Commissioning for outcomes, Wednesday 21 January 2015 - 13.00 to 13.45 Hosted by Bob Ricketts CBE, Director of Commissioning Support Services and Market Development for NHS England.

1. WELCOME
Wednesday 21 January 2015
Webinar
Commissioning for Outcomes

2. Commissioning for Outcomes
Wednesday 21 January 2015
1pm – 1.45pm
Bob Ricketts CBE
Director of Commissioning Support Strategy
& Market Development, NHS England
&
Beverley Matthews
LTC Programme Lead, NHS Improving Quality

3. Bev Matthews
A nurse by background, Beverley has worked extensively throughout the NHS in a variety of
clinical, managerial and strategic roles. Beverley’s current role as Programme Delivery Lead
for Long Term Conditions Improvement Programmes: LTC Year of Care Commissioning
Model and LTC Framework. Prior to joining NHS Improving Quality in April 2013, Beverley
was Director of NHS Kidney Care and NHS Liver Care.
Passionate about service transformation through developing networks and leading complex
programmes. Providing strategic leadership to partners within health communities,
managing stakeholders and working across agencies.
Bob Ricketts, CBE
Director of Commissioning Support Services & Market Development for NHS England since
September 2012. Focus: developing and implementing two core strategies for NHS England
– developing commissioning support services (published in June) and creating autonomous
NHS Commissioning Support Units (provisionally to be published in December).
Previous Director roles within the Department of Health included developing the NHS
Standard Contract, competition policy, patient choice and choice of any qualified provider,
the social enterprise sector, Transforming Community Services, and commissioning and
demand-side reform.
Meet the Speakers

4. Commissioning for Outcomes
• Aligning with shared commissioning ambition.
• Sharing experience and what works.
• Using routine data to measure impact on health
outcomes.
Learning Outcomes

5. Beverley Matthews
LTC Programme Lead
NHS Improving Quality
Beverley.matthews@nhsiq.nhs.uk

6. www.england.nhs.uk
LTC Framework
6
Organisational &
Clinical
Processes
Informed and
engaged patients
and carers
Health & Care
Professionals
committed to
partnership
working
Commissioning
• Information and
technology
• Case finding & risk
stratification
• Care Planning
• Safety and
Experience
• Guidelines,
evidence and
national audits
• Care Delivery
• Self Management
• Information and
Technology
• Group and Peer
Support
• Care Planning
• Policies for carers
• Voluntary sector
patient & carer
support
• HSC Integration
• Multi Disciplinary
Teams
• Culture
• Workforce
• Technology
• Care Co-
ordination
• Care Planning
• Needs
Assessment and
Planning
• Joint
Commissioning
• Metrics and
Evaluation
• Service User and
Public Involvement
• Contracting and
Procurement
• Care Planning
• Tools and Levers
The table below sets out some of the key components needed to deliver the central
aim for LTC Framework - Person Centred Coordinated Care

7. Bespoke Support

9. Tools and Resources

10. Links
Long Term Conditions Dashboard
http://ccgtools.england.nhs.uk/ltcdashboard/flash/atlas.html
Long Term Conditions House of Care Toolkit
www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/house-of-care.aspx
SIMUL8: Simulation Model
http://www.simul8.com/viewer/download.htm
#LTCyearofcare #LTCimprovement @NHSIQ

11. LTC Learning Forum
“Lunch & Learn” Webinar Series
&
Bite Size Master-classes

12. Virtual Learning Network
“Lunch & Learn”
• 45 minute “real time” Webinar
sessions
• Topics agreed and learning outcomes
identified
• Faculty of Speakers identified
Open invitation
Bite Size Learning Master-Classes
• Pre-recorded 20 minute Master-
classes
• Master-class either as stand alone
sessions or pre-requisites for
Wednesday “Lunch & Learn”
Webinars
• Faculty of Speakers identified
Open invitation

13. To register email LTC@nhsiq.nhs.uk
LTC Lunch & Learn Series
….coming soon…
Date Webinar Hosted by Bev Matthews &
4 February 2015 The Organisation of Integrated
Care: encouraging collaboration
through contractual
mechanisms
Dr Rachael Addicott
Senior Research Fellow
The Kings Fund

14. www.england.nhs.uk
Commissioning
for Outcomes
NHSIQ: LTC Lunch & Learn
Webinar
21st January 2015
Bob Ricketts
Director of Commissioning
Support Services Strategy

