2. If every organisation (provider and commissioner) improved its 10 steps that NHS commissioners can follow to realise Better
performance to match that of the top quartile in each Better Care, Better Value benefits:
Care, Better Value (BCBV) indicator, NHS England could realise 1 - Understand the benefits highlighted by the Better Care, Better Value indicators
2 - Identify your own Better Care, Better Value enthusiasts
£2.4 billion in productivity benefits
3 - Use the indicators to understand the size of the opportunity for your organisational
Introduction This guide will show you how to continue to deliver
high quality care within the challenges of the current
health system
The Better Care, Better Value (BCBV) indicators
economic environment. Commissioning and provider 4 - Connect with your providers
reveal the potential to make significant cash organisations have the opportunity to look at new ways
or resource savings whilst improving quality. 5 - Understand what your high performing peers do
in which all parts of the local health system benefit from
However, the key issue is what has to be the redesign of services, so that they provide best value 6 - Decide which areas to improve
done to actually realise the benefits. For this for money. Specifically, the BCBV indicators provide a 7 - Get board engagement and commitment
reason we are introducing the ‘Converting the starting point for your organisation to:
8 - Create an ambition for change and success
potential into reality’ guides - one is aimed • see how you are performing relative to your peers
9 - Use commissioning levers to facilitate improvement
at NHS commissioners and the other is for • determine individual high and low performing areas
10 - Realise the benefits - release the cash or re-invest in the service
provider organisations. This guide contains ten • prioritise areas of work to make improvements
steps that commissioners can take to use the • monitor your improvement on a quarterly basis.
BCBV indicators to maximum effect to improve Each BCBV indicator has an associated ’productivity NHS Institute for Innovation and Improvement tools and support are available to help you
quality and increase productivity. opportunity’ which is an estimate in monetary terms of with each of the ten steps and can be accessed on www.institute.nhs.uk
As a commissioner, this guide will show you: what an organisation could realise if its performance
matched that of the upper quartile in NHS England.
• how the 10 steps can relate to the World Class
The BCBV indicators in this guide focus on providers of
Commissioning competencies, and which
acute care and prescribing in community care. In the
commissioners can use to provide evidence as part
future, we are planning to extend the BCBV indicators to
of the assurance framework. Look for WCC logo on
incorporate mental health, community and primary care
each page where competencies relating to that step
services.
are identified. A full list of competencies can be found
in Annex 5 on page 32
• where the BCBV indicators align themselves to the
quality and productivity challenge (quality, innovation,
productivity and prevention)
• what the current experience is from commissioners
on quality and cost, as outlined in the example that
accompanies each step.
2 3
3. 1. Access the BCBV indicators quarterly via the NHS
1 - Understand the benefits highlighted by the Better Care, Institute web site www.productivity.nhs.uk
Better Value indicators 2. Read your own reports and consider the following:
• the performance value shows the organisation level
The table shows 12 Better Care, Better Value indicators. Six are aimed at providers and six at
performance for each indicator. Using the NHS Indicator
commissioners. These highlight the potential benefits for each in the form of a ’productivity opportunity’.
Explorer you can see how this value has changed over
BCBV indicator description Primary target Potential benefits for provider and commissioner the quarters and, also, view the indicator performance
Reduce Improve Reduce Release Reduce Productivity* at either specialty/procedure or diagnosis level
costs patient Health capacity cancelled Opportunity • the national position identifies where you sit when
experience Care operations range for
ranked against all NHS organisations included in the
Associated individual
Infections organisations indicator. The SHA report data shows where you sit
(HCAIs) against the organisations in your area
Reducing length of stay Provider £2,000,000 - • the NHS Indicator Explorer enables you to compare
£21,000,000 against a set of pre-defined peers or you can create
Increasing day case surgery rates Provider £20,000 - your own groups of 3-5 peers
£700,000
• the BCBV indicators should be used to stimulate
Reducing pre-operative stay Provider £10,000 -
(elective) £5,000,000 the improvement discussion and to help identify
Reducing Did Not Attend (DNA) Provider £150,000 - areas where potential performance efficiencies could
appointments £4,000,000 be made. The ranking can be used to identify ‘best
Reducing new to follow-up Provider £350,000 - performers’ who may have evolved practices that can
appointments ratio £3,500,000 be shared.
Reducing emergency Provider £150,000 -
re-admissions at 14 days A&E £2,500,000 3. The five annexes to this document provide related
Managing variation in Commissioner £150,000 - information:
surgical thresholds £2,500,000 Annex 1 – Facts about the BCBV data
Managing variation in Commissioner £1,000,000 - Annex 2 – How to access and use BCBV indicators
emergency admissions A&E £10,000,000 Annex 3 – How to access and use the NHS Indicator Explorer
Managing variation in Commissioner £150,000 - Annex 4 – Information about the Opportunity Locator
outpatient attendances £4,000,000 Annex 5 – World Class Commissioning Competencies
Increasing low cost prescribing Commissioner £0 - £2,000,000
for lipid modification
Increasing low cost proton pump Commissioner £0 - £650,000
inhibitor prescribing
Increasing low cost prescribing Commissioner £0 - £650,000
for drugs affecting the
renin-angiotensin system
* the Productivity Opportunity gives a monetary estimate of potential savings achievable if a health system improved that indicator performance by
achieving top quartile performance. The figures show the range of potential savings obtainable for that indicator. Note that managing variations in
emergency admissions and outpatient attendances are potential shifts in spending into primary care (rather than savings).
