1 Commissioning Challenges for PCTs - shared learning and thoughts from the Southern Cambridgeshire health system Sally Hind, Chief Executive South Cambridgeshire.

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Commissioning Challenges for PCTs

- shared learning and thoughts from the Southern Cambridgeshire health system

Sally Hind, Chief Executive

South Cambridgeshire PCT

30 January 2004

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What’s the Southern Cambs Health system’?

• Addenbrooke’s main provider: a large acute teaching Hospital, providing DGH and specialist services

• serves a ‘core catchment’ population of c 230,000; Specialist Services cover approx 1million

• necklace of Community Hospitals

• long history of joint working with Addenbrooke’s

• 8 PCTs in 3 StHA areas and 5 counties working collaboratively

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Will share: • making our collaborative commissioning

arrangements work

• preparation for Payment by Results from April 2004, with Foundation Trust status of local acute Trust

• preparation for Choice and managing demand

• using Care Pathways as a focus for commissioning

• engaging our clinicians

• local thoughts on future role of PCTs

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Making our collaborative commissioning

arrangements work ...

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Commissioning structure:Countywide Lead Commissioning arrangements:

• Lead Commissioner for each Trust

• Supported by:

– Cambs Commissioning Leads’ Group “C4” which includes Social Services

– County wide Commissioning Leads’ Group “C6” plus Finance Leads’ Group “F6”

– County wide Clinical Priorities Forum

– Commissioner Leads for the Cancer Network, Ambulance Services, Maternity Services

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Addenbrooke’s’ Collaborative Commissioning:

SCPCT Lead Commissioner for Addenbrooke’s:

– Cambridgeshire is 63% of Addenbrooke’s business

– Joint Commissioner’s Group around Addenbrooke’s (8 PCTs, Add’s, LSSCG) - Chaired by Uttlesford PCT

– SWAP (8 PCTs ) and Addenbrooke’s- performance review

– Lead Commissioner mandate; 75% rule for decision making

– a Locality Commissioning Manager co-ordinates the process, funded by several PCTs

– Chief Executives Addenbrooke’s/SCPCT regular ‘one to one’ sessions

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Benefits:

• All partners involved

• Less bureaucracy with lead arrangements

• Pooling of expertise

• Improved communication

• Risk Sharing

• NICE Implementation

• Strength in numbers!

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Our Learning Points:• recognition of a ‘bigger system’

• need for transparency

• building trust between partners

• sharing the workload

• PCTs have different priorities

• application of the 75% rule regarding decision making

• representatives must be mandated to take decisions

• allowing sufficient time for communication and co-ordination

• evaluation and evolution

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Preparation for Payment by Results from April 2004, with

Foundation Trust status of local acute Trust ...

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Our Learning Points re FTs:• agree the baseline early:

– define the baseline: actual, plan or other?

– agree line on transfers between providers in Networks: agree early what this does to funding below the baseline

– negotiate with prospective FT what baseline they declare for Purchaser Parity Adjustment

• partnerships will be under pressure:– PCTs will need strategies to retain and strengthen

partnership working and avoid returning to an ‘us and them’ culture between provider and commissioner

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Our Learning Points re FTs:

• competition between providers - will have an impact on collaboration and development of Clinical Networks

• tensions between primary and secondary care - how willing to reduce income by shifts to primary care?

• work to avoid loss of an open book culture

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From here, we’ll be wanting to:

• explore scope for developing new services where a local acute trust is above national tariff

• monitor and watch for:

– over treatment: as additional activity means additional income

– ‘HRG inflation’: pushing the episode into a more complex category to increase income

– gaming ! Providers may seek to lessen their WT/WL risks by not declaring ‘surplus’ capacity once overheads covered

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From here, we’ll be wanting to:

– a rapidly falling acute av. length of stay: day case and InP same tariff, so risk of PCT picking up greater rehab bill after swift discharge, so…

• negotiate reduction in tariff for rehab undertaken by primary/community care

• refine our Risk Sharing arrangements - essential

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Preparation for Choice and managing demand...

