Long Term Conditions Year of Care Commissioning EIS workshop

www.england.nhs.uk
18th January 2016
10.30am – 3.30pm
WELCOME!
LtC Year of Care
Commissioning
EIS Workshop

www.england.nhs.uk
• Introduction and welcome
• Outline of today's workshop
• National update
• EIS future plans and discussion
• Proactive health coaching - followed by EIS
updates and discussion
• Approaches to developing currencies and
payment systems: mental health and NHSE
pricing team updates / approaches - followed by
YoC capitated budget updates from EIS and
discussion
Introductions and outline of today:

www.england.nhs.uk
• To hear and learn about other EIS plans for YoC
Commissioning beyond March 2016
• To develop contacts and learning from others to support local
thinking and robust planning around proactive health
coaching
• To update knowledge on national approaches to currency
development and payment – thinking about and discussing
EIS year of care capitated budget approaches
Learning Outcomes:

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National Update
Bev Matthews

www.england.nhs.uk
LTC Framework
Commitment
to Carers
Frailty
Health Ageing
Guide
Fire Service as
an asset
Care Homes
Quick Guides
Care & Support
Planning
Navigating Health
& Social Care
Self Care
Ambitions for
End of Life Care
Our Declaration
Delivery Models
Planning for Change:
• Capitated Budget
• Contracting
• Simulation Modelling
Patient and
Service
Selection
Planning for Change:
Workforce
Whole Population
Analysis;
Understanding your
population
LTC Dashboard LTC Toolkit

www.england.nhs.uk
Long term conditions resources
Simulation model
Unbundling recovery simulation model

www.england.nhs.uk
7
Using behavioural
change to open
minds
o Make a declaration at
www.engage.england.nhs.uk/survey/ltc
-declaration
o Tell your teams about our work
o Encourage them to make a declaration
o Ask them to feed back thoughts and
ideas
o Use our hashtag – #A4PCC – when
you see work that is relevant to
person-centred care for people with
LTCs
o Let us know of any events, activities or
social media opportunities that we can
join forces with you
#A4PCC – Action for Person-
Centred Care
Person
with long
term
condition

www.england.nhs.uk
Date Topic Led by and details of session Venue
20 January
12.30pm
Clinical input to care homes
www.nhs.uk/quickguides
Nicola Spencer and Emily Carter
NHS England
Guest speakers:
• Angela Dempsey, - Baker Tilly on
the Quest4care tool
• Dawn Moody – North Staffs on
MDT working and a model
implemented in a CCG
Via WebEx
10 February
11.30am
Health Coaching in the community-
the role of non-clinical staff and
people with lived experience as
coaches
Anya De Iongh & Jim Phillips Via WebEx
TBC Self-management in the community
and on the Internet
Peter Moore, The Pain Toolkit Via WebEx
LTC Virtual Learning Community Lunch & Learn webinars:
Sharing and Learning …

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Date Topic Led by and details of session Venue
11 January
2016
12.30 – 1.30
Developing robust capitated budgets
- Integrated data
- Developing capitated budgets
- The Southend process and experience
Steve Downing, Head of Finance and
Bill Woods, Business Intelligence
NHS Southend
Southend LTC Year of Care
Commissioning
Early Implementer Site
Via Webex
Click here to
register
19 January
2016
12.30 – 1.30
integrated data to support service
redesign decision making:
- The Leeds approach
- How and who...using the integrated
data
- Challenges, lessons learned...what next
Tricia Cable, LTC Year of Care
Commissioning Programme lead,
NHS Leeds
Leeds LTC Year of Care Commissioning
Via Webex
Click here to
register
4 February
2016
10.30 – 3.30
LTC Community of Practice Workshop Please save the date for this workshop -
details to follow
Central
London
11 February
2016
12.30 – 1.30
Commissioning Integrated models of
care:
- The South Kent model of care (what it
looks like)
- Roadmap to delivery
- Contracting models and evaluation.
Alison Davis, Integration Programme
Health and Social Care, Working on
behalf of Kent County Council and
South Kent Coast and Thanet CCG's
Kent LTC Year of Care Commissioning
Via Webex
Click here to
register
LTC Community of Practice webinars:
Scan, Focus, Act …

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• Individual EIS monthly update calls (30 mins)
• Quick updates (national and EIS)
• Your opportunity to raise any issues / request help
• Calls in diary for West Hants, BHR and Leeds
• Dates still to be agreed with Kent and Southend
LTC YoC Commissioning – EIS sites
Dates for Diary
EIS workshops
(10.30 – 3.30, central London, venues tbc):
Monthly project leads forum
2pm – 3.30pm (webex)
18th Jan 2016  Mon 1st Feb 2016
23rd March 2016  Tues 1st March 2016

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EIS updates and future
plans
...beyond March 2016
• Kent
• BHR
• Leeds
• Southend
• West Hants