4 5
4. 2 - Identify your own Better Care, Better Value enthusiasts 2 - Example
To make changes to realise the benefits highlighted by the Better Care, Better Value indicators NHS Halton and St Helens
initially, you need to mobilise and proactively support a team of enthusiasts. BCBV focus: innovation strategy, energise staff
Practical steps you can take now • Use this in-depth knowledge to address any data • The PCT identified roles in innovation and expert
• Identify potential enthusiasts to fill four key roles: quality issues head on. Until these are addressed, leaders to take forward programmes of activity related
data analyst - a technical expert who will: it can be difficult to move on. to the BCBV indicators.
– know what is being measured and how - • Show data using simple graphs and bar charts. • The team aligned the BCBV indicators with their
refer to annex 1,2, 3 & 4 • Add local data to provide context to the potential commissioning and strategic plan, with focused
– understand underlying assumptions identified in BCBV indicators. activity on their biggest gains:
– appreciate how this influences commissioning managing variation in accident and emergency
– understand data limitations and issues about increasing day case surgery
The NHS Institute tools and resources available to
data quality reducing DNAs
help you include:
clinical leads - who will present the data and lead outpatients.
the change through the Professional Executive • Patient and Public Engagement Toolkit for
World Class Commissioning - although not • They have executive sign-up, support from the
Committee (PEC) and practice-based commissioners
an institute tool, this provides support to performance team and dashboard reporting.
executive lead - who will be a visible and proactive
commissioners and provides information and • They have an innovation enabling strategy which
sponsor
practice-based commissioning lead - who will methods of engagement includes:
encourage leadership within practice-based www.institute.nhs.uk/engagementtoolkit interventions to mobilise, energise and engage staff
commissioning groups to consider alternative • The ebd approach guide and tools - improving the patient experience as a way of
provision of services within the community. the experience based design approach helps to getting into the detail of making transformational
design healthcare services based on patients and change happen.
• Avoid compartmentalising. Encourage as many of your
staff as possible to feel comfortable performing these staff experience www.institute.nhs.uk/ebd
roles and, also, develop similar enthusiasts within your • The Power of One, the Power of Many -
providers. bringing social movement thinking to health
• Identify and understand your audience, and tailor your and healthcare improvement
delivery accordingly. www.institute.nhs.uk/powerofone
• Identify and support any development your experts
need to fulfil their role.
• Ensure your enthusiasts do their homework! As a
minimum they need to understand how the indicators Adding life to years and years to life
are constructed and the assumptions used in their Competencies 4c and 5a
construction.
- refer to annex 5
6 7
5. 3 - Use the indicators to understand the size of the opportunity 3 - Example
for your organisation or health system NHS Hillingdon
The NHS indicators ‘scorecard’ for each organisation in your local health system shows the national BCBV focus: care closer to home
position, any changes from the last period (rebased yearly) and the productivity opportunity. NHS Hillingdon looked at both its BCBV indicators
productivity profile and the NHS Institute’s Opportunity
A large productivity opportunity and/or a poor national
Locator to identify:
position points to an ‘outlier’ and should be investigated The NHS Institute tools and resources available to
further. Clicking on the indicator link in the scorecard help you include: • a potential productivity opportunity of £10million a
(in the online version of this document) takes you to year achieved by reducing emergency admissions,
• The Opportunity Locator - a tool to
the SHA or foundation trust report for that indicator. outpatient first attendances and follow-up
support the commissioning priorities of
This contains key steps for further analysis and suggests appointments
local health communities, refer to annex 4
improvement actions, too. It shows how you relate to www.institute.nhs.uk/opportunitylocator • how potential productivity spend could be reinvested
others and also where you might learn from others. in primary care services that would bring greater
• BCBV methodology - explains how indicators are
quality and cost benefits
Practical steps you can take now constructed www.productivity.nhs.uk/definitions.aspx
• jointly planned services with social care, management
• Use the Indicator Explorer to create a peer group and • The Indicator Explorer tool - which enables
of long term conditions and polyclinics.
drill down below PCT level to investigate at condition analysis of some data down to specialism level
/speciality level for where your potential really is - refer www.institute.nhs.uk/explorer Application of the priority selector:
to annex 3 for help on how to use Indicator Explorer. • The Good Indicators Guide - a guide to help you
• Check that the data ascribed to your organisation to understand how to choose and use indicators
matches what your local data systems are telling you. www.institute.nhs.uk/goodindicatorguide
Match it, too, against local opinions about the service • How to engage staff in thinking differently
or services covered and also the Opportunity Locator, shifting care closer to home - a range of tools
if appropriate. and techniques on thinking differently to help
• Use the charts as displayed within the Indicator when implementing ‘care closer to home’ projects
Explorer or use the ‘export data’ button to download www.institute.nhs.uk/engagestaff
the data and create your own. Keep any charts simple.
