innovative commissioning for integrated out-of-hospital care: emerging approaches
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Innovative commissioning for integrated out-of-hospital care: emerging approaches. Bob Ricketts Director of Commissioning Support Services Strategy Community Health Services Forum 20 February 2014. Innovative commissioning for integrated out-of-hospital care: emerging approaches. Topics: - PowerPoint PPT PresentationTRANSCRIPT
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Innovative commissioning for integrated
out-of-hospital care: emerging approaches
Bob RickettsDirector of Commissioning Support Services StrategyCommunity Health Services Forum 20 February 2014
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Innovative commissioning for integrated out-of-hospital care: emerging approaches
Topics:• Context• Commissioning for better outcomes & value:
- capitation-based
- ‘accountable lead provider’ v. ‘alliance’
- value-based• Currencies & payment mechanisms• TCS contract expiry?
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1. Context:
The NHS is facing unprecedented challenges to its sustainability – Call to Action:
• Demographic pressures – an ageing population
• Demand – incidence of LTCs (diabetes, dementia)
• Rising expectations – patients, public, politicians
• Quality – failures & gross variation
• Outcomes – still often poor comparatively
• Failure to deliver integrated care at-scale
• Resource constraints - £30bn gap opening up
• Outdated & over-stretched delivery systems – including primary care & ‘community services’
= clear ‘burning platform’ for transformation
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1. Policy context:
The new commissioning architecture provides unprecedented opportunities for innovative commissioning & provision: • Clinically-led commissioning• Strengthened partnerships with local government • Renewed focus on integration (Better Care Fund = 3% of total health
& social care £ plus wider pooled funds )
• Opportunity to re-design primary care• Growing support for ‘innovative commissioning & contracting’ –
outcome-based contracts for populations, ‘lead provider’ models, risk-sharing, much longer contract durations to support investment & disinvestment to transform, review & alignment of incentives …
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1. Context:
Community services key to a sustainable NHS: • Scale: 100m contacts pa; £9.7bn, 10.6% of NHS expenditure
• Vehicle for at-scale service transformation & major shifts in care settings (if alternative services are available)
• Offer wide range of opportunities for prevention, early intervention & co-production
• Ability to engage patients, carers, communities & other agencies• Unmet potential – Transforming Community Services
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1. Context:
Community Services: How they can transform care
Nigel Edwards, King’s Fund, Feb. 2014
• Long-standing ambition to move care closer to home:
- some reduction in hospital LoS, but much more to be done
- patchy adoption of service models & limited progress to
integration
• Transforming Community Services (2008-), but “mostly concerned with structural change rather than how services could be changed. It is now time to correct this.”
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1. Context:
Community Services: How they can transform care: • Develop a simple pattern of services based around primary care &
natural geographies, offering 24/7 services as standard. MDTs need to work differently with specialist services, offering patients a more complete & integrated service.
• New models should include both health (and mental health) & social care, managing the health & social care budgets for their patients
• Services must be capable of very rapid response , to sustain independence & speed up discharges from hospital
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1. Context:
Community Services: How they can transform care: • “New ways to contract & pay for these services are needed. This
will also require changes in primary care & hospital contractual arrangements and in the infrastructure to support the model”:
• “Eliminating obstacles in contractual and payment arrangements”:
- block contracts
- poor specifications
- replicating historic commissioning patterns
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Our ambition is to deliver great outcomes, and reduce inequalities. But the current shape of the health and care delivery system is not sustainable in the medium-term given the challenges if faces.• Service transformation at scale and
pace will be essential to secure a successful, sustainable NHS.