15. www.england.nhs.uk
1. Context:
15
The Forward View sets out unprecedented challenges:
• Rising demand
• Increasing public & political expectations
• Constrained resources
• Out-dated over-stretched service models (all sectors)
• Persistent unacceptable variation – in outcomes,
access & VFM

16. www.england.nhs.uk
1. Context: Demand for care is growing rapidly
We are facing a rising burden of avoidable illness across England from
unhealthy lifestyles:
• 1 in 5 adults still smoke
• 1/3 of people drink too much alcohol
• More than 6/10 men and 5/10 women are overweight or obese
• 70% of the NHS budget is now spent on long term conditions
• People’s expectations are also changing
16

17. www.england.nhs.uk
1. Context: New opportunities
17
New technologies and treatments
• Improving our ability to predict, diagnose and treat disease
• Keeping people alive longer
• But resulting in more people living with long term conditions
New ways to deliver care
• Dissolving traditional boundaries in how care is delivered
• Improving the coordination of care around patients
• Improving outcomes and quality
Support
• NHS IQ Improving Quality in Supporting CCGs to commission
personalised care for people with LTC via LTC Improvement Progr.
• Commissioning Support: Lead Provider Framework
…but the financial challenge remains, with the gap in 2020/21
previously projected at £30bn by NHS England, Monitor and
independent think-tanks

18. www.england.nhs.uk
To deliver the Forward View we need approaches which …
• Incentivise high quality integrated pathways which deliver high
quality ‘joined-up care’ – MSK: Bedfordshire
• Are place-based, with effective co-commissioning - avoiding
fragmentation from ‘multiple commissioners’
• Make the best use of resources (NHS-funded, LAs, communities,
users) – “there is only one Leeds pound”
• Reward delivery of the best outcomes for users, carers &
communities (social value)
• Address demand risk explicitly
• Catalyse new configurations/partnership of providers
• Include, not marginalise, non-NHS partners
• Are deliverable & proportionate to the problem – commissioner
and provider capacity & capability is a real issue
2. Commissioning for outcomes: Why?

19. www.england.nhs.uk
Narrative on OBC
NHS CA Quality
Working Group
2. Commissioning for outcomes: What is it?

20. www.england.nhs.uk
There is a spectrum of approaches:
Embedding outcomes in contracting:
Using outcome measures in, e.g. secondary care, to drive-up quality, linking
payment much more closely to performance. ICHOM
Outcome-based population commissioning
a key vehicle to drive transformation & secure better outcomes, service
integration 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
COBIC
*International Consortium for Health Outcomes Measurement
2. Commissioning for outcomes = a spectrum

21. www.england.nhs.uk
2. Embedding outcomes in contracting:
ICHOM Standard Set for Localised Prostate Cancer:
Outcomes
Treatment approaches
covered
▪ Watchful waiting
▪ Active surveillance
▪ Prostatectomy
▪ External beam radiation
therapy
▪ Brachytherapy
▪ Androgen Deprivation
Treatment
▪ Other
Details
1 Recorded via the Clavien-Dindo-Classification
2 Recorded via the Common Terminology Criteria for
Adverse Events (CTCAE), version 4.0
3 Recommended to track via the Expanded Prostate
Cancer Index Composite (EPIC)-26
© 2013 ICHOM. All rights reserved. When using this set of outcomes, or quoting therefrom, in any way, we solely require that you always make a reference to ICHOM a s the source so
that this organizationcan continue i ts work to define more standard outcome sets.

22. www.england.nhs.uk
2. Embedding outcomes in contracting:
Bedfordshire CC Group developed an outcomes based contract using
ICHOM Lower Back Pain outcomes Set
Bedfordshire CCG has
constructed a
musculoskeletal care
contract with Circle
ICHOM Lower Back Pain
Set incorporated into the
contract and Circle
expected to report on
these outcomes
A baseline will be
measured inYear 1 and
then annual
improvements in the
outcome Set will result in a
financial reward.
ICHOM conclusion: Incorporating outcomes into contracts with providers is an
excellent way to ensure quality measurement and to incentivise improvement.
ICHOM conclusion: Incorporating outcomes into contracts with providers is an
excellent way to ensure quality measurement and to incentivise improvement.