• When preparing a presentation based on Better Care,
Better Value indicators, tell a story with the data.
So, be selective in your use of tables and charts. Adding life to years and years to life
Focus on the areas with the highest potential.
• Find the common ground between BCBV and locally
Competencies 5a & 8a - refer to annex 5
perceived problems.
8 9
6. 4 - Connect with your providers 4 - Example
Improving organisations’ performance against the Better Care, Better Value indicators Central Manchester
requires you to work with your providers to realise the benefits.
University Hospitals NHS Foundation
Practical steps you can take now
• Talk to your providers - where are the opportunities
The NHS Institute tools and resources available to
help you include:
Trust and NHS Manchester
for realising greater benefits if you were to work BCBV focus: referral ratios, partnership working, patient and staff benefits
• Converting the Potential into Reality: 10 steps
together?
a provider can take to realise the benefits of The trust carried out exploratory and investigative work The development of consultant
• Understand what actions your provider is taking Better Care, Better Value - 10 steps a provider to understand the clinical system by: to consultant gateways which offers
forward with the BCBV indicators. can take in order to use the BCBV indicators to alternatives to secondary care treatment
• analysing historical data which showed that for
• Use the Opportunity Locator to identify areas for maximum effect to help improve quality and every ten patients referred into the hospital for enabled:
greater gains by ‘moving care closer to home’ - increase productivity www.institute.nhs.uk/pctportal treatment only three went on to have further • the trust to work with NHS Manchester with
refer to annex 4. or www.productivity.nhs.uk treatment. By understanding the details of referrals, whom they are currently piloting a gateway system
• Work in partnership with your provider to develop • Commissioning Patient Pathways Guide - the clinical staff were able to triage referral into which offers the opportunity for patients to be treated
patient services in the community as part of delivering supports commissioning managers by creating sub-specialisation clinics earlier, avoiding possible in primary care
care closer to home. a structured approach to exploring the activities duplication and, so, improve the patient experience • a pilot study to be carried out that involved the use of
• Identify where high impact improvements could be required to commission planned care pathways • examining new to follow-up referral ratios at a GP triage system before any consultant to consultant
made and agree how to make them. Engage with www.institute.nhs.uk/commissioning consultant level and then developing specialty referral is made
your providers in the prioritisation process. • Project Delivery for Commissioners - a guide protocols • a pilot study to be conducted in adult surgical and
• Understand who will take the benefits and have a which covers the whole project management • encouraging clinical teams working with GPs with medical specialties with a-imminent wider rollout
straight forward conversation with your providers process from creation of the project team right specialist interests and nurse practitioners to develop planned
about it so that expectations are clear. It may be through to implementing the new pathway referral/triage systems. • a strict criteria so that patients will automatically go
that reductions on length of stay or pre-operative www.institute.nhs.uk/commissioning
By developing clinical assessment protocol for referrals it through the consultant gateway, for example if they
assessment may benefit the health system rather than have cardiac history.
meant that:
the provider organisation.
• the development of Tier 2 and CATS services
• Discuss including measures based on the BCBV
Adding life to years and years to life streamlined the patient pathway and increased the
indicators within contracting arrangements.
quality of referral to secondary care. This was evident
• In your meetings with providers, ensure that you Competencies 2b, 7b, 10b and 10c in the increased patient conversion rate from 30% to
are able to articulate performance differences in a - refer to annex 5 40% with no lowering of thresholds
way that encourages understanding and action (for
• quality improvements in referrals allowed secondary
example, at consultant and general practitioner level
care resources to be adapted accordingly and offered
rather than at service level).
greater scope to meet 18 week targets
• Use the BCBV indicators as part of your material for
• the patient experience improved as the patient
market stimulation events with current and potential
receives the right assessment at the right time, and is
providers.
put on the right care pathway.
10 11
7. 5 - Understand what your high performing peers do 5 - Example
The example of upper quartile performing organisations demonstrate the potential improvements Peer assessment of performance
in efficiency that can be achieved using the Better Care, Better Value indicators. These are BCBV focus: comparing to, and learning from, the best
summarised in the NHS indicator downloads.
“Better Care, Better Value indicators methodology provides
Practical steps you can take now systematic data that enables improvement leaders to
• Compare your performance against one of the The NHS Institute tools and resources available to ask rational questions about their own organisational
standard peer groups already defined - refer to help you include: performance, benchmarked against their peers. This
Annex 3. • NHS Institute networks - access via leads to further insight gathering, which in turn leads to
• Create a peer group in the NHS Indicator Explorer www.institute.nhs.uk/share and network opportunities to learn and diffuse knowledge into local
to benchmark your organisation against your choice • the PCT Portal - the PCT portal is a resource for systems. To me, this is a clear example of how we can turn
of peers. commissioners, accessible via the NHS Institute data into improvement.” Denis Gizzi, Director of Reform
website, it has recently been enhanced by the and Innovation, NHS Oldham
• Download the peer group time series charts into Excel
to identify which of your peers are doing really well. introduction of river diagrams, which enable PCTs An example of comparing your PCT with others in
to identify examples of good practice or other the region:
• Talk to those organisations that are performing well
sources of support and information relating to the
and understand what they are doing and how they
world class commissioning competences access via
got there.