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• Kent Integrated Dataset - to continue data work
• Funding secured from CCG’s and KCC Social Care
• Kent Integrated Payments Group – to continue work on
capitated payments
• Capitated Payments Workplan drafted
• Additional Programme Management resources under
discussion
• Vanguard and Integrated Care Organisations in East Kent
developing Whole Population Budgets using the dataset
• Public Health to lead evaluation and system modelling work
using the Kent Integrated Dataset
• Further Datasets to be added e.g. children’s services,
police
Kent Post LTC Year of Care Plans

www.england.nhs.uk
Report by: Chris Hume Date: 17 December 2015
Progress this month Plans for next month
• 112 out of 202 GP practices have agreed to share data
• Draft implementation plan prepared for 2016/17 shadow
capitated budget for Thanet ICO. Vanguard (Canterbury
and Coastal) and ICO (South Kent Coast ) also looking to
adapt the plan for their use
• Work continuing on key actions from Data Quality
Improvement Plan – reconciling cost data to CCG spend,
data dictionary. New Analyst commenced
• Application made to Integration Pioneer Bespoke Fund for
additional resources to support remaining data collection
(GP data, Acute non-SUS, Continuing Health Care and
IAPT)
• Application prepared to HSCIC to receive IAPT data
• Uncertainty over future of data warehouse resolved – to
be hosted by Maidstone and Tunbridge Wells Trust
• Increase the number of GP Practices flowing data
• Set up local project with Monitor and HSCIC to calculate
prescribing costs
• Continue work with Vanguard and East Kent ICO’s to
develop shadow capitated budgets
• Review preliminary findings from PSSRU analysis of costs
• Continue to implement the data quality improvement plan
• Create Kent wide group on capitated funding
• Commence preparation for post- March arrangements
Risks & Issues Seek (Help needed) and Share (Learning offered)
 Timescales for ICO/MCP development by CCG’s mean
capitated budgets will not be produced in 2015/16
 Length of time taken to collect GP Practice data leading
to insufficient data to calculate capitated budgets
How to engage CCG commissioners in planning the
implementation of capitated budgets
LTC Year of Care Commissioning Early Implementer Site Update - KENT

www.england.nhs.uk
Report by: Leeds EIS • Date: December 2015
Progress this month • Next steps
• Data analysis by practice level using the selection
toolkit and the data packs. They will be shared to all
practices in LSE.
• Closer working with the self-management group
and Leeds Involving People (LIP) to organise a
workshop involving the self-management patient
forum
• Further engagement in local discussions on models
of care and YoC contribution
• Refresh of data packs for each CCG based on
14/15 data (full financial year 14/15 data expected
in the next few weeks)
• Case study to be finalised based on data packs and
selection toolkit, to be submitted to NHS England
(Sustainable Improvement Team, formerly NHS IQ)
• Demonstration of the Simul8 tool (scenario
generator tool) by Jamie Day (Jan/Feb)
• Self-management/YoC workshop involving self-
management forum (workshop arranged for 13th
January 2016)
• Development of patient stories/patient journeys,
potentially based on ethnography evaluation that
the Sustainable Improvement Team, carried out
• YoC EIS webinar presenting data packs and
carrying out demonstration of selection toolkit to the
wider EIS community
• Further development of Framework for development
of Capitated Budgets and discussion with CFOs
• Development of initial Capitated Budgets for
shadow monitoring
LTC Year of Care Commissioning Early Implementer Site Update - LEEDS

www.england.nhs.uk
Report by: Date: As at end Nov 2015
Progress this month – November Plans for next month – December
20th November: we have started running run the
integrated information including Social care, 21
primary care with Health data through the risk
strat tool and re –run the LTC report. This will
be compared to the first time we run. This will
identify any changes in the YOC tariff.
• PI Benchmarking will produce the first set of
dashboards.
• Care-Coordinator project lead assigned.
Risks & Issues Seek (Help needed) and Share (Learning
offered)
 Delayed start of Community Recovery
Pathway – may not be able to deliver
outcomes by March 2016.
 Not all surgeries have signed up for data
sharing.
Webinar – 11 Jan 2016 from 12.30pm – 1.30pm
Creating robust capitated budgets with Steve
Downing and Bill Woods
LTC Year of Care Commissioning Early Implementer Site Update – Southend

www.england.nhs.uk
Report by: Rashid aleem Date: 17/12/2015
Progress this month Plans for next month
• Recruitment of Business Intelligence
personal
* JD written
• Nuffield Report encouraging and
presented at Board Meeting
• Interviews for Business Intelligent
recruitment
* In post by Feb
• CCG is looking to establish a long term
partnership in order to improve automated
reporting across the system (still in
progress)
Risks & Issues Seek (Help needed) and Share (Learning
offered)
• The implementation of a Financial Model
by all parties remains a challenge
Patient Recruitment for H1000
Help around capitated model for Urgent
Care
• Approach NHS England about dual
registration
LTC Year of Care Early Implementer Site Update - BHR

