world class commissioning: the road ahead claire whittington acting director of commissioning...

World class commissioning:

the road aheadClaire Whittington

Acting Director of CommissioningDepartment of Health

2Adding life to years and years to life 2

“The aim of world class commissioning, and therefore the ultimate test of its success,

will be an improvement in health outcomes and a reduction

in health inequalities”


WCC is making an impact

Neutral

Prioritisation of key health outcomes

Plans to improve key health outcomes

Strategic planning

Financial planning

Board role in shaping and driving thecommissioning agenda

The WCC assurance process is leading to an improvement in PCTs’* %

Strongly agree Agree Disagree Strongly disagree

51

56

46

54

49

33

34

43

24

43

4

112

216

3 18

2 10

8


Competency results

0010151

09135

8

02

10941

01102

49

006686

04116

32

019556

0049

103

0017135

020124

8

2 31 4

4. Collaborate with clinicians

3. Engage with public and patients

1. Locally lead the NHS

5. Manage knowledge & assess needs

10. Manage the local health system

6. Prioritise investment

8. Promote improvement and innovation

9. Secure procurement skills

7. Stimulate market

2. Work with community partners

n = 152

Frequency

Source:152 panel scores as of 31 January 2009 (post national calibration)


1 2 3

2.1

2.4

1.9

2.0

2.0

1.7

1.4

2.0

1.6

1.9

2.0

2.1

1.7

1.4

1.7

Self-assessment

Panel assessment

1.4

1.7/

1.7

1.7

1.2

Panels scored PCTs below their self-assessment, with the largest gaps on competencies 5 and 6

U.K. overall

Work with community partners

Stimulate the market

Prioritise investment

Collaborate with clinicians

Engage with public and patients

Manage the local health system

Promote improvement and innovation

Secure procurement skills

Manage knowledge and assess needs

Locally lead the NHS1

2

3

4

5

6

7

8

9

10



7178

3

Red Amber Green

Panel governance ratings

45

90

17

6178

13

n = 152

Strategy

Finance

Board



1.62South East Coast

1.76Yorkshire and The Humber

1.73South West

1.71North West

1.68East Midlands

1.65West Midlands

1.59South Central

1.56North East

1.56London

1.55East of England

Av = 1.64

Comparison of SHAs by competency score

SHA Average across all competenciesSHA

% of sub-competencies scored as 3

Competencies Governance (% by rating)

National average across all competencies*

Strategy Finance Board

29647

216414

54388

33670

245918

226711

582517

19746

07129

0 63 38

29

88

67

59

78

33

74

64

86

64

22

35

67

7

88

16

7

7

130

11

6

022

0

10

1421

13 0

86140

57430

88130

56440

24760

226711

58420

16813

21717

0 50 50

9

5

4

5

9


4

3

3

4

0


"Tax increases and spending cuts are inevitable immediately after the election,

assuming that there are signs of economic recovery by then - and any managers of a

public service who are not planning now on the basis that they will have substantially less money to spend in two years time are living in

cloud-cuckoo-land."

Steve Bundred, Chief Executive, Audit CommissionThe Times, February 27 2009

But the financial context has tightened


The economic climate

5.5% growth in both 2009/10 and 2010/11 Invest to save opportunities

Assuming little or no growth from 2011 onwards

Release efficiency savings between £15-20bn across the service between 2011 - 2014

Need transformational approach to come through this


Commissioners need to lead the way

Quality

Innovation

Productivity

• Focus on improving health outcomes

• Prioritise most effective treatments and services

• Manage demand and performance

• People make healthier choices

• The healthier choice is easier

• Advice and support for people most at risk

• Prioritising reduction in harmful behaviours

• Technical efficiency

• Allocative efficiency

Prevention


Levers

• Clinical commissioning

• Transforming community services

• Information• To eliminate unwarranted variation• To stimulate debate & change behaviours• Publication of survival rates etc• To produce evidenced based commissioning decisions

Community services: 12-fold variation in productivity, starting from a low baseAverage number of daily visits by nurse in specified period (%)

Source: 3-month sample of district nurses in provider arm of a PCT

12

4

8

2324

20

12

4

1

5–64– 5 9–10 10–11 11–127–86–72–3 3–41–2

Examples of key levers to increase efficiency

• Streamline travel routes

• Replace night agency staff with permanent staff

• Adjust staffing levels to demand

• Standardize process/ interventions

*Age and need weighted population

Source: PCTs spend, Mckinsey analysis

1b PCTs’ prescribing costs: more than twofold variation in prescribing cost per weighted population*

Prescribing cost per weighted population* by PCT. £/ capita, 2006/07

Median: £151/pop

85

192

Typical sources of inefficiencies

• Unexploited switches to cheaper alternatives with identical outcomes

• Avoidable specialist and restricted drug spend

• Waste reduction

• Lack of formulary

• Supply chain inefficiencies

The specific opportunities for improvement fall into four areas with a range of mechanisms to capture

Technical efficiency

Drive through cost efficiencies in all provider services

Shift care into more cost effective settings

Optimize spend and ensure compliance with commissioners’ standards

Allocative efficiency

Prevent people from becoming ill through increased prevention

1 2 3 4

Pricing/ reimbursement

Market structure/management

Areas of opportunity

Contracting and setting/ enforcing standards

Mechanisms to capture value

Mechanism applicable to capture the value


The 10 most frequently selected account for 60% of all outcomes chosen by PCTs in the WCC assurance system

