. Further investigation of the information in this tool will be necessary to determine the actual savings that may be realised.

You can measure your actual versus expected shift • potential by selecting the appropriate level. You can also choose to view the chart by finance, attendance shift, number of admissions or number of patients affected.

All figures are not absolute savings; rather, they give • a perspective on how the approaches of different organisations differ and offer potential opportunities for learning from the practice of others.

On the first page of the Opportunity Locator is a link • to the methodology that has been used to calculate the values in the tool. This is helpful for individuals who wish to examine values further.

One approach to analysing this data further would be • to select one of the categories (eg outpatient follow-up appointments) and look for common areas of opportunity across PCTs.

The Opportunity Locator indicators

The Outpatient Follow-Up indicator• - this outlines the shift potential that could be realised by reducing the number of follow-up attendances in line with the top 25th percentile of PCTs. A high number of outpatient follow-up appointments could indicate that the patient may be able to be treated in the community - perhaps by GP.

The Outpatient First Attendance indicator• - this outlines the shift potential that could be realised if first attendances were reduced in line with the top 25th percentile of PCTs. This indicator enables PCTs to identify which specialties have statistically higher than average outpatient appointments, with adjustment for age, sex, population and case mix.

The Emergency Admissions indicator• this demonstrates the shift potential through the calculation of emergency admissions for ambulatory care sensitive (ACS) conditions and a selection of healthcare resource groups (HRGs) by PCT. Ambulatory care sensitive (ACS) conditions are those which have been deemed to be treatable at home or in primary care, rather than in a hospital setting.

The Intermediate Care indicator• - this demonstrates the shift potential by calculating the number of excess bed days for intermediate care susceptible health care resource groups (HRGs). Identified intermediate care susceptible HRGs indicate which HRGs that are

currently being treated in hospital could be treated in community settings. Excess bed days are the number of days beyond the long stay trimpoint for the relevant HRG. Trimpoints are used to cost activity in the delivery of care in an acute setting. Trimpoints are the points from which excess bed days apply. The value of each excess bed day is summed up to give the shift potential.

Quality Outcomes Framework (QOF) predicted • admissions (password protected) - this provides an indication of the shift potential to be gained by reducing the number of avoidable emergency admissions. It does this by analysing the relationship between the emergency admissions and QOF prevalence. This indicator is designed to stimulate thinking about why and how practices have differing emergency admission rates for their relative prevalence of long term conditions.

Diagnostics (password protected)• - this provides an indication of the shift potential to be gained if the number of diagnostic tests were increased. Diagnostic data collection is required to monitor waiting times and activity. A high rank suggests that patients are not being referred for diagnostic tests.

For more information:

Better Care, Better Value indicators • www.productivity.nhs.uk

Opportunity Locator• www.institute.nhs.uk/opportunitylocator

30 31

Annex 5 World Class Commissioning Competencies Commissioner Acknowledgements 2. NHS Halton and St Helens John Holden Head of Innovation Email: [email protected] Tel: 01744 457218

3. NHS Hillingdon Yi Mien Koh Chief Executive Email: [email protected] Tel: 01895 452 001

4. Central Manchester University Hospitals Foundation Trust Anthony Middleton Director of Performance Email: [email protected] Tel: 0161 276 6718

6. NHS Oldham Denis Gizzi Director of System Reform & Service Innovation Email: [email protected] Tel: 0161 622 6500

7. NHS Northamptonshire Jan Norman Director of Safeguarding Email: [email protected] Tel: 01604 651175

8. NHS South Gloucestershire Louise Rickitt Associate Director Email: [email protected] Tel: 0117 330 2400 (switchboard)

9. NHS Knowseley Paul Brickwood Director of Finance & Commissioning Email: [email protected] Tel: 0151 443 4900

10. South Central PCT Alliance Michaela Firth WCC Patient & Public Intelligence Programme Manager Email: [email protected] Tel: 07500 915128 To be contacted on Patient and Public Engagement Toolkit for World Class Commissioning

Competency Sub-competency a Step Sub-competency b Step Sub-competency c Step

1 Locally lead the NHS

Reputation as the local leader of the NHS

Reputation as a change leader for local organisations

Position as an employer of choice

2 Work with community partners

Creation of Local Area Agreement based on joint needs

Ability to conduct constructive partnerships

Reputation as an active and effective partner

3 Engage with public and patients

Influence on local health opinions and aspirations

Public and patient engagement

Improvement in patient experience

4 Collaborate with clinicians

Clinical engagement Dissemination of information to support clinical decision making

Reputation as leader of clinical engagement

5 Manage knowledge and assess needs

Analytical skills and insights Understanding of health needs trends

Use of health needs benchmarks

6 Prioritise investment

Predictive modeling 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 investment plan to reflect different financial scenarios

7 Stimulate the market

Knowledge of current and future provider capacity and capability

Alignment of provider capacity with health needs projections

Creation of effective choices for patients

8 Promote improvement and innovation

Identification of improvement opportunities

Implementation of improvement initiatives

Collection of quality and outcome information

9 Secure procurement skills

Understanding of provider economics

Negotiation of contracts around defined variables

Creation of robust contracts based on outcomes

10 Manage the local health system

Use of performance information

Implementation of regular provider performance discussions

Resolution of ongoing contractual issues

11 Make sound financial investments

Measuring and understanding efficiency and effectiveness of spend

Identifying opportunities to maximise efficiency and effectiveness of spend

Delivering sustainable efficiency and effectiveness of spend

Key ‘Converting the potential into reality’ guide definitely helps deliver WCC competency

‘Converting the potential into reality’ guide possibly helps deliver WCC competency

Related BCBV step

2

3

7

7

4

9

10

4

8

6

10

2

1

6

7

9

9

9

49

10

4

3

5

9

10

1

8

5

32 33

bcbv for commissioners

Health & Medicine