www.england.nhs.uk
Report by: Kate Smith Date:as at end Nov
Summary of plans 1516: Progress to date:
Supporting integration and service development:
• Understand how the YoC can help drive service
development and support evaluation of integrated
working
• Information and profiling
• Improve data quality
• Robust costing methodology to feed commissioning
development
• Understand the current resource utilisation profiles
of those with LTCs
• Demonstrate delivery and outcomes of Integrated
Care
Commissioning development:
• Provider development
• Identify models of commissioning that facilitate
delivery of Integrated Care Services to improve
outcomes
Data development
• looking at LTC profiles across federations, costs and
activity within each profile
• presented to clinical lead and being refined to inform
priority areas and further service developments –
cost and activity proportions creating questions of
models
• Local pack structure being developed
• Social care data input - ?Jan
• Working with 7 practices not feeding HHR (on TPP)
• Agreed approach to depression and hypertension
• Considering use of specialist services data,
equipment needs and medicines costs
• Ongoing input into the development of simul8
• Depth interview approach approved and
implementation plan agreed
Risks & Issues: Seek (Help needed) and Share (Learning offered):
• Social Care data integration
• Contracting methodology to support both YoC and
new models of care development
• Resources – capacity and finance
• Local information pack structuring
• Capitated budget structuring
LTC Year of Care Commissioning Early Implementer Site Update – WEST HAMPSHIRE

www.england.nhs.uk
Proactive Health
Coaching
Magnus Liungman and Chris Bound
Health Navigator Ltd

Proactive Health Coaching
Early Implementer Sites (EIS) workshop
18th of January 2016

In the UK, 35% of non-elective admissions are
concentrated in just 1% of the population
20
Example from a UK CCG; non-elective hospital admissions, 2013/2014
Note: Hospital spells between 1 April 2013–31 March 2014. Only non-elective admissions (all emergency admission methods; A&E of provider, A&E of other
provider, bed bureau, GP, outpatient, other, visit by consult, transfer from other provider)
Source: Hospital statistics UK CCG
6.2% of population (21,500 people),
100% of the non-elective admissions (31,070)
1% of the population (3,472 people),
35% of the non-elective admissions (10,950)
53% of the non-elective bed days (100,000)
CONFIDENTIAL
0 300,000250,000
30,000
35,000
350,000100,00050,000 200,000150,000
25,000
20,000
15,000
10,000
5,000
0
Non-elective admissions
Capita

This 1% is highly transient and needs proactive support
21
Example from a UK CCG
19%
29%
52%
2014/15
100%
Some inpatient care but
no longer in top 1% group
Still part of top 1% group
No inpatient care
(or deceased)
2013/14
Patient group
with highest
use of
non-elective
care
(top 1%)
CONFIDENTIAL
Source: Hospital statistics UK CCG

A typical patient in the 1% group “regresses towards the
mean” after a period of high healthcare utilisation
22
Increasing frequency
of A&E attendances
Healthcare cost
per patient
Time
Period of non-elective
activity starts; often
involves repeated
admissions
Integrated care package for
patient in place; healthcare
utilisation stabilises
Patient flagged as high-risk
Secondary prevention
initiatives initiated
CONFIDENTIAL

23
Intervention
cohort
No
intervention
cohort
Proactive Health
Coaching
intervention
Proactive Health Coaching circumvent the period of high
healthcare utilisation
CONFIDENTIAL
Healthcare cost
per patient
Time

Patient case: “Helena” - in programme 133 days
24
Main gaps
Background
Early resultsActions and planning
Person
• Female, Mid 60’s
• Widow (Lost husband 2
years ago)
Medical history
• Syncope (undiagnosed cause despite attending
specialist syncope clinic)
• Sexual abuse (never disclosed before)
Recent care events
(last 12 months)
• 15 A&E attendances
• 10 hospital admissions
• Anxiety and social isolation
• No confirmed diagnosis and lacking
necessary resources
• Lack of knowledge to recognize
syncope episodes in time
• Contacting GP, as referral for
psychology not done
• Finding local organization which
offers more specialist and
appropriate counselling services
• Supporting patient to approach
organization (through motivational
calls)
• 2 A&E attendances (but no
admissions)
• Now recognizing syncope episodes
and has strategies to remove herself
from situations which she finds
stressful
• Recognized the syncope episodes
related to stress and anxiety and not
physiological
• Has disclosed more distressing
history (son in prison for child
abuse) - coach supporting to
disclose these issues to counsellor
Anxiety and social isolation possible triggers for acute care need
CONFIDENTIAL