* Childhood obesity was the only locally-defined outcome among the top 20, and so is not included in graph on the left hand side of the page.Source: 152 PCT submissions; DoH; team analysis

64

20

18

18

54 outcome choices

Nationally

defined outcomes

940 nationaloutcomes selected

60

20

Outcomes from national set chosen by PCTs

Top 20 choices

Top 10choices

Percent

100% = Top 10 measures nationally #PCTs

1 Smoking quitters 100

2 Rate of hospital admissions per 100,000for alcohol related harm

75

3 CVD mortality 72

4 Percentage of all deaths that occur at home

69

5= Under 18 conception rate 53

5= Childhood Obesity (locally-defined)*

53

7 Cancer mortality rate 51

8 Diabetes controlled blood sugar 43

9 Infants breastfed 41

10 Percentage of stroke admissions given a brain scan within 24 hours

33


Over 80,000 life years and about 60,000 QALYs can be gained over 5 years if PCTs improve their performance by a quartile

16,000

13,00082,170

3,600

Smoking** Alcohol

70

CVD mortality

~40,000

Cancer mortality Stroke

9,500

Diabetes** Total

10,000

26,600

8,8008,700

59,150

5,000

TotalDiabetes**Cancer mortality StrokeAlcohol

50

Smoking** CVD mortality

Years to life….

Life to years….

Life years gained*

QALYs gained*

CUMULATIVE

Source: Team analysis – details in appendix.

* By a one quartile improvement relative to historical baseline for PCTs selecting the outcome. PCTs in top quartile improve based on vital signs.** 10 year time delay between intervention and full benefit capture


A one quartile improvement in PCT performance for these outcomes would result in a 10-15% reduction in health inequalities* by year 5

Source: 152 PCT submissions; DoH; team analysis

Health inequality gap – rate of smoking quitters Health inequality gap - Cancer mortality rate per 100,000

Health inequality gap - rate of admissions for alcohol related harm

Health inequality gap - CVD mortality rate Health inequality gap - Stroke admissions given a brain scanPercent gap*

Health inequality gap - Diabetes controlled blood sugar

7363 -10

8069 -11

6151 -10

4535 -10

44

27 -17

7458 -16

Percent gap*

ESTIMATES

Percent gap*

Percent gap*Percent gap*

Percent gap*

Baseline BaselineUp a quartile** Up a quartile*** Between top and bottom PCTs.** PCTs in the bottom three quartiles move up a quartile whilst top quartile PCTs improve at the rate of their Vital Signs ambitions.


Assurance Year 2 – fine tuning the system

Scope of the

changes

WCC will not change substantially in the future The principles, framework and high-level process will be

maintained Feedback indicates four main implications for the future

iterations Focused yet rigorous process Allocate more time for the process More resource/support National consistency

Outcomes: review national list, provide greater guidance for choosing outcomes and introduce more ‘stretch’

Competencies: clarify criteria where needed, introduce competency 11

Governance: strengthen and clarify criteria, streamline financial template

Process: extend PCT prep and analytical phases, streamline document submissions and provide greater guidance to panelists on where to focus during the panel days

Better Website

Main changes


Given the current economic climate, Competencies 6 & 11 are being revised

Identifying opportunities to maximise effectiveness of spend

b

Delivering effectiveness of spend sustainably

c

Competency 11 – ensuring technical and allocative efficiency and effectiveness of spend

Measuring and understanding effectiveness of spend

a

*whilst fulfilling health outcome requirements of the population

Competency 11 is being introduced . . . . . . and Competency 6 is being enhanced

Competency 6 – prioritise investment in line with funding expectations and according to local needs, service requirements and the values of the NHS

b

c

Sub-competency Additional focus

Based on impact on health outcomes: Rigorous prioritisation of

investment Named disinvestment

Strategic commissioning plans for different financial scenarios to include downside funding


Freedoms and Incentives in 2010/11

Rewards would apply to top performers from 2010/11, following the conclusion of the second round of WCC assurance

Financial

Support

Non-financial

Manage financial risk over a greater period Access to innovation and development funds Consider pay flexibilities

A lighter touch performance management approach proportionate to overall performance of a PCT;

The kudos of being within the high performing group Creation of a franchising model to facilitate high performing

PCTs to take over commissioning functions of underperforming PCTs

Direct input into national policy formulation


Intervening in under-performing PCTs in 2010/11

Those PCTs defined as poor performers after the second round of WCC assurance will be subject to intervention by the SHA, in line with Developing the NHS Performance Regime and The Transaction Manual

New Commissioner Performance Framework to apply from 2010

- with clear thresholds for early intervention- a clear rules based process for escalation, and- based on clear set of performance metrics

Will be working with NHS over coming months to develop the Framework


Next steps – prepare for year twoJune 2009 - Fine tune year two co-production

Competencies – tighten language & focus (3,4 & 10) Competency 11 Strengthen governance Strategy – focus on allocative efficiency

September 2009 Data pack Web site Communications & materials

Timetable Sept – Dec 2009 PCTs collate evidence Jan – Mar 2010 Analytical phase Apr – May 2010Panels July 2010 Publish Scorecards

Freedoms commence


The road ahead

Clinical commissioning

Integrated care

Partnerships

Managing the health system

world class commissioning: the road ahead claire whittington acting director of commissioning...

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