Yorkshire Centre for Health Informatics

PCT Commissioning,Business Models & Pathology

Dr Rick Jones

Leeds Teaching Hospitals Trust

A Patient-led NHS requires:

• Informed Patients: – responsibility – choice– tax payers

• Effective Commissioners: – responding to Patients– understanding the evidence base– managing demand

• Responsive providers: – liberated from central control– competing to improve– managing costs

Commissioning

‘the means by which we secure the best value for patients and taxpayers. By ‘best value’ we mean:

– The best possible health outcomes – The best possible healthcare– With the resources made available by the tax payer’

DH 2006

Commissioning

The term “commissioning” is interpreted in different ways by different people. It is often used to denote “contracting” but in reality refers to a much broader process encompassing planning, procurement / contracting and performance management underpinned by partnerships.

Keith Douglas,

Director of Planning and Service Redesign, Eastleigh and Test Valley South Primary Care Trust and New Forest Primary Care Trust

Commissioning:

• ‘the set of linked activities required to assess the health care needs of a population, specify the services required to meet those needs within a strategic framework, secure those services and monitor and evaluate the outcome’

Woodin, 2007

The Commissioning CycleAssess health needs

Decide priorities

Review current service provision

Develop new service model

Procure provider

Award contract

monitor contract

What people want

• Local services there when you need them• Emergency care when you need it• No waiting• The best patient experience• To have a say, to have a choice• More emphasis on prevention• Health and social care working together• Improved health

OP

Other

A&E Tertiary

Assess

Diag(OP)

Diag(IP)

Diagnosticphase

OP OP

1st OutpatientAppointment

Decision to treat

GP IP OP

Follow-upTreatment/Discharge

18 weeks

Data flows

ElectiveAdmissionList

AdmittedPatientCare

Outpatients(CareActivity)

FutureCareActivity

A & E

ChooseandBook

Where does Pathology fit in?18 Weeks

Delivery of 18 weeks: Diagnostics

NOW:• Clarify commissioning

objectives– Patient pathway

– Measurement

• Identify best practice– Redesign patient flow and

scheduling

• Plan demand & capacity– Procure capacity

2008:• No waiting• Improved productivity• Appropriate access points• Demand & capacity in

balance• Clinical futures &

commissioning aligned

Imaging Pathology

Endoscopy Physiological Measurement

Pathways

Pathways need to be focussed on the needs / demands of the population and on resources available: one of the really difficult tasks for commissioning to address is what should and should not be delivered as clearly not everything can be afforded…

Keith Douglas,

Director of Planning and Service Redesign, Eastleigh and Test Valley South Primary Care Trust and New Forest Primary Care Trust

How should pathology engage?

• Who to approach?• By what route?• What type of services to present?• Reactive or pro-active engagement?

First know your customer and your product(s)

From Craftsmen to Service Providers

• Our society has become what it is today through the forces of– Specialization

– Standardization

– Scalability

• It is now almost exclusively “service” oriented– Transportation

– Telecommunication

– Retail

– Healthcare

– Financial services

– …

The IT industry which has many parallels to Pathology – high tech, rapidly developing, knowledge-based, ill understood by majority of users

Tidal Wave of Business Shift

• Classic 1900’s Companies– Control Delivery – Control Services– Control Information– Have expensive acquisition processes and static relationships– Managed pricing and expectations

• Information Age 21st Century– Consumer is empowered by information access– Businesses win by being open– Businesses win by leveraging new mechanisms to drive their own

costs down.– Dramatic lower overall cost potential, higher level of services.

Traditional Pathology Organisation

HaemClin

BiochemHisto Micro Immuno Genetics

Pathology

Local Trust GPs Other TrustsScreening

Service-based Organisational Framework

Operations Management Capability

Operations Execution Capability

RelationshipManagement

ProductManagement

DeliveryManagement

QualityAssurance

Cust1

Cust2

Cust3

Service AProcess

XService AOutcome

ProcessY

ProcessZ

Service B

Service C

Service BOutcome

Service COutcome

SalesProduct

DevelopmentProcess

Engineering Measurement

What exactly is a service?

+ + =Technology, Products & Platforms

People Process

Service• Intangible• Non-persistent• Described in Benefit or Customer Terms• An Action, not a Thing

A Service

“Giving assistance or advantage to another”

These are NOT services

What is pathology?

• Laboratory Processing• Near Patient Testing• Clinical Advisory Service• Screening Services• Chronic Disease Management• Direct Clinical Service to Patients• Training and Education• Research and Development• Clinical Audit• Policy support• ………………………….plus other services

What are the key features of good commissioning?

• Not just the responsibility of one organisation - input from wide range of people with different skills

• Strong local partnerships, e.g. – PCT, local authority– Network– local users

• Different types of commissioning, e.g.– PCT commissioning– Joint commissioning– Practice based commissioning– Network commissioning– Specialist commissioning

Supply chain management: The commissioner needs to understand the supplier and aim for mutual success on behalf of local people... understanding the cost base and the problems… the provider needs to understand the commissioners problems, aspirations, targets.