Patient case: “Peter” - in programme 62 days
25
Main gaps
CONFIDENTIAL
Background
Early resultsActions and planning
Person
• Male, Mid 70’s
• Married, living w wife
• No exercise, does not drink much fluids
Medical history
• Stroke and hypertension
• Cancer of bladder
• Cataract
Recent care events
(last 12 months)
• 9 A&E attendances
• 0 hospital admissions
• No treatment/management plan in
place from GP
• Awaiting consultant appointment
and scan
• Anxious and worries about cancer
returning
• Pain, and lack of knowledge about
symptoms and therefore attends
A&E frequently
• Low confidence and motivation to
follow up with GP
• Arrange GP appointment to review
pain control
• Contact medical secretary to ask for
reduced waiting time for follow up
with consultant after scan
• Discuss symptoms with patient to
identify any gaps in knowledge
• Increase fluids to reduce risk of
urine infection
• Motivation calls to increase
confidence to act proactively
• No further A&E since enrolled in
Proactive Health Coaching
• Reviewed plan and pain control
with GP
• Consultant confirmed no secondary
cancer
• Now talks about his anxieties, and is
able to manage and understand his
physical symptoms better
• Commenced medication to alleviate
symptoms
Now able to manage and understand his physical symptoms better

Patients are satisfied and increase their quality of life with
the intervention
26
”I now get a better
access to my GP and
other clinicians”
”The health coach has
been a constant
throughout my ordeal –
the other health care
contacts has changed
consistently”
”Someone who cares, who follows up, who has the time
to listen, who calls when promised and who you can
contact when you need to”
”Other healthcare services
can’t compete with the
frequency of calls from the
health coach”
”The biggest difference is
having contact with the same
person all of the time – very
valuable”
40%
2%
45%
14%
Negative
Positive
Neutral
Significantly positive
Are you satisfied with the support?
40%
27%
4%
30%
Yes
No
Neutral
Very
How has your quality of life changed?
CONFIDENTIAL

We’ve got positive reactions and support from local GP’s,
community services as well as from York hospital
27CONFIDENTIAL
”Proactive Health Coaching is
making my job much easier”
– Community specialist nurse
”I am pleased finally someone
is looking out for her”
- GP in York
”I hope the service will scale up soon. We
needed you for our mother recently”
- Patient in Health Watch reference group
”This has been needed for a
long time”
- Clinician at York Hospital
”PHC is a great fit with our
strategy to move out care
from the acute hospital to
other proactive services”
- Vale of York CCG
CCG

The intervention leads to fewer non-elective admissions,
reduced LOS, better health and higher quality of life
28CONFIDENTIAL
Source: Kings Funds report; HN research articles
Non-elective
admissions
Other cost
effects
Other effects
Patient reported
outcomes
Reduced non-elective
admission
Fewer ER and follow-
up out-patient visits
Reduced other costs,
e.g. ambulance
Shorter LOS for un-
avoided admissions
Reduced excess cost
due to longer LOS
Category
Better health
outcomes etc
Impact
Higher quality of life
1
2
3
4
Tracked in PHC
Not tracked in PHC
“Some of the outcomes demonstrated
as a result of interventions include
improved quality of life; improvements
in clinical indicators (eg, in cholesterol
levels and blood pressure); better
adherence to treatment; improved
lifestyle; reduced symptoms; asking
more questions during meetings with
health professionals; reduced re-
admissions to hospital; fewer visits to
A&E; and fewer nights spent in
hospital”
Summary from Kings Fund report: “An overview of patient activation” and
results from Proactive Health Coaching
Patientactivation

Results vary among sites but in most cases a 20–40%
reduction in inpatient care utilisation has been achieved
29CONFIDENTIAL
Reduction in inpatient bed-day utilisation in intervention group vs control group (%)
* Results of yes-sayers vs control group in Zelen design regions
Source: Evaluation of full study population 2010–14, all sites
-5%
-10%
-15%
-20%
-25%
-30%
-35%
-40%
Frequent visitors
-0%
-45%
COPDCHF
Östergötland
Västra Götaland
Uppsala
Stockholm
County council RCT design
Zelen
Traditional
Zelen
Traditional
Evaluation
period
2010–14
2012–14
2013–14
2012–14
Sörmland Traditional 2013–14*
*
*
*

A telephone-based case-management intervention reduces healthcare utilization for
frequent emergency department visitors
European Journal of Emergency Medicine, 2013 Oct;20(5):327-34.
• 268 patients followed for up to one year (2010–11) in a single-centre nurse-led
intervention trial to reduce care utilisation for frequent emergency department
visitors
• The intervention indicated that a nurse-led telephone-based intervention
significantly decreased the incidence of hospitalisation, number of bed days and
healthcare costs
Latest results from 12,000 patients published in the
European Journal of Emergency Medicine
A case management intervention targeted to reduce healthcare consumption for
frequent emergency department visitors: results from an adaptive randomized trial
European Journal of Emergency Medicine, 2015
• 12,181 patients identified as frequent emergency department visitors in three
Swedish counties were randomised to intervention or control group and followed for
a minimum of one month and a maximum of two years
• This study indicates a significant overall 12% decrease in hospitalisation incidence for
intervention patients compared to controls. The results improved over time as the
intervention was continuously evaluated and improved.
30CONFIDENTIAL

