Commissioning Commissioning Anticoagulant Anticoagulant

ServicesServicesEric WattsEric Watts

Basildon HospitalBasildon Hospital

A Brief History of the A Brief History of the NHSNHS

1948 - 1971 - ‘envy of the world’1948 - 1971 - ‘envy of the world’

1971 - 1992 - Trials of resource management1971 - 1992 - Trials of resource management

1992 - 1997 - Purchaser provider split Fund 1992 - 1997 - Purchaser provider split Fund holding GPsholding GPs

1997 - 2007 - Commissioning by PCTs1997 - 2007 - Commissioning by PCTs

CommissioningCommissioning PCT’s want value for moneyPCT’s want value for money Professional service providers want to Professional service providers want to

see patients treated to high standardssee patients treated to high standards Service commissioned to provide Service commissioned to provide

required service at the agreed pricerequired service at the agreed price Logical solution – identify cost of Logical solution – identify cost of

providing the required standard of providing the required standard of care & agree the contractcare & agree the contract

Reality..Reality..

PCT approachPCT approach We have to reduce costsWe have to reduce costs If you can’t provide a cheaper service, If you can’t provide a cheaper service,

we will put it out to tenderwe will put it out to tender No benchmark for anticoagulant costsNo benchmark for anticoagulant costs Assess value of service by asking Assess value of service by asking

neighboursneighbours Continue current service unless there Continue current service unless there

are perceived problems - cost, are perceived problems - cost, complaintscomplaints

Commissioning – Commissioning – Hospital ViewHospital View

We have an established record in We have an established record in providing good servicesproviding good services

We’re happy to embrace changeWe’re happy to embrace change We’re happy to discuss proposals We’re happy to discuss proposals (eg Tier (eg Tier

2)2) We can advise on the quality We can advise on the quality

implications of the alternativesimplications of the alternatives We recommend HCC ‘standards for We recommend HCC ‘standards for

better health’better health’ Consider the added valueConsider the added value

contractscontracts BlockBlock Cost /volumeCost /volume Individual casesIndividual cases

Basildon Anticoagulant Basildon Anticoagulant Service -Patient NumbersService -Patient Numbers

0

500

1000

1500

2000

2500

3000

3500

1987 1992 1997 2002 2007

Monitoring or Monitoring or comprehensive care?comprehensive care?

A continuumA continuum How much education & support?How much education & support? Give ‘em an inch …Give ‘em an inch … Basildon.. Initial Consultation with Basildon.. Initial Consultation with

nurse ‘phone advice always availablenurse ‘phone advice always available Nurse consultations arranged by Nurse consultations arranged by

appointmentappointment Limited community POCT by our nursesLimited community POCT by our nurses

Blah, blah, blah INR blah, blah, blah

The routine a/c clinic

It hurts when IDo this, doctor

Costing of servicesCosting of servicesthe Tariff - PbRthe Tariff - PbR

New haematology OP referral -£275New haematology OP referral -£275 Haematology follow up - £86Haematology follow up - £86

Lab testsLab tests Haematology……………………£2.94Haematology……………………£2.94 ‘‘discreet’ phlebotomy……..……..£2.68discreet’ phlebotomy……..……..£2.68 Some are more costly than others; these are the Some are more costly than others; these are the

overall averageoverall average

Costing the anticoagulant Costing the anticoagulant service - hospital view - 100 service - hospital view - 100

f.u.pts/dayf.u.pts/day If all patients seenIf all patients seen £8,600 /day,£8,600 /day, £1,815,000 pa£1,815,000 pa All postal/’phoneAll postal/’phone £294/day,£294/day, £72,840 pa£72,840 pa

Is anticoagulation a clinical activity funded though PbR, or Is anticoagulation a clinical activity funded though PbR, or aa

pathology test funded through the block contract ?pathology test funded through the block contract ?

Block contract income unrelated to activityBlock contract income unrelated to activity

DoH ViewDoH View Hospitals are expensiveHospitals are expensive Primary care is cheapPrimary care is cheap ““average OP attendance is 10x av average OP attendance is 10x av

GP attendance”GP attendance” If we move services into primary If we move services into primary

care we can make huge savingscare we can make huge savings

GP ViewGP View ““PBC is about giving clinicians the PBC is about giving clinicians the

resources and support they need to resources and support they need to become more involved in service become more involved in service development”development”

““aligning clinical actions with aligning clinical actions with financial responsibility”financial responsibility”

The ProblemThe Problem Current activity X tariff = TOO Current activity X tariff = TOO

MUCH (capped budget)MUCH (capped budget)