• We still have a big gap in delivering the best outcomes – internationally & within England
We need to support & develop the NHS commissioning sector to lead the transformation of services:• Transformation is a key leadership
role for CCGs & direct commissioners
• Outcome-based population commissioning is a key vehicle to drive transformation & secure better outcomes and value
2. Commissioning for better outcomes & value: the case
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2. Commissioning for better outcomes & value: OBC & VBC
• Outcome-based population commissioning: a key vehicle to drive transformation & secure better outcomes and value for specific populations or groups (e.g. frail older people with multiple, complex problems; EoLC), or re-balance incentives by paying for outcomes
• Value-based commissioning: emerging approach from U.S. Potentially useful for:
- assessing priorities
- comparing disparate service offers
- re-directing/re-focusing incentives to driving-up value
within services commissioned on Tariff
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2. Commissioning for better outcomes & value: OBC
Key components of fully-developed OBC: • Population-based (frail older people, multiple complex problems; EoLC)
or major pathway(s) (MSK)
• Outcome-focused capitation payment • ‘Lead provider’• Provider co-ordinates care planning & delivery• Provider takes on much of the demand risk
Still emerging, but examples: Bedfordshire (MSK), Cambridgeshire (older people services), Staffordshire (cancer & EoLC for 1m+), Oxfordshire & Milton Keynes (sexual health; substance abuse), Oxfordshire (adult mental health, maternity & older people – on hold)
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2. Commissioning for better outcomes & value: OBC
To be transformational, OBC should …• be genuinely patient-centred & outcome-led ; aim high• focus on local priorities for improving outcomes & quality more
widely AND reducing inequalities• build on sound analysis & prioritisation – RightCare & STAR• address prevention, not just treatment & care• span primary, community & secondary health care – see King’s
Fund Top 10 Priorities for Commissioners
• consider & involve other relevant services – social care but also other agencies influencing outcomes
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2. Commissioning for better outcomes & value: OBC
Staffordshire - at the leading-edge …
• Collaborative: 5 CCGs + Macmillan Cancer Support (strategic partner) + NHS England + CSU
• Outcome-focused & integrated services: • At scale: key services for 1m people across the footprints of people3
acute provider trusts. Will be the biggest contracts yet tendered for integrated NHS care
• Transformational: patient-centred re-design; joined-up care
• Innovative contracting: lead provider; 10 year duration
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2. Commissioning for better outcomes & value: OBC
Upside: • Potential to deliver sustainable whole-system service transformation
• Better care co-ordination & planning> more ‘joined-up’ care, better outcomes & value
• Strong synergy with integration
• Can catalyse & incentivise providers to work differently
‘Urban myths’: • Doesn’t preclude personalisation or choice – embed in requirement for
‘lead provider’
• Shouldn’t freeze-out SME & SE participation - enable through sub-contracting
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2. Commissioning for better outcomes & value: OBC
Downside: • Resource-intensive
• Long lead times
• Clarity re desired outcomes & behaviours crucial
• Requires commissioner collaboration at-scale
• Effective user engagement from the outset crucial
• May require substantial (and challenging) market development – will be difficult if existing relationships are immature/tense
• For most commissioners, probably one OBC project at a time
Is it the right approach for the problem? Value-based?
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2. Commissioning for better outcomes & value: Value Based Commissioning:
Value based commissioning
Patient Value
PublicValue
Allocation Value
Economic Value
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2. Commissioning for better outcomes & value: Value Based Commissioning:
Low patient value / high
savings
High patient value / high
savings
Low patient value /
high cost
High patient value /
high cost
Select service proposals
Assessing priorities:
1. Patient Value – value from the perspective of an individual patient
2. Public Value – value from the perspective
of the public considering health care as a whole
3. Allocation Value – economic benefits within a
fixed annual commissioning allocation
4. Economic Value – economic benefit across the
whole of the health and social care system
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3. Currencies & payment mechanisms:
• Still very difficult for commissioners to compare providers, performance & value
• Information systems & measurement = key barriers• Limited progress from block contracts • Compounded by often unsophisticated approaches to
commissioning & prioritisation
But … • Increasing support commissioners to prioritise & assess value
systematically – Right Care & STAR• CFTTN work on indicators
Indicators > Currencies > Fairer Payment Systems• Wheelchair tariff?
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3. Currencies & payment mechanisms:
Indicators: • Foundations laid in Initial work led by the CFTN to develop
indicators of performance & value • Indicators based around 3 domains: performance; quality; social
value, equity & inclusion
• Signalled support from Monitor, NHS England, CQC, NHS TDA, HSCIC & Commissioning Assembly
• Long lead time (2 years for indicators?), but great start• Should enable value-based commissioning for those services not
included in capitation OBC
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3. Currencies & payment mechanisms:
Deferred payment – Social Impact Bonds?• Need for upfront investment prior to social impact & financial
return • Applications? Frail older people – admission avoidance & promoting
independence; reducing use of anti-psychotic drugs in residential care; challenged families
• Examples? GLA & St. Mungo’s – homelessness; Essex County Council & Action for Children – children at the edge of care; Sandwell & West Midlands CCG with Marie Curie – EoLC; Age UK in Cornwall – admission avoidance (under development)
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3. Currencies & payment mechanisms: SIBs
SOCIAL INVESTOR
(Investment contract
for financial return)
↕
COMMISSIONER ↔ SPECIAL PURPOSE
(OBC contract for VEHICLE
cashable savings & (Sub-contract for activity)
better outcomes) ↕
SERVICE PROVIDERS
(Acknowledgement to Bevan Brittan)
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4. TCS contract expiry?
Poses real dilemmas for commissioners & regulators …
• PCT divestment of community services under ‘TCS’ 2011
• Contracts 2-3-5 years
• Uncontested contracts to social enterprise spin-outs, on condition open competition on expiry
• Decisions subject to procurement law, public law (Gloucs. TCS judicial review) & s.75 regulations – caveat emptor!
• We now have a diverse non-NHS market (SEs & corporates
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4. TCS contract expiry?
What to do?• Roll-over for another full term (but not for TCS Social Enterprises)
• Extend pending disaggregation and/or OBC • Re-procure for service transformation and/or better value (Bath &
NE Somerset CCG; Hambleton, Richmondshire & Whitby – terminating contract with York Teaching FT & re-procuring)