Copyright 2011 Right Care The Accountable Integrated Care System Sept 2011 Commissioning for Value

2 The primary objective for Right Care is to maximise value the value that the patient derives from their own care and treatment the value the whole population derives from the investment in their healthcare To successfully increase value for both patient and population, health service reform must integrate both in an single model; separately, they become opposing imperatives

3 Right Care for Patients – No decision about me without me No patient faced with a significant decision about their healthcare should decide in the face of avoidable ignorance. All healthcare, even of the highest quality, carries risks as well as benefits and the patient needs to know sufficient about both and be supported in making a personal decision which is right for them. Patient Decision Aids are important tools that the patient can use to supplement and complement the information exchange in the consultation and ensure that they make a high value decision which is right for them, when there is not clinical evidence in favour of single best option. However, the clinician needs to personalise that evidence to the unique clinical condition of the individual, as well as to the patient’s unique values and preferences and the patient needs to be supported by access to decision support interventions ( such as Patient Decision Aids, short comparison tables, decision coaching etc). Empowered patients, making informed decisions, can deliver high value care for both the individual and for the whole population served by the service; evidence shows that Shared Decision Making is the best route to ethical and sustainable demand management. Every service needs to ensure that the patient has the time and resources to participate in decisions about their care. For this to happen, shared decision making needs to become embedded in the culture of healthcare, which includes clinicians, patients and the public and in the management of healthcare, both commissioning and delivery of healthcare.

4 Right Care for populations – commissioning for value “Value in any field must be defined around the customer, not the supplier. Value must also be measured by outputs, not inputs. Hence it is patient health results that matter, not the volume of services delivered. But results are achieved at some cost. Therefore, the proper objective is.. the patient health outcomes relative to the total cost (inputs). Efficiency, then, is subsumed in the concept of value. ” Source: Porter ME. (2008) What is Value in Health Care? Harvard Business School. Institute for Strategy and Competitiveness. White Paper. “Value in any field must be defined around the customer, not the supplier. Value must also be measured by outputs, not inputs. Hence it is patient health results that matter, not the volume of services delivered. But results are achieved at some cost. Therefore, the proper objective is.. the patient health outcomes relative to the total cost (inputs). Efficiency, then, is subsumed in the concept of value. ” Source: Porter ME. (2008) What is Value in Health Care? Harvard Business School. Institute for Strategy and Competitiveness. White Paper. …How can the NHS commission healthcare to increased value?

5 Right Care for populations – accountable, integrated, population based systems To improve outcomes and value for their whole populations, clinicians and commissioners need to: understand and address the whole population needs address whole populations and those that appear in their clinic manage investment in treating conditions such as at a Programme Budget level, so that questions such as “how much is spent on diabetics and for what benefit?” can be accounted for ensure that the systems delivering care are integrated across the whole pathway in order to control unwarranted variation in outcome, quality and efficiency of care and improve patient experience to collectively remove waste and shift health investment to higher value interventions To deliver this commissioners need to: Understand how their current and future spend is related to population health outcomes identify and address unwarranted variation in outcomes benchmark spend and outcome against other similar populations Integrate care across the pathway Be clear on who is accountable and leading the system Focus on commissioning outcomes – devolve pathway design

6 For your population, can you answer these questions? What is Rheumatoid Arthritis (RA)? What are the causes and scope for prevention? How many people have this in my population? What are the best value diagnostic tests and treatments? How can individuals and carers be best supported long term? Is our spending on RA above or below average compared to similar populations? How do we compare, with other populations, on activity, quality and outcome? What are the objectives, standards and criteria needed for an RA system of care for a population? What commissioning service models can support the delivery of a safe, effective service, that delivers a good patient experience and provides high value for the commissioner and the local population What can commissioners do to improve the delivery of RA service and improve the RA related health of their population

7 For Patients For Populations Better Value Healthcare Accountable Integrated Systems Mobilise the patient No patient should make decisions in avoidable ignorance – the informed and empowered patient leads to more appropriate and sustainable care – embrace the Shared Decision Making paradigm Understand spend and outcome To deliver high value healthcare, commissioners need to manage the services they contract at programme budget levels – how much is spent on diabetics and for what outcome for the population served? Understand variation commissioners and providers need to identify unwarranted variation and benchmark against other populations in order to remove waste and shift spend to higher value interventions Ensure clinical and financial accountability In order to deliver integrated care providers need to work together and accept clinical and financial responsibility for entire programme budgets The Accountable, Integrated Care System (AICS) …but who is accountable? What do we mean by commissioning? Devolve Pathway Design and Management Commissioners should focus on outcomes - devolving performance management (clinical outcomes delivered within budget) and responsibility to develop integrated pathways to a provider in the programme budget pathway Address whole populations to maximise value, not just those patients who appear in clinic – and provide clinical leadership to develop the network which delivers the service to the population and to lead innovation

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