PHC is already implemented in Vale of York and will now be
implemented in three new CCGs during the spring
Three new CGGs will be implemented March 2016
• Vale of York implemented spring 2015
• Wolverhampton CCG, Cannock Chase CCG and South East Staff
CCG will be implemented spring 2016
• One more slot for spring/summer 2016
31CONFIDENTIAL
Evaluation
• Nuffield Trust evaluates the Randomised Control Trial
• The intervention is adopted on the NIHR CRN portfolio which means
that participating trusts will benefit from conducting the research
• Martin Bardsley, Director of research at Nuffield Trust is Chief
Investigator
Other aspects
• Visit from NHS England in York during the autumn 2015
• Case study of PHC in York is distributed to Vanguard CCGs from
NHS England

Contact information
Magnus Liungman
Managing Director
07736 160993
magnus.liungman@healthnavigator.se
32CONFIDENTIAL

www.england.nhs.uk
National context:
Emerging themes from the
Mental Health Taskforce
Kevin Mullins
Head of Mental Health
18th January 2015

www.england.nhs.uk
NHS Five Year Forward View
“Over the next five years the NHS must
drive towards an equal response to
mental and physical health, and towards
the two being treated together...we have
a much wider ambition to achieve
genuine parity of esteem between
physical and mental health by 2020.”

www.england.nhs.uk
The Taskforce is creating a 5 year cross-system all
ages strategy for mental health
Scope • Strategy developed by setting priority outcomes (across life course), supported by
measurable objectives, with annual delivery milestones for each ALB contribution
• 20k online survey participants, content workshops, 100+ written responses to
evidence call-out, on-going expert input from National Clinical Directors and Taskforce
Economic
aspects
Economic work in preparation, focusing on establishing spend and cost baseline for
reform opportunities over 5 years.
• Utilising current spend on MH services more effectively
• Integrated care models primary/secondary/specialised, including access &
waiting time standards
• Wider economic impact of mental health / ill-health on the public purse
Activity • Established framework to co-produce measurable objectives & year-on-year ALB
milestones
• Priority themes set (prevention, access, integrated treatment/care, empowerment)
working in partnership with ALBs signatory to Five Year Forward View
• Coordinating the content provided by Taskforce membership and experts
• Priority outcomes established
• Publication of recommendations and response early 2016 (No 10 Announcements on
Perinatal, Liaison etc)

www.england.nhs.uk
What the Taskforce heard, in summary
People want our society to become a place where there is no stigma in
talking about mental health problems and people are confident in seeking
help when they need it.
• People want mental health problems to be prevented and for intervention to be
as early as possible
• People want to quickly access effective evidence-based care and treatment,
when they need it
• People want integrated treatment and care, with their physical and mental health
responded to
• People want to be treated compassionately with hope, dignity and respect
Resulting in three clear strategic themes:
• Prevention - “I know how to achieve good mental health”
• Access - “I can get the right help when I need it, and my physical and
mental health are valued equally”
• Empowerment - “I am treated with hope, dignity and respect”
37

www.england.nhs.uk
Approach of the Taskforce
• Transformation is achievable, urgent and necessary
• Prevention focusing on children & young people, employment and
older people
• Access through waiting times, pricing and payment, secure transition
to grow community based support
• Integration of physical and mental health (plus social care) e.g.
diabetes and other long term conditions
Underpinned by:
• Skills of workforce for compassion, dignity and respect
• Empowerment of people to look after their mental health in their own
communities
38

www.england.nhs.uk
Findings of economic analysis
Annual spend on mental health is currently ~£34bn p.a., of which ~£19bn is via HMG
• Spend includes ~£15bn of non-HMG activity, primarily driven by carers looking after friends and
family
• National spend on treating dementia, learning disabilities and substance abuse add an additional
~£50bn to this
~67% of spend has little or no national cost data available, significantly limiting ability to
analyse overall cost base
Where data exists, significant variation in spend across services, providers and geographies
• Spend per capita across CCGs varies more than 5x fold, reducing to 1.8x fold after taking into
account underlying need
• Spend per unit across providers of the same service can vary 3 - 4x, with variation in some
services more than 10x fold
Linking spend to activity and outcomes highlights exciting opportunities to improve
effectiveness
• Data shows some CCGs are much more effective than others in their ability to convert money
spent into positive outcomes
• Ongoing publication of cost and activity data is a powerful lever to improve effectiveness, and
closing variation in outcomes
39