www.institute.nhs.uk/pctportal
• Pull out the things that could work in your local health
• see also NHS Comparators - although not
economy and incorporate them into your operational
an NHS Institute tool it provides comparative
plan and improvement projects.
data about inpatient and outpatient activity
• Use other data sources to benchmark performance www.nhscomparators.nhs.uk/nhscomparators
against the NHS Institute for Innovation and
• BCBV and methodology - explains how
Improvement High Volume Care Pathways eg the
indicators are constructed
NHS Comparators.
www.productivity.nhs.uk/Definitions.aspx
• the Indicator Explorer tool - which enables
analysis of some data down to specialism level
www.institute.nhs.uk/explorer
The above example means that that you can establish
baselines so that you can:
Adding life to years and years to life • monitor your own performance over time
• have a common understanding of current performance
Competencies 5a & 8a
with your provider
- refer to annex 5
• measure any improvements
• demonstrate value for money.
12 13
8. 6 - Decide which areas to improve 6 - Example
Aim to focus your improvement efforts on achieving the greatest gains for your local health system. NHS South Gloucestershire
Practical steps you can take now describe a SMART (specific, measurable, agreed, BCBV focus: demand management, prioritisation
• Sources of data: realistic, timely) goal against each benefit so that of services, best value for money
you can measure improvement • The PCT developed a collaborative partnership
understand where your high spend areas are by
ensure each improvement project is covered by with representatives from acute providers, general
using the BCBV indicator information
contract management and monitoring throughout practitioners, general managers and clinical leads.
prioritise BCBV into high spend, risk, patient
your local health system. • The collaborative partnership has ten work
benefit, low value adding procedures, quality of
services, and consider ease of implementation streams and has agreed criteria for referrals and
use other sources of information (for example The NHS Institute tools and resources available to intervention rates.
the Opportunity Locator, NHS Comparators, local help you include: • They used the NHS Productivity procedures that
data and patient satisfaction) to get a rounded view • Prioritising Commissioning Opportunities - identified low value procedures for example; lumbar
of problems provides a simple but robust planning process to spine, hernia and tonsillectomies.
develop a marginal analysis approach to plan where help PCTs make decisions quickly and effectively • To reduce low value procedures they have developed
BCBV areas of activity could either be: www.institute.nhs.uk/commissioning an approval method:
– further invested (eg shift of care into • Focus On series for high volume care pathways prior approval required while access criteria is
primary or community services by using the - a set of 16 documents supporting health developed
Opportunity Locator) communities and organisations to improve the consultant gains consent for treatment using
– disinvested (eg ratio of new to follow-up ratios) quality of care and value for money by focusing patient decision-making aids to discuss the risks
– decommissioned services with low value improvement efforts on high volume HRGs and benefits of the operation.
threshold (eg non-value surgical interventions). www.institute.nhs.uk/qualityandvalue
• Clinical involvement, prioritisation and planning: • 10 High Impact Changes for Service
ensure that the resources, time and improvement Improvement and Delivery - contains the
skills to make changes in priority areas are in place changes that organisations in health and social
engage clinicians before recommending care can adopt to make significant, measurable
any changes improvements in the way they deliver care
develop a continuous improvement approach www.institute.nhs.uk/10highimpactchanges
identify each benefit as an improvement that • Service improvement library - searchable library
can be measured (reduction in time, reduction of 80+ quality and service improvement tools from
in number of patients being treated or numbers the NHS Institute www.institute.nhs.uk/qualitytools
of patients being treated against agreed clinical
criteria)
develop milestone trigger points to identify if the
goals are on or off track
Adding life to years and years to life
Competencies 4b and 4c
- refer to annex 5
14 15
9. 7 - Create an ambition for change and success 7 - Example
As the key commissioner of services, take the lead in promoting changes based on BCBV indicators. NHS Oldham
Use BCBV enthusiasts to present to a wide range of clinical and managerial leaders, focusing on BCBV focus: governance framework, clinical
areas where there are high productivity opportunities or low value adding procedures. variation, partnership working
Your health system can succeed and realise the patient • Use the BCBV data as the basis of a dialogue with • The PCT has incorporated BCBV indicators into its
and financial benefits highlighted by the BCBV indicators, clinical leaders to get the buy in to change. governance frameworks to manage clinical variation.
but it may involve new thinking, working differently and • Identify local clinicians who are already at, or near to, • It has developed a robust approach in setting
learning from the best. the desired performance level and find out how they standards in pathways, contracting, performance
Practical steps you can take now got there. monitoring and cost, and quality.
• Ask challenging questions based on what the data is • The suite of governance programmes, underpinned
telling you: The NHS Institute tools and resources available to by the Quality and Productivity strategy, determine
where do we want to be? help you include: an ethos of joint working (both at local and broader
what are we good at doing? health economy level) to tackle their greatest quality
• The medical leadership competency framework
what are we not good at doing? and productivity opportunities.
