Improving the local healthcare system Commissioning for Value March 2015 Bob Ricketts Director of Commissioning Support Services Strategy

1. Context: 2 The Forward View sets out unprecedented challenges for the NHS nationwide & local healthcare systems: Rising demand Increasing public & political expectations Constrained resources Out-dated over-stretched service models (all sectors) Persistent unacceptable variation – in outcomes, access & VFM

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

1. Context: New opportunities 4 New technologies and treatments Improving our ability to predict, diagnose and treat disease Keeping people alive longer But resulting in more people living with long term conditions New ways to deliver care Dissolving traditional boundaries in how care is delivered Improving the coordination of care around patients Improving outcomes and quality Support NHS IQ Improving Quality in Supporting CCGs to commission personalised care for people with LTC via LTC Improvement Prog. Commissioning Support: Lead Provider Framework …but the financial challenge remains, with the gap in 2020/21 previously projected at £30bn by NHS England, Monitor and independent think-tanks

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

Narrative on OBC NHS CA Quality Working Group 3. We need commissioning for outcomes: What is it?

There is a spectrum of approaches: Embedding outcomes in contracting: Using outcome measures in, e.g. secondary care, to drive-up quality, linking payment much more closely to performance. ICHOM Outcome-based population commissioning a key vehicle to drive transformation & secure better outcomes, service integration and value for specific populations or groups (e.g. frail older people with multiple, complex problems; EoLC), or re-balance incentives by paying for outcomes COBIC *International Consortium for Health Outcomes Measurement 3. Commissioning for outcomes = a spectrum

The core of ICHOM's mission is to define a common language to measure outcomes: "ICHOM Standard Sets" Physician and registry leaders Patient representatives ICHOM facilitates a process with international physician and registry leaders and patient representatives to develop a global Standard Set of outcomes that really matter to patients, by medical condition

Our end-product: a Standard Set, with the domains that should be systematically measured, and clear definitions Treatment approaches covered ▪ Watchful waiting ▪ Active surveillance ▪ Prostatectomy ▪ External beam radiation therapy ▪ Brachytherapy ▪ Androgen Deprivation Treatment ▪ Other © 2013 ICHOM. All rights reserved. When using this set of outcomes, or quoting therefrom, in any way, we solely require that you always make a reference to ICHOM a s the source so that this organization can continue i ts work to define more standard outcome sets. Details 1Recorded via the Clavien-Dindo-Classification 2Recorded via the Common Terminology Criteria for Adverse Events (CTCAE), version 4.0 3Recommended to track via the Expanded Prostate Cancer Index Composite (EPIC)-26 A "reference guide" contains all the details to measure in a standard way the outcomes recommended (link to download)link to download

ICHOM have already developed 12 Standard Sets, covering 35% of the disease burden

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

Integral to core OBC’ /COBIC model are: Identifiable & measurable outcomes That those outcomes can be linked to desired behaviours That those behaviours can be incentivised through payment systems Spans primary, community & secondary care At-scale for populations (but can be done on a smaller scale, introducing a % payment for specific outcomes) More mature & long-term relationship with providers (7+ year contracts) ‘Lead provider’ or ’Alliance’ contracting 3. Outcome-based population commissioning:

Key components of fully-developed OBC: Population-based (frail older people, multiple complex problems; EoLC) or major pathway(s) (MSK) Outcome-focused capitation payment* ‘Lead provider’ or ‘alliance’ Provider(s) co-ordinates care planning & delivery Provider(s) takes on much of the demand risk *LTC Year of Care Commissioning EI sites – testing population capitated budget for LTC cohorts, new contracting & delivery models 3. Outcome-based population commissioning:

OBC still emerging, but examples: Bedfordshire (MSK) Cambridgeshire (range of services for older people) Staffordshire (cancer & EoLC for 1m+) Sussex (MSK) Greater Huddersfield & Kirklees CCGs (community services lead provider) Smaller-scale: Oxfordshire & Milton Keynes (sexual health; substance abuse) EI sites for Year of Care commissioning: Southend, Leeds, Kent, West Hampshire, Barking, Dagenham & Havering and Redbridge 3. Outcome-based population commissioning:

Critical Success Factors: Know what problem you’re trying to solve Commission the underpinning analysis – e.g. RightCare ‘deep dive’; CfV packs Be clear what you’re trying to achieve Set identifiable & measurable outcomes Link outcomes to desired behaviours Think about how to incentivise the right behaviours – not just through payment systems Engage systematically, consistently & early – users, communities, clinicians, providers, ‘politicians’ Budget for resources - capability & capacity Start small! 3. Outcome-based population commissioning: CSFs

General overview: NHS CA Quality Working Group King’s Fund: How to measure for improving outcomes: a guide for commissioners Embedding outcomes: ICHOM International Consortium for Health Outcomes Measurement Useful sources:

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