www.england.nhs.uk
Three economic deep dives
• Prevention approach illustrated by focus on employment support
• 1m people with mental health problems are unemployed, only 8% will be in work after
accessing current Work Programme support
• Suggested opportunity for specific evidence-based interventions integrating employment
and clinical support to improve outcomes
• Whole person care approach illustrated by focus on type 2 diabetes
• £8.8bn p.a. treating Type 2 diabetes, forecasted rise to £12bn by 2030. £8bn-13bn on
long term conditions linked to poor mental health
• Mental health treatment generic and isolated from diabetes pathway, with presence of
poor mental health appearing to drive 50% cost increase - suggested potential reduction
if specialist psychological support in place
• Suggested opportunities to improve outcomes through integrated physical and mental
healthcare for long term conditions
• Access approach illustrated by focus on secure care pathway
• £1.2bn p.a. spend on secure inpatient (low, medium, high adult) with 90% low secure
inpatient stays longer than 5 years in total care. Difficulties finding step-down placement
resulting in 6-9 months delay in discharge
• Suggested opportunities by shifting emphasis to prevention, focusing on high-risk and
over-represented groups e.g. BME men of working age and growing community-based
support to avoid inappropriate admission and support effective discharge
NB Assumptions need further testing against clinical best practice
40

www.england.nhs.uk
• We are committed to:
• Reduction in unaccountable wholly block payment models
• Increasing incentives that reward improving outcomes, quality and
access for individuals and across the system
• Getting rid of incentives that reward poor outcomes
• Driving efficiency and increasing public value
• To deliver this we are:
• Exploring how to deliver an effective outcomes focussed payment system
with data we have now to deliver rapid change
• While making it flexible and responsive to new care models and data coming
online
• Including aligning with 5 year forward view models of care and ensuring work
to develop payment models that cross primary and secondary care
• Supporting data improvement that reflects best practice
• With effective clinician and service user drive in the use of outcomes
• We are working towards launching mental health payment guidance by the
end of the year to support Taskforce recommendations
Payment systems for all mental health across
the life course need to support this journey
41

www.england.nhs.uk
Strategic Context
Increased Transparency:
• “…the continued use of unaccountable, ill-defined, block contracts by mental
health commissioners is detrimental to patient access to mental health
services” IMHSA Policy Paper
Move towards commissioning based on quality and patient outcomes
rather than historical service provision.
• “payment mechanisms that enable person-centred approaches to care and
parity between physical and mental health. Payment agreements for mental
health services are to be transparent, consider the needs of patients and
ensure accountability”.
Enhancing Quality through Allocative Efficiency
• Using the payment system to incentivise adoption of practice that promotes
sustained recovery, in the most appropriate setting

www.england.nhs.uk
Monitor / NHS England’s Objectives for
Commissioners
43
By April 2015 all contracts to be underpinned by an
understanding of need, evidence-based responses to need and
expected outcomes
By April 2016 all contracts to include clear incentives for the
delivery of outcomes, outcome and quality driven payment
models will have been introduced in a limited number of areas
AND have robust data on cost, activity, quality and outcomes
By April 2017 a wholesale shift to outcome-focused contracting

www.england.nhs.uk
IAPT Payment
Approach
Developing an Outcomes-
based currency for IAPT
Robert Finnin | Project Manager
Mental Health Clinical Policy & Strategy Unit, NHS England
robert.finnin@nhs.net | 07584 27 55 44 14th January 2016

www.england.nhs.uk
• Rewards good outcomes rather than just activity
• Is fair (MONITOR criteria):
• To Patients;
• To Providers;
• To Commissioners;
• To Tax Payers
• Minimises perverse incentives and opportunities for
gaming
• Is efficient and stable
• Incentivises innovation, efficiency and improvement
• Enables Parity with Physical Health Services
IAPT “PbR” Currency Objectives

www.england.nhs.uk
Cluster 1
£x
Cluster 2
£y
Cluster 3
£z
IAPT Currency Payment Approach
• Guiding Principle:
• Value of Payment = Cluster Tariff x %’age Outcomes Achieved
• Price per Cluster: Recognition that Complexity of Need drives cost
Cluster 4
£p

www.england.nhs.uk 47
High / Low Intensity Treatment Split
per Cluster

www.england.nhs.uk 48
MH Cluster Based Costs
Cluster weighted average cost £619.94

www.england.nhs.uk
Cluster 1
£x
Cluster 2
£y
Cluster 3
£z
Cluster 4
£p
IAPT Currency Payment Approach
49
Quality &
Outcomes
Premium
Assessment
Price
Cluster-Based
Activity
Payment Quality &
Outcomes
Premium
Assessment
Price
Cluster-Based
Activity
Payment Quality &
Outcomes
Premium
Assessment
Price
Cluster-Based
Activity
Payment Quality &
Outcomes
Premium
Assessment
Price
Cluster-Based
Activity
Payment
Outcomes measures
• Guiding Principle:
• Value of Payment = Cluster Tariff x %’age Outcomes Achieved
• Price per Cluster: Recognition that Complexity of Need drives cost
• Three core Domains critical to operation of payment approach:
• Assessment; Cluster-based Activity Element; Quality & Outcomes

www.england.nhs.uk
Tailoring Weighting of Outcomes
Domains to meet local needs
10 Outcomes incentivised and a percentage of the price paid
for meeting targets