- describes the leadership competences clinicians
which specialities and procedures offer the biggest need to become more actively involved in the • It has aligned the change programmes with their
opportunity for improvement? planning, delivery and transformation of health governance structure and designated responsibilities
what are the incentives and barriers to change? services www.institute.nhs.uk/leadership to staff and targets to teams.
where do we need to focus our attention? • Organising for Quality and Value - a service • NHS Oldham looked at international best practice and
which are the most achievable changes? improvement development programme which gives developed an ‘evidence preference- based decision’
who should be involved? you the skills to roll out proven service improvement approach, so that clinical decisions take into account
• Identify the potential benefits and how will you techniques that will deliver a significant return on the use of evidence to better inform patients regarding
measure them over time. Don’t just rely on the investment. Email: organisingquality@institute.nhs.uk risks, options and informed preferences.
quarterly BCBV updates. • The PCT is developing an enabling approach called
• Identify and engage with your stakeholders and agree the ‘Continuous Quality Improvement Programme for
how you will involve them to make it happen. Agree Primary Care’ which is geared towards the adoption of
the best methods of communicating with them and best practice and reducing clinical variation.
be reliable. Adding life to years and years to life
• Recognise the whole system of care (patient journey/ Competencies 6c ,10a & 11a,
pathway) and the impact on other services. Involve - refer to annex 5
these services in any discussion about changes.
16 17
10. 8 - Get board engagement and commitment 8 - Example
Your organisation will use the BCBV indicators if they are high on the board’s agenda and if NHS Northamptonshire
they are aligned with your strategic aims for the health system. BCBV focus: health system partnership working,
Practical steps you can take now best value for money, patient pathways of care
• Share and demonstrate the value of using BCBV The NHS Institute tools and resources available to NHS Northamptonshire has:
indicators: help you include: • recognised the need to further develop and evolve
use the first BCBV agenda item to introduce the • The Board Development Tool - a diagnostic the partnership board to meet the new economic
indicators, and show where your local health leadership framework for individuals with facilitated situation
system sits regionally and nationally in comparison feedback www.institute.nhs.uk/leadership • established a Savings Cabinet to engage county
with its peers. Be prepared to discuss the data • The Sustainability Model and Guide - a finance directors, clinical cabinet and clinical leaders
quality issues diagnostic tool that is used to predict likelihood in identifying the services/pathways for quality
focus on how the BCBV indicators impact on your of sustainability for your improvement project improvement and savings
highest spend areas www.institute.nhs.uk/sustainability • developed the Partnership Board into the Quality,
involve those responsible for delivering strategic • Medical Engagement Scale (MES) - designed Innovation, Prevention and Productivity Board with
goals and overseeing the local health economy to assess medical engagement in management membership of all NHS CEOs, medical directors,
spend and quality. and leadership in NHS organisations nurse directors, finance director representatives and
• Commit the board to a specific improvement project: www.institute.nhs.uk/mes others to prioritise and ratify all proposals from the
choose the directors who will support Savings Cabinet
improvements carefully - they will need to be visible • agreed that prioritisation will be based on clinical
assign a support role to a non-executive director effectiveness, cost benefit analysis and value for
who sits on the board Adding life to years and years to life money. This includes considering improvements
assess your local health economy’s state of to standards of care, innovation, prevention and
readiness for change and sustainability by using Competencies 6b and 11b productivity, encompassing those areas identified
the Sustainability Model and Guide - refer to annex 5 through the Better Care, Better Value indicators
link to local clinical leaders’ networks • identified a buddying scheme between
regularly report the impact of your project. Use local non-executive directors (NEDs) from NHS
data monthly and BCBV indicator data quarterly. Northamptonshire and NEDs from its key NHS
• Create a standing board agenda item. End with providers to ensure that all NEDs within the area
actions assigned. are engaged with this critical agenda.
• Communicate progress across your local health
economy and/or embed within the board’s regular
performance report so it gets mainstreamed.
18 19
11. 9 - Use commissioning levers to facilitate improvement 9 - Example
Using the Better Care, Better Value indicators as part of the commissioning cycle provides NHS Knowsley
an approach which demonstrates which productivity opportunities can be realised. BCBV focus: prescribing: value for money and
Practical steps you can take now • agreeing how savings accruing to providers through patient choice
• Understand when the BCBV indicators can be used the Productive Series or BCBV can be reinvested to • The prescribing indicators are being used to give a
within the commissioning cycle. benefit local patients value for potential savings from generic prescribing.
• Develop evidence based service specifications which • developing a business case for change in services with • This has provided additional evidence for using Script-
include BCBV indicators in discussion with your your providers Switch. Script-Switch is a supporting module to the
providers. GPs information module which automatically flags
• agreeing joint approaches with your providers, with
potential alternatives for prescriptions and asks the
• Develop CQUIN (Commissioning for Quality and collectively developed performance management
GPs if they are happy to change going forward.
Innovation) schemes utilising BCBV indicators. interventions.
• GPs still make the decision, as cheaper generic drugs
• Ensure business case proposals for commissioning and
may not always be as effective.
contesting services include BCBV benefits.