This requires honest and open lines of communication, using the right medium for the right message. Only with this can commissioners and providers deliver in partnership for communities.

Martin Barkley, Chief Executive, Hampshire Partnership NHS Trust

Knowing your place in the Service Fulfilment Chain

A

B

CD

A = ProviderB = Customer

B = ProviderC = Customer

C = ProviderD = Customer

A & B =Pathology

C =Clinician

D =PatientThere are many providers and customers

in a service fulfilment chain, but…

….. services must be expressed in terms of the ultimate end customer,

Examples of PBC Service Redesign

• Chronic obstructive pulmonary disease• Long-term conditions• Ophthalmology• Heart failure

– BNP in community– In-house ECHO

• Urology– Haematuria protocol for diagnostic tests– H.pylori

Knowledge: Commissioners need to know national policy, guidance, standards, targets. They need: a passion (or at least an interest) in the services being commissioned, to understand local needs and priorities, to be able to speak and commit on behalf of the organisation and know the service being commissioned.

Martin Barkley, Chief Executive, Hampshire Partnership NHS Trust

Pathology Commissioning

• Direct Access• Provider / Provider• Clinical contract with Trust• Specialist commissioning

Do commissioners know what to commission?

Continuum of commissioning

Level of commissioningSmith et al 3

individual……...practitioner……….practice……….locality……….community…….region……….nation

Single practice based commissioning

Patient choice

PCO/PCT commissioning

Multi-practice or locality commissioning

Joint commissioning Lead PCT/LHB

commissioning

National commissioning

micro meso macro

What SHAs will want

• Strategic Planning (major investment / configuration / workforce)

• Support for research, innovation and education / training• Help in creating new health system• System management with regulators• Performance management of PCTs / market• Possibly some tertiary level via PCT groups & networks

Commissioning Specialist Services

Example: Haemoglobinopathy screening

1. Universal neonatal screening– NHS roll out programme, funded until March 2007

2. Universal antenatal screening funded study for 2 years to screen women in Leeds / Bradford

Post 2007: PCT sign up?

What PCTs will want

• Strategic Commissioning - not short term fixes• Programmes to improve the health of the community• Reduction in inequalities - standard packages• Assurance of safe, high quality services• Managed contracts on behalf of Practices• Performance within budgets• Transparency on costs• Verification of secondary care requirements - checklists• Public engagement - informed choices• May need some community services

Commissioning Cancer Services

Example – leukaemia• Panels of cell markers• Commissioning only from laboratories who meet current

guidelines• Audit of current activity / practice• Need sufficient activity / expertise

North Bradford PCT Service Improvement Pyramid

Practice managed

Groups of practices

PCT managed

PCT +

Service delivery informed by patients

Corporate bodies Practice based commissioning

Performance Improvement Model

Unit of Service Delivery

PLT/PBE

Pursuing Perfection

Collaboratives

Educatio

n

Information

Sup

port Advisory Groups

Specialist Groups

Practice Review Meetings

Performance Packages

PMSIncentive Scheme

PBC Culture

Vision

Mission

Patient/Consumer Involvement

Optimising Hospital Utilisation

Patient Experience

Clinical leads

Practice Manager leads

What GPs Want From Pathology

• Benchmarking data (test rates)

• Integration of pathology into care pathway

• Standardised guidance, up-to-date

• Best practice guidelines

• Reduction in inappropriate testing

• Electronic requesting / reporting

• Automatic prompts

• Governance role of laboratories

• Standardisation across the patch

• POCT where appropriate

VALUE ADDED PARTNERSHIP

Must be taken at least 12 hours post chest pain

What patients will want

• Convenient and accessible services• To know why tests are being done• Tests are safe and kept to a minimum• Results in the shortest possible time• Reliable results• Information on meaning and implications of results

Putting it all together

Serv

ice

R

edes

ign

Wor

kfor

ce

Con

nect

ing

for

H

ealth

Faci

litie

s

£ Fi

nanc

ial

im

pact

Strategic commissioning objectives• Long-term conditions• Diagnostics

Enabling projects

• Elective care• Urgent care

How should pathology engage?

• Who to approach?– Trusts– PCTs– SHAs– GPs

• By what route?– Some direct – POCT, INR, DMARDS– Some indirect – clinical bundles, composite services

• What type of services to present?– Coherent - results & evidence & support– Complete – clinical answers not widgets

• Reactive or pro-active engagement?– Pro-active – now or never

Service Orientated Organisation

Users ServiceSupport

Production & Back Office

Regional

AcuteTrusts

&PCTs

National

High Volume Core

Lab

SpecialistFunctions

e.g. MolecularCytologicalScreening

Drugs

LogisticsBusinessSupport

Research / Training / DevelQuality Assurance / Audit

ClinicallyOrientated

ServiceDelivery

PatientCentric

Approach

Knowledge Management

Remember

“ A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty”

Sir Winston Churchill

Yorkshire Centre for Health Informatics

Conclusion

Price & Jones The challenges in commissioning laboratory medicine (pathology) services.Journal of Management & Marketing in Healthcare. VOL. 1 NO. 2. PP 1–13. Jan 2008