www.england.nhs.uk
Overview of Currency Model –
IAPT PbR Payment System
Activity:
Appointments in Month
IAPT PbR Tool:
Calculate Payments
Prices & Targets (annually set):
 Assessment Only Price
 Sub-caseness Price
 Cluster Based Treatment Prices
 Access & Outcomes Targets
 Balance Between Targets
Submitted IAPT MDS
Monthly Payment Calculation:
Each Commissioner to each Provider
Quarterly Reconciliation Payment:
Business Rules:
Cap or Collar
History File:
Appointments where episode has not
finished
Appointments from previous months,
where episode has not finished
Annual Activity & Finance Plans:
 Annual Activity (Monthly Plan)
 Finance Envelope (Monthly Plan)
 Quality & Outcomes Premium
Activity:
Appointments in Month
IAPT PbR Tool:
Calculate Payments
Prices & Targets (annually set):
 Assessment Only Price
 Sub-caseness Price
 Cluster Based Treatment Prices
 Access & Outcomes Targets
 Balance Between Targets
Submitted IAPT MDS
Monthly Payment Calculation:
Quarterly Reconciliation Payment:
Business Rules:
Cap or Collar, etc
History File:
Appointments where episode has not
finished
Appointments from previous months,
where episode has not finished
Annual Activity & Finance Plans:
 Annual Activity (Monthly Plan)
 Finance Envelope (Monthly Plan)
 Quality & Outcomes Premium

www.england.nhs.uk
• “Where there are
commissioners struggling to
secure or efficiently utilise
capacity we should support
them piloting the currency
model in order to stimulate
better provision (coupled with
choice)”
• IAPT as Local Payment
Example
• Published in conjunction with
Monitor
IAPT Local Payment Example
https://www.gov.uk/government/publications/supporting-innovation-
in-the-nhs-with-local-payment-arrangements

www.england.nhs.uk
• 2014/15 – IAPT PbR Extended Pilot
• Publication of LPE
• Currency Calculator Developed
• 2015/16 - IAPT Currency Market Assessments
• Provider performance will be assessed against currency
model by central team;
• Infrastructure developed to support a national
implementation
• Develop local prices, business rules and guidance
• Commissioners to develop clear understanding of
local need informed by robust provider clustering.
• 2016/17 - IAPT Currency Road Test
• Shadow Implementation of Currency
• 2017/18 - IAPT Mandatory currency with local prices
• Contractual implementation of IAPT Currency Model
IAPT Currency Timeline

www.england.nhs.uk
Questions /
Discussion

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New payment
systems to support
new models of care
David Cryer
NHSE pricing team

www.england.nhs.uk
Whole
population
budgets:
David Cryer
18 January 2016
GOV.UK/monitor

Moving towards whole-population budgets
Evidence suggests capitation may be an effective payment approach for helping to implement
new care models and the 5YFV vision.
Monitor and NHS England recognise that capitation departs significantly from existing
payment approaches and we need to support transition.
A whole-population budget is the proposed solution for vanguard sites that have not yet
developed a locally determined capitation approach, or for any site that may choose to follow
in the near future.
WPB is a multi-year payment for the total population covering all in-scope services based on
current spend or cost. Current costs or spend are only the starting point: they will be
adjusted for factors such as the target pattern of care and efficiency to avoid locking in
current costs.
WPB seeks to apportion risk appropriately between the provider and the commissioner,
based on available data.
Our expectation is that all multispecialty community providers (MCPs) and primary acute care
systems (PACS) vanguard sites will develop a whole-population budget spanning several
years for implementation in April 2017, unless they are already developing a locally
determined capitation approach.

Choosing the population scope: why whole
population?
We recommend that local areas that have not started developing a new
payment method focus on a whole-population approach.
The population is large enough to mitigate the risks caused by random variations
(ie payment otherwise at risk of being too high/low purely based on external factors)
Larger £ amount, minimise risk transfer to the provider (all other things being equal).
This can be mitigated with gain/loss sharing
Can more easily use the current contract values as a starting point to calculate the
baseline payment (otherwise difficult to accurately identify the cost of a specific cohort)
Greater incentive for prevention
(otherwise limited to patients already in the selected cohort)
Easier to operate (easier for a provider to identify whether a patient is covered by the whole
population budget or not, and invoice accordingly)
Wholepopulation

7 steps to a whole population payment approach
Enablers
(including leadership; governance; linked data)
59
Steps to
developing
a capitated
payment
approach
Define the
population scope
covered by the
payment approach
Define the service
scope covered by
the payment
approach
Determine the
contractual form
and duration
Determine
the payment
amount(s)
Determine the
provider-to-provider
payment approach
Determine gain and
loss sharing
arrangements
Agree quality and
outcome measures
linked to payment
1
2
3
4
5
6
7