The NHS Institute tools and resources available to
• Produce different types of performance monitoring help you include:
approaches for contracts using BCBV indicators as
• The PCT Portal – using the CQUIN payment
trigger points.
framework www.institute.nhs.uk/pctportal
• Ensure performance management of contracts contain
• Commissioning to make a bigger
elements relating to price and quality.
difference – provides commissioners with
• Ensure contracts contain robust quality indicators from insight to making a bigger difference in
a patient satisfaction perspective. service and marketplace development
• When including BCBV indicators in contracts, ensure www.institute.nhs.uk/commissioners-bigger-difference
they are compliant with the Department of Heath NHS
Contract standards, (available from the Department of
Health‘s website).
Understand your provider relationship through PCT Adding life to years and years to life
development by:
Competencies 7c, 8c, 9b, 9c, 10a & 10c
• taking an active role in leadership and relationship
management between the interface of PCT and acute - refer to annex 5
providers to improve BCBV indicator performance
• creating innovative commissioning approaches
related to BCBV indicators through practice-based
commissioning consortia
20 21
12. 10 - Realise the benefits - release the cash or re-invest in the service 10 - Example
Have you have achieved what you set out to achieve? How do you make sure that your efforts Realising the benefits -
result in benefits and realisation of money. Many set out to improve their service but not all
succeed. Make sure that yours is one of those projects that does. Remember that the Better Care, cash releasing potential for
Better Value indicators have helped you pinpoint gains that can be made. So don’t give up! commissioners
As a commissioner, keep going until the service you are • Use charts and graphs to display progress in offices For 2010-11 contracts:
commissioning is performing as you would want it to. and clinical areas as this will: • include BCBV-inspired new to follow up ratios.
Remember, taking forward initiatives in transformational show what progress is being made to the Many follow-up appointments are not necessary; for
change takes time and commitment from staff and workforce and also to patients and their carers example, routine follow-up outpatient appointments
patients. So, be realistic in your undertaking and encourage and stimulate discussion about what after uncomplicated laparoscopic cholecystectomy.
understand that it might take up to one year before real needs to happen next. Or follow-ups can be done without the patient present
results are seen at system level. • Use real stories from other areas to engage, motivate (phone calls, questionnaires)
Practical steps you can take now and mobilise clinical teams. • use practice-based commissioning to incentivise GPs
• Have an integrated approach that covers the whole • Celebrate your success - it’s a great way to say thank to manage patients with the five conditions for which
process from identifying opportunities and making you to your staff. patients derive little benefit from surgery in a more
improvements to freeing up money. • Share that success with others - you may be the appropriate manner
• Regularly report progress and actions to clinical teams, source of motivation for them. • increase the number of GPs with a special interest,
other stakeholders and the board, having identified so that patients can be referred to them rather than
the benefits to the public, patients, staff and the The NHS Institute tools and resources available to hospital outpatients
organisation and the fit with your strategic plan. help you include: • for one of the 19 ambulatory care sensitive conditions,
• Bring finance leaders, clinical leaders, operational • The Sustainability Model and Guide - a fund appropriate and effective community-based
leaders and improvement leaders together to work diagnostic tool that is used to predict likelihood support and monitor patient flows to ensure
collectively on this agenda. of sustainability for your improvement project compliance.
• Understand at what points on the funding pathway www.institute.nhs.uk/sustainability
patient care benefits occur for providers and • Patient Safety First ‘How to measurement
commissioners eg look at spells over trim-point, for improvement’ - a good guide on how
high quality care from alternative providers and/or in to use facts and data to drive continuous
alternative settings. improvement for providers and commissioners
• Be explicit that you are releasing the cash by taking www.institute.nhs.uk/safetysupport
the money out of commissioning budgets or
re-investing in other services that will increase cost
and quality dividends.
Adding life to years and years to life
Competencies 3c, 8b, 11a & 11c
- refer to annex 5
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13. Annex 1 Facts about the Better Care, Better Value data Annex 2 How to access and use Better Care, Better Value indicators
1. The BCBV indicators are published quarterly in: 5. The NHS Indicator Explorer is updated within a day Productivity web site navigation
• January or so of the publication of this data on the website. Visit www.productivity.nhs.uk to view the most recently published Better Care, Better Value
It should be used in conjunction with the PDF (BCBV) indicators, together with all indicators published since 2006. Also available on the website
• April
documents. Access to use the tool is free and if you
• July are indicator definitions, a selection of case studies and access to an online analytical tool.
work in an acute trust or PCT you can register for your
• October. own account at Registration to use the tool is free.
2. The BCBV indicators are published on the website www.nhsindicatorexplorer.productivity.nhs.uk You will 1. To view Better Care, Better Value indicators
www.productivity.nhs.uk where NHS staff can access then receive an email with the final registration details. Figure 1 shows each lettered step described here:
the information. After you have registered you can start to use the tool. A. first select the SHA that you belong to, either by
SHA users need to request an account by emailing selecting from the drop down list or by clicking the
3. The clinical indicators are compiled by Dr Foster D
productivity@institute.nhs.uk SHA area on the map
Intelligence using an extract of the data submitted
to the Secondary Uses Service (SUS) by provider 6. When looking at the data, if there is a fluctuation B. select the BCBV indicator that you want to view and
trusts. The prescribing indicators are compiled by the in the trend that is outside what would normally be the period from the lists (the most recent data is the
expected, first check the SUS submission to rule out C
NHS Information Centre using ePACT.net data. The default period). Click the ‘Get PCT Indicator’ button A
workforce indicators were originally compiled from any data quality problems in the SUS data extract.