NHS always underfundedNHS always underfunded

Commissioning problemsCommissioning problems I am currently involved in this with our PCT. What I am currently involved in this with our PCT. What

is clear is that the commissioner's, ie PBC and PCT is clear is that the commissioner's, ie PBC and PCT people have no idea of the service implications of people have no idea of the service implications of service re-organisation. Similarly the PCT service re-organisation. Similarly the PCT management have no concept of what management have no concept of what anticoagulation services comprise. The current anticoagulation services comprise. The current strategy is to shift everything into the community, strategy is to shift everything into the community, shut hospital services and save money. Problems shut hospital services and save money. Problems with this approach are:with this approach are:

1. It is more expensive to provide the service in the 1. It is more expensive to provide the service in the communitycommunity

2. You can't close the hospital service anyway.2. You can't close the hospital service anyway.

Problems - 2Problems - 2 Anticoag working group for our PCT, we were Anticoag working group for our PCT, we were

asked to look at revising the service spec for asked to look at revising the service spec for anticoag, this is on a background of the pct anticoag, this is on a background of the pct attempting to implement community based attempting to implement community based services but capping this because of lack of services but capping this because of lack of money.money.

Current situation is that current funding levels Current situation is that current funding levels will be cut and the service put out to tender to will be cut and the service put out to tender to something called "accredited willing providers", something called "accredited willing providers", whatever that means. the whole ethos is to whatever that means. the whole ethos is to reduce direct costs rather than to provide a reduce direct costs rather than to provide a quality service.quality service.

Problems - 3Problems - 3 In my experience funding for anticoagulation is linked In my experience funding for anticoagulation is linked

to path lab services.to path lab services.

Our service which is primary care based has never Our service which is primary care based has never received any of the money back from secondary care received any of the money back from secondary care and has been funded by the PCT. and has been funded by the PCT.

Our service has been recognised in the White paper, Our service has been recognised in the White paper, our health, our care, our say, as an exemplar of service our health, our care, our say, as an exemplar of service redesign but we still struggle for funding.redesign but we still struggle for funding.

Anticoagulation has always been the Cinderella service Anticoagulation has always been the Cinderella service yet is one of the biggest causes of litigation, when it yet is one of the biggest causes of litigation, when it goes wrong. Maybe it is ignorance that leads to poor goes wrong. Maybe it is ignorance that leads to poor funding and sometimes poor service for the patients.funding and sometimes poor service for the patients.

Commissioning summaryCommissioning summary Widespread discontentWidespread discontent Cheapest service appears to be Cheapest service appears to be

preferredpreferred Lack of concern re Quality Lack of concern re Quality

StandardsStandards

What constitutes a high Q What constitutes a high Q service?service?

Appropriate patientsAppropriate patients Good communicationGood communication Education, education, educationEducation, education, education Established, documented, safe Established, documented, safe

practicepractice Patient centred servicePatient centred service Audits of quality & safety Audits of quality & safety

What specifies safe What specifies safe practice?practice?

NPSA guidelines !NPSA guidelines !

Take home message :- Take home message :-

In commissioning discussions advise In commissioning discussions advise the PCT of their responsibility to the PCT of their responsibility to contract for a service which meets contract for a service which meets NPSA standardsNPSA standards

Successful Redesign - Successful Redesign - BLTBLT

PCT approached the Hospital - pts PCT approached the Hospital - pts unhappy with serviceunhappy with service

Long waits - “traditional clinic”Long waits - “traditional clinic” Redesign agreedRedesign agreed Now POCT & immediate dosingNow POCT & immediate dosing It took years +++It took years +++ Frequent business plansFrequent business plans

Successful Redesign – 2Successful Redesign – 2 Main Driver from PCT was Patient Main Driver from PCT was Patient

ExperienceExperience Money never became a big issueMoney never became a big issue Continued constructive dialogue with Continued constructive dialogue with

PCT ensured continuation of contractPCT ensured continuation of contract A Win Win outcome - PCT initiated A Win Win outcome - PCT initiated

change - BLT kept business in change - BLT kept business in providing a service & leading providing a service & leading development of community servicesdevelopment of community services

Achieving Successful Achieving Successful Negotiations With Negotiations With

ManagementManagement Remember - They’re only humanRemember - They’re only human Purchasing is 15 yrs oldPurchasing is 15 yrs old Commissioning is 9 yrs oldCommissioning is 9 yrs old Anticoagulant care is much olderAnticoagulant care is much older We can provide the benefits of our We can provide the benefits of our

knowledge & experienceknowledge & experience There are now explicit standardsThere are now explicit standards

Hit all the right buttonsHit all the right buttons Tick all the boxesTick all the boxes