Creating a
whole
population
budget
GOV.UK/monitor

Transition to whole population budget
• As well as the above arrangements, you will need a transition approach for gain and loss
sharing and performance and outcome measures
• These arrangements could be put in place during the shadow-testing period, and then sit
alongside the WPB (or locally determined capitation) when the latter is implemented
• Areas could follow a three-stage approach:
• Note: the three areas do not have to progress at the same speed and not all areas will need
to progress to stage 3 with gain and loss sharing.
Three areas Stage 1 Stage 2 Stage 3
Gain and loss sharing:
example
One-sided shared
savings for limited
scope of services
Expand: for example,
two-sided risk share for
broader range of
services
Full accountability for all gains and
losses, or could be used for services
outside the scope of base payment
(eg acute for MCPs)
Performance and
outcomes:
example
Determine baselines
Payment for data
gathering and
reporting
Locally determined
Initial amount rewarding
outcome improvement
Move to a national approach
Target full amount on outcomes
2016/17 2020+
61

Proposed methodology: overview (1)
• The projected payment needs to ensure the commissioner carries the demographic and
epidemiological risk while the provider carries the remaining risks (eg efficiency)
• Monitor and NHS England are designing an approach to calculating a whole-population
budget, structured around three elements:
1. Establishing a baseline
2. Forecasting forward
i. Inflation
ii. Efficiency
iii. Pattern of care (new care model)
iv. Population size
v. Care needs
3. Adjusting based on outturn relative to forecast
To forecast forward population size and
care needs, and to adjust based on outturn
of these two factors, it may be helpful to:
1) Use the growth in allocations
published recently in the 5 year
allocations
2) Use the published changes in
primary care allocations to forecast
the primary care component of your
whole population budget

Proposed methodology: overview (2)
Following this method, a whole-population budget should:
• use current commissioner spend as a starting point for the calculation
• consider the changes in patterns of care expected from the new care
model
• be benchmarked to incentivise efficiency
We will test examples of such an approach with interested sites from January, to
enable sites to start shadow-testing in April 2016
We are keen to work with you.

Step 1: Establish baseline
Monitor and NHS England consider that ‘commissioner spend’ should be the starting
point for the calculations. This could include:
• Monitor and NHS England providing CCGs and trusts with projected 2015/16
baseline acute activity using a standardised SUS script and a forecasting tool as
a basis for forecasting for 2016/17 to 2020/21, starting with ‘a single version of
the truth’
• NHS England providing MCPs and PACS with the 2015/16 baseline and
forecasting tool for acute activity for their GP-registered populations, based on
the same data and method as CCGs
– This is likely to be relevant as an input to setting MCP/PACS baselines
because the baseline and forecasting tool is built up from GP-registered list
populations

Step 2: Forecast forward
• The multi-year approach means the baseline payment needs to be forecast forward
over the life of the contract
• CCGs and vanguards with good data and analytical support may be able to forecast
on a population segment basis, to reflect the variable changes in cost associated with
different population groups. Alternatively they could use the changes to the CCG and
primary care allocations that have recently been published that are themselves based
on appropriate capitation formulae
Step 3: Adjust when needed
• Payment should then only be adjusted if change is outside agreed
boundaries:
o segment-specific boundaries, eg if the number of people over 75 grows
by more than X%
o global boundaries, eg if the total impact of all changes would affect
payments by more than X%
• Changes may need to be made to the service scope, utilisation risk share
agreement and the outcome payments during the duration of the contract

Whole-population budget:
Shadow testing

What’s involved?
67
Shadow testing can begin with desk-based financial modelling. It should then
progress almost to full running of the new payment approach (except for actual
payment of providers under the new payment approach)
67
SHADOW TESTING
Day-to-day operations the
same, dummy invoice
calculation reflects the new
payment approach
Day-to-day operations
reflect the new model,
dummy invoice calculation
reflects the new payment
approach, actual invoice
reflects old payment
approach
May begin
as a
backward-
looking
analytical
exercise
Full
simulation
of end-to-
end
processes
of new
approach

Activities required for shadow testing
68

www.england.nhs.uk
A methodology to
develop a year of care
capitated budget
Intro and national thinking (YoC Commissioning):
Jamie Day
Followed by sharing of approach by each EIS

www.england.nhs.uk
Select
patients for
referral
Assessment
of patient
need
MDT –
develop and
share care
plan
Deliver
services to
patients
Assign to
patient
cohort
Patient
dies or
leaves area
Change to
patient
cohort
Review
contract
and
budget
Set
contract
and
budget
Perform
and
quality
Payment
Patient pathway
Payment
cycle
Generalised patient pathway and the
payment cycle for complex care patients

www.england.nhs.uk
LtC Year of care
capitated budget
Discussion...
What’s in, what’s out,
what’s next...

www.england.nhs.uk
Developing an LTC YoC capitated budget...

www.england.nhs.uk
EIS updates on approach to
develop LTC YoC capiated
budget and progress towards
implementation
• Southend
• Kent
• West Hants
• Leeds
• BHR

www.england.nhs.uk
Summary of the day
and key messages
Bev Matthews

www.england.nhs.uk
18th January 2016
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