C. select ‘Get Scorecard’ to view all the indicators that B
WIMS data by the workforce team at the Department 7. If you would like help, please contact us by emailing apply to your PCT for a selected quarter
of Health (DH). However, this data source is no longer productivity@institute.nhs.uk A
D. the blue navigation pane can be used to view other
available and we are looking to use the NHS Workforce
areas of the website. These include:
dataset through the NHS Information Centre.
• Indicator Definitions
4. The indicators are published as soon as possible after Figure 1 www.productivity.nhs.uk Entry Screen
the quarter end date. We need to ensure that we • Publication Schedule
have meaningful data, but we don’t wait for the final • Case Studies
‘quality’ cut off dates. The SUS dates are: • NHS Indicator Explorer.
• quarter one data submitted to SUS up to 31 July
• quarter two data submitted to SUS up to 31 October
• quarter three data submitted to SUS up to 31 January
• quarter four data submitted to SUS up to 30 April.
The BCBV indicators are published as a ‘snap shot’
at that time and are not re-published to include
any changes.
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14. 2. The selected indicator data will be shown as a
table in a PDF document (see figure 2).
Annex 3 How to access and use the NHS Indicator Explorer
The tables contain the selected quarter results for The NHS Indicator Explorer offers one simple system for commissioners and providers to view
the PCTs within the SHA, or all indicators for your and monitor their performance and it is available free via the website www.productivity.nhs.uk
particular PCT.
Features provided by the system 2. If you are using the NHS Indicator Explorer for the
• National Position - this is the position of the PCT
• Breakdown of the Clinical Indicators first time, you need to register your user account
relative to others (the PCT with the best value is which can be done by selecting ‘Click here to
given the rank of one). • Trend Analysis
Register’, shown at A, figure 2 and following the
• The Indicator Rate - this is the actual value for the • Peer Group Comparison - within the trend analysis instructions on the login screen. Once you have
PCT for the selected indicator. you can select from a number of pre-defined peer submitted your details, you will be sent a confirmation
groups to display and compare performance. email with the final details for activating your account.
• Productivity Opportunity - this is the potential
Alternatively, you can create any number of your own
financial gain to be made if the PCT were to move 3. User name and password are entered in to the fields
peer groups containing three to five organisations.
to the upper quartile performance. shown at B, figure 2 and then you click the Login
• Data Export button to enter the system.
• Change from Last Period - this is the difference
in the rate from the previous quarter. The arrows • Reports - use the ‘printable view’ to create images for
indicate if performance has improved (green) or local reporting.
worsened (red). • Commissioning Group - you can create a group
of acute trusts that you have a commissioning
relationship with and, then, use the NHS Indicator A
Explorer to view in more detail their Better Care,
Better Value indicator performances.
B
1. To access the NHS Indicator Explorer tool, select the
‘NHS Indicator Explorer login’ from the blue navigation
panel on the right hand side of any of the website
pages shown at A, figure 1.
Figure 2 PDF Documents
Figure 2 NHS Indicator Explorer Login Screen
A
Figure 1 www.productivity.nhs.uk Entry Screen
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15. D
4. The NHS Indicator Explorer Entry Screen allows 5. The Clinical Effectiveness Dashboard is accessed 6. The Indicator Breakdown Scorecard - by clicking 7. Trend Analysis - by selecting the trend analysis
you to select any of the dashboard links shown at A, through the NHS Indicator Explorer. It shows the top within any of the indicator dial faces you can view the hyperlink (or icon for the specialty/procedure view)
figure 3 to view the BCBV indicators. specialty, diagnosis or procedures and displays the detailed information based on specialty, diagnosis or you can view the performance/rank trend for your
greatest opportunities for improvement. The full list procedure, as appropriate (see figure 5). organisation for a particular indicator.
Select the dashboard link shown at B, figure 3 to view
is displayed in a ‘scorecard’ view if you click within a A. In figure 6 - the graph displays the performance
acute trust BCBV indicators for your selected trusts.
selected indicator dial face. ‘trend’ for the selected indicator. If you select a peer
The links shown at C, figure 3 can be used to create group comparison (shown as C, figure 6), these
The tables shown at B, figure 4 display the top
your own peer groups and the acute trust list can be values are shown as dotted lines on the graph.
opportunity from the lower level information for
used to ‘tailor’ the views in the system to suit your
the particular indicator. Click in any of the dial faces B. In figure 6 - the bar graph charts the national
own requirements. Follow the instructions shown on
shown at A, figure 4 to ‘drill down’ to the next level of ranking trend for your PCT for the selected indicator.
the screens to create the groups.
detailed information (see figure 5).
You can use the ‘Export Data’ button shown at C,
figure four to produce an Excel spreadsheet with all
the data displayed for the selected indicator.
C
To look at how the performance has changed over
time use the link ‘Trend Analysis’ shown at D, figure
A
B four (figure 6 shows how trend analysis information
is displayed). Figure 5 Indicator Breakdown Scorecard A
C
The export data feature is available on all screens.