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Our emerging learning points:• Choices pilot - Orthopaedics:

– 3 PCTs, 5 providers, Ambulance Trust, 134 6m+ waiters

• Planning for Choice with FTs:– model expected flows:– anticipate influx from neighbouring areas to specialist

teaching trust

• agree arrangements ‘closing lists’ when it’s clear that waiting lists won’t be met

• demand management:– close engagement of practices re their activity levels– seeing spend across all budgets

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Choice and demand management:– practice utilisation packs– practice visits– GPSIs (dermatology, orthopaedics, sexual health, vasectomy,

ophthalmology, plus others in collab’n with neighbouring PCT)– Diabetes Specialist Nurse– investigating ‘Frequent Fliers’– Vulnerable People's register– Direct Access to Radiology and Pathology– training practice experts - Dermatology– our monitoring information - you need to identify the problem

to tackle it– GP referral Audit– increased equipment to avoid admission– RRT– referral protocols....

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Using Care Pathways work to focus commissioning needs ...

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• Care Pathways as a framework within which to make commissioning decisions

• an holistic focus on the patient: i.e. not just a series of care spells

• Payment By Results as a tool for exercising choice

within the pathway: currently only choice for the acute part of the pathway GMS contract offers scope for choice in primary care in future, will support choice for community services currently ‘set price menu’; needs to be ‘a la carte’

Working through Care Pathways:

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Choice Along the Pathway:

• Aiming for Choice to be available at every node along the pathway

• Payment By Results (Financial Flows) supports this Choice

Advice Tests & Primary Care

re symptoms investigations Management

Ongoing Specialist

Management Opinion

Treatment Follow up and Care

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• supports engagement of patients and carers in commissioning decisions:

- about the individual’s needs

- about the population’s needs

- about where investment should be made / new services developed

• as a tangible means of involving clinicians

• stroke, falls, CHD

• slow progress: learning points:

– mapping current practice risks reinforcing it !

– no prizes for perfectionism: results are too slow

Working through Care Pathways:

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Engaging our clinicians ...

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• engagement though Care Pathway commissioning - commissioning on specific areas of personal interest and relevance

• bringing together across trusts’ organisational boundaries to avoid an ‘us and them’

– harder to fall out over the LDP if our clinicians jointly drove the decisions !

• PBR as the tool to deliver clinicians’ commissioning decisions

Engaging our clinicians:

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• Decisions re which quality/other indicators (e.g. distance) should drive ‘Choice’ options:

– both GP and hospital clinicians

– build the body of information that will inform Choice

• engage in understanding the reason for a provider trusts distance from Nat Tariff:

– if above - scope for cost improvements

– if below - making quality investment decisions

Engaging our clinicians….

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Focusing our attention:

Payment by Results = ‘pay as you refer’

“...all the money goes into the hospital black-hole”… because that’s where we refer the patients !

now a direct correlation: we pay for what we send

focus attention on investment in alternatives

clear message to PCTs/GPs that they drive the pattern of investment

Engaging our clinicians….

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Local thoughts on what the future holds for PCTs ...

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What the future holds for PCTs:

• refocusing on the ‘non contracting’ bits of commissioning

• up our performance management skills:

– Foundation Trusts no longer accountable to StHAs through the Annual Accountability Agreement

– PCTs will need to hone their performance skills for managing their SLAs

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And finally

Seeing system reform in context...

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The key elements of system reform are all complimentary:

Choice(the principle)

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The key elements of system reform are all complimentary:

Payment by Results (the tool)

Choice(the principle)

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The key elements of system reform are all complimentary:

Payment by Results (the tool)

Choice(the principle)

Foundation Trusts (locally accountable and responsive)

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The key elements of system reform are all complimentary:

Payment by Results (the tool)

Choice(the principle)

Foundation Trusts (locally accountable and responsive)

Integration(the means to patient focused care)

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Underpin with a commissioning framework based on Care Pathways

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The key elements of system reform are all complimentary:

Payment by Results (the tool)

Choice(the principle)

Pathways(the framework)

i.e. Pathways as a tool to commission (planning, service development, ‘contracting’)

Foundation Trusts (locally accountable and responsive)

Integration(the means to patient focused care)

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