23. www.england.nhs.uk
Integral to core OBC’ /COBIC model are:
• Identifiable & measurable outcomes
• That those outcomes can be linked to desired behaviours
• That those behaviours can be incentivised through payment
systems
• Spans primary, community & secondary care
• At-scale for populations (but can be done on a smaller scale,
introducing a % payment for specific outcomes)
• More mature & long-term relationship with providers (7+
year contracts)
• ‘Lead provider’ or ’Alliance’ contracting
2. Outcome-based population commissioning:

24. www.england.nhs.uk
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’ or ‘alliance’
• Provider(s) co-ordinates care planning & delivery
• Provider(s) takes on much of the demand risk
*LTC Year of Care Commissioning EI sites – testing
population capitated budget for LTC cohorts, new contracting
& delivery models
2. Outcome-based population commissioning:

25. www.england.nhs.uk
2. Outcome-based population commissioning:
Two main contracting models
Attribute Lead Provider Alliance
Fit local culture Requires significant trust &
effective partnering
Probably easier to implement where
relationships less mature/damaged
Shift in risk from commissioner Substantial post-
mobilisation
Significant post-mobilisation
Requirement for commissioners
to co-ordinate care & providers
Low Low for care
Low-Medium for providers –
accountability & procurement
processes
Resource intensity & lead times High High
Proof of concept in NHS Limited Very limited
Evidence base in NHS?
Evaluation?
Minimal Nil?
Fit NHS Standard Contract Can be accommodated Not currently
Deferred funding/pump-priming Major problem Major problem

26. www.england.nhs.uk
OBC still emerging, but examples:
• Bedfordshire (MSK)
• Cambridgeshire (range of services for older people)
• Staffordshire (cancer & EoLC for 1m+)
• Sussex x3 (MSK)
• Greater Huddersfield & Kirklees CCGs (community
services lead provider)
• Smaller-scale: Oxfordshire & Milton Keynes (sexual
health; substance abuse)
EI sites for Year of Care commissioning: Southend,
Leeds, Kent, West Hampshire, Barking, Dagenham &
Havering and Redbridge
2. Outcome-based population commissioning:

27. www.england.nhs.uk
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
2. Outcome-based population commissioning

28. www.england.nhs.uk
Downside:
• Resource-intensive
• System capacity & capability (CSS Lead Provider Framework)
• 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
• Funding double-running costs & deferred payment (SIBs?)
Is it the right approach for the problem? “Sledge-hammers &
nuts”
2. Outcome-based population commissioning:

29. www.england.nhs.uk
Critical Success Factors:
• Know what problem you’re trying to solve
• Commission the underpinning analysis – e.g. RightCare ‘deep
dive’; CfV packs
• Be clear what you’re trying to achieve
• Set identifiable & measurable outcomes
• Link outcomes to desired behaviours
• Think about how to incentivise the right behaviours – not just
through payment systems
• Engage systematically, consistently & early – users, communities,
clinicians, providers, ‘politicians’
• Budget for resources - capability & capacity
• Start small!
2. Outcome-based population commissioning: CSFs

30. www.england.nhs.uk
Useful sources:
General overview:
NHS CA Quality Working Group
King’s Fund: How to measure for improving outcomes: a guide for
commissioners
Embedding outcomes:
ICHOM International Consortium for Health Outcomes
Measurement
www.ichom.org
www.ichom.org/project/cataracts
www.ichom.org/project/low-back-pain
2. Commissioning for outcomes:

31. www.england.nhs.uk
Useful sources:
Outcome-based population commissioning:
COBIC & Cobic Club www.cobic.co. uk
Right Care Casebook series : Paul Corrigan & Nick Hicks
“What organisation is necessary for commissioners to develop
outcomes-based contracts?”
COBIC Explained – NHS Change Model
www.changemodel.nhs.uk/dl/cv
Contracting models:
King’s Fund: Contractual models for commissioning integrated
care Nov. 2014
2. Commissioning for outcomes:

32. To register email LTC@nhsiq.nhs.uk
LTC Lunch & Learn Series
….coming soon…
Date Webinar Hosted by Bev Matthews &
4 February 2015 The Organisation of Integrated
Care: encouraging collaboration
through contractual
mechanisms
Dr Rachael Addicott
Senior Research Fellow
The Kings Fund