You can export the data shown by clicking the
“export data” button available from each screen. B
Figure 3 NHS Indicator Explorer Entry Screen Figure 6 Trend Analysis and Peer Group Comparison
C C C
A A A
D D D
B B B
Figure 4 Clinical Effectiveness Dashboard
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16. Annex 4 Opportunity Locator for Commissioners
Introduction • the Opportunity Locator shift potential is calculated • On the first page of the Opportunity Locator is a link currently being treated in hospital could be treated
The Opportunity Locator is an online data tool that for the quarter, whereas Better Care, Better Value to the methodology that has been used to calculate in community settings. Excess bed days are the
supports commissioning priorities and stimulates thought indicators are annualised. the values in the tool. This is helpful for individuals number of days beyond the long stay trimpoint for
as to where commissioners should focus their attention. Data from the Opportunity Locator web site who wish to examine values further. the relevant HRG. Trimpoints are used to cost activity
It has been designed to give you and your community • One approach to analysing this data further would be in the delivery of care in an acute setting. Trimpoints
• The first thing to do with this data, and with any
relevant and useful data in an easily accessible format to to select one of the categories (eg outpatient follow- are the points from which excess bed days apply.
other from the Opportunity Locator, is to check
support the ‘care closer to home’ agenda. up appointments) and look for common areas of The value of each excess bed day is summed up to
that these results make sense locally. There may be
opportunity across PCTs. give the shift potential.
The Opportunity Locator helps you explore the potential understandable reasons why performance appears as
and opportunities for shifting services. It should it is, or there may not. The Opportunity Locator indicators • Quality Outcomes Framework (QOF) predicted
prompt you to start thinking about how and why your admissions (password protected) - this provides
• The Opportunity Locator tool provides a means to • The Outpatient Follow-Up indicator - this outlines
organisation might differ from others and to support an indication of the shift potential to be gained
analyse the shift potential that can be gained from the shift potential that could be realised by reducing
commissioning priorities for health communities. by reducing the number of avoidable emergency
moving care closer to the community. PCTs can the number of follow-up attendances in line with
admissions. It does this by analysing the relationship
The shift potential is indicative and local health examine their shift potential through a range of the top 25th percentile of PCTs. A high number of
between the emergency admissions and QOF
communities should interpret it taking into account local comparative PCT datasets. You can measure your shift outpatient follow-up appointments could indicate
prevalence. This indicator is designed to stimulate
knowledge. The Opportunity Locator might help you to: potential against the top 10%, 25% and 50%. You that the patient may be able to be treated in the
thinking about why and how practices have differing
• highlight services that could potentially be shifted can also compare yourself to similar organisations community - perhaps by GP.
emergency admission rates for their relative prevalence
from a hospital setting to a community setting outside your SHA area which have been pre-selected. • The Outpatient First Attendance indicator - this of long term conditions.
You can also reorganise the data to be presented to outlines the shift potential that could be realised if
• identify situations where transferring services into the • Diagnostics (password protected) - this provides
individual GP practices or clusters that can be adjusted first attendances were reduced in line with the top
community might give better value an indication of the shift potential to be gained if the
by yourself to reflect local arrangements. 25th percentile of PCTs. This indicator enables PCTs to
• improve planning for cost and quality benefits. number of diagnostic tests were increased. Diagnostic
• Charts can be downloaded from the Opportunity identify which specialties have statistically higher than
Values are calculated differently in the Opportunity data collection is required to monitor waiting times
Locator to identify where individual PCTs may wish to average outpatient appointments, with adjustment for
Locator than in the Better Care, Better Value indicators. and activity. A high rank suggests that patients are not
focus their priorities in shifting care outside hospital. age, sex, population and case mix.
The difference in the calculation means that the being referred for diagnostic tests.
Further investigation of the information in this tool will • The Emergency Admissions indicator this
monetary values will be different but the figures are be necessary to determine the actual savings that may For more information:
demonstrates the shift potential through the
still an important indicator of potential efficiency be realised. • Better Care, Better Value indicators
calculation of emergency admissions for ambulatory
improvements. In neither case should the figures be www.productivity.nhs.uk
• You can measure your actual versus expected shift care sensitive (ACS) conditions and a selection of
taken as an absolute achievable saving; they are more of
potential by selecting the appropriate level. You can healthcare resource groups (HRGs) by PCT. Ambulatory • Opportunity Locator
an indication of the scale of potential savings.
also choose to view the chart by finance, attendance care sensitive (ACS) conditions are those which have www.institute.nhs.uk/opportunitylocator
The differences in the calculation are caused by the shift, number of admissions or number of patients been deemed to be treatable at home or in primary
following factors: affected. care, rather than in a hospital setting.
• both use the same data source. However, the timing • All figures are not absolute savings; rather, they give • The Intermediate Care indicator - this demonstrates
of the extracts differ, which may result in some a perspective on how the approaches of different the shift potential by calculating the number of excess
differences due to the data submission process organisations differ and offer potential opportunities bed days for intermediate care susceptible health
for learning from the practice of others. care resource groups (HRGs). Identified intermediate
care susceptible HRGs indicate which HRGs that are
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