Business Case: Project Name To support the introduction of ......Dec 13, 2013 · outcomes based services sought support to develop outcomes based contracts for three service areas

Business Case - Maternity

Project Name

Business Case:

To support the introduction of Outcomes Based Contracting - MATERNITY

Document Authors: OCCG Maternity Project Team supported by the Cobic Consortium

Project Sponsor: Stephen Richards [CEO]

Directorate/Locality: OCCG – All localities

Programme Manager: Catherine Mountford / OCCG Jennifer Tait / Cobic Consortium

1 19 Nov 2013

19 Nov 2013 Business Case - Maternity 2

Contents

Section Page 1 Executive Summary

4-5

2 Introduction and Approach

6-10

3 Maternity Services in Oxfordshire – the context today 11-15

4 Case for change 16-26

5 Outcomes that matter 27-34

6 The Vision for Maternity Services in Oxfordshire 35-38

7 Commercial and contractual options 39-49

8 Risks and Mitigations 50-52

9 Options for decision 53-58

10 Appendices 59-70

Business Case - Maternity 3 19 Nov 2013

1. Executive Summary


Executive Summary Maternity

Outcomes based commissioning is an innovative approach to commissioning that align incentives to deliver value through improving outcomes for patients/carers and driving transformational efficiencies. They also help drive the delivery of integrated care across health and care economies. There is a good evidence base of successful implementation in a number of systems internationally.

2: Introduction and Approach

Maternity services in Oxfordshire are considered good but there is significant variation geographically. 3: Maternity Services in Oxfordshire

What happens before, during and after pregnancy has a lifelong impact on the health of both the mother and baby. As a result the scope includes from before pregnancy to a year after the baby is born.

4: The case for change

The financial envelope is c£25m. There are a number of areas the new scope has the potential to release savings and efficiencies which will be developed in the next Phase.

5: The case for change

Over the past 18 months there has been a rigorous process for describing, testing and checking the outcomes that matter for women and their partners. Four outcomes have been agreed, with strong consensus from users, the public, clinicians and other stakeholders.

6: Outcomes that matter

A vision for and principles for the mother and baby programme include: one system of care, an integrated network approach, a multi-disciplinary team, choice and shared decision making, locally based care, holistic care, collaboration between providers and professional groups.

7: The vision for the mother and baby programme

The process to move to Phase 3 including the route to contract has been discussed with Monitor and determined to adhere to Monitor’s guidance.

8: Commercial and contractual options

The process has a number of risks including the significant change management for both providers and commissioners which will need to be effectively managed and mitigated.

9:Risks and mitigation

The decision to move to Phase 3 has been outlined, this will be considered by OCCG Outcomes Based Commissioning Governing Body who will recommend to OCCG’s Governing Body for decision.

10: Options for decision


The outcomes based approach to maternity services has led to a shift from a ‘traditional maternity service’ to a longer and broader mother and baby programme that is supported by users and stakeholders. In addition this is backed up by the evidence base around healthy mother and healthy baby, parenting and seamless services. By aligning financial incentives across the system, this approach can also drive the delivery of improved outcomes for patients.

The process of building the business case in developing the outcomes that matter, engagement with service users and clinicians, has enabled a momentum and dialogue with providers of these services in Oxfordshire that has not been achieved previously.

5 19 Nov 2013

2. Introduction and Approach The purpose of this section is to: • Outline the purpose of this business case

• Explain Outcomes Based Commissioning in general terms, highlighting the potential benefits of the approach

• Outline the process and methodology followed by OCCG in developing Outcomes Based Commissioning

• Highlight the key activities in the current phase of the process and summarise the next steps


Introduction and Approach The purpose of this business case

Support to implement Outcomes Based Contracting OCCG’s specification for this contract for their programme to deliver outcomes based services sought support to develop outcomes based contracts for three service areas maternity, mental health and older people to build on the work undertaken in Phase 1. The CCG requested that this work was delivered in two further phases (Phase 2 and Phase 3). This business case represents the activity undertaken in Phase 2 to support this work as required - specifically: • the clinical vision • defined outcomes • financial envelope • potential for improvement • recommending contractual options for the service areas This represents a “stop-go” point in the process for the OCCG to take a decision regarding proceeding to Phase 3.

Question Focus

Question Outcome

Step 1: Business Case Does the business case

demonstrate this method of contracting has the potential to deliver the strategy for the service area

YES - Proceed to Step 2: Timescale NO – Stop. Consider other options

Step 2: Timescale What is the timescale

over which OCCG wish to progress to Stage 3? Is there sufficient information/analysis to progress to next stage? YES or NO - is more time required to achieve sufficient alignment with key stakeholders e.g. OCC?

YES - Progress to Step 3: Route to contract NO- Agree milestones and time period to deliver final additional actions prior to route to contract.

Step 3: Route to contract Is there potential for the

incumbent provider market to deliver the outcomes?

– YES/NO YES – Continue in stage 3 with a structured engagement process with incumbents to assess potential to deliver OBC. NO – Continue in Step 3 and proceed to wider procurement.


“The CCG wants the ability to review and monitor this work appropriately; including defined milestones of “stop/go” points, particularly between Stage 2 and Stage 3 and where decision makers can review progress and ensure on-going alignment with CCG strategic objectives.” “Phase 3:- Based of the recommendations agreed from Phase 2 the CCG would require support moving into revised contractual arrangements for 2014-15. (The scope of this will be very dependent on Phase 2).” (OCCG ITT specification document June 2013)

The process for decision The final business case will be presented to the OCCG Outcomes Based Commissioning Programme Board on Tuesday 19th November. This group will make recommendations to the OCCG Governing Body on 28th November 2013.

In reaching the decision OCCG is considering the following questions for all service areas.

7 19 Nov 2013

Introduction and Approach Understanding outcomes based commissioning - the approach explained

Outcomes Based Commissioning – OBC - is a value-driven approach to commissioning. In simple terms it is a process that links the “Outcomes that matter to patients/carers” to the contractual framework. The health and care system currently faces an unprecedented set of financial and quality challenges. These are well known, and include a potential funding gap of up to £56 billion for the NHS in England by 2021/22, alongside an existing funding crisis in social care. Meeting these challenges requires a new approach, a shift from activity to outcomes; from episodic, fragmented care to a co-ordinated whole system approach. OBC seeks to drive this through a new commissioning model; aligning incentives across the care economy to create an environment where providers must collaborate and innovate to deliver outcomes focused care which provides value for money. Through this approach OBC aims to deliver:

OUTCOMES BASED COMMISSIONING

– driving value across the system

Aligning Provider, commissioner and

patient goals

Incentivising providers to innovate to deliver highly

valued outcomes for patients and service users

Incentivising system efficiency through the use of a capitated or

bundled payment mechanism

Removing perverse incentives for

providers to deliver low value activity

Removing barriers to shifting resource to where it produces greater value –

and, importantly better outcomes for users

Working with stakeholders across the care economy to define outcomes that

matter


•Through a new clinical model of care designed by both clinicians and key stakeholders across the system that focuses on the outcomes patients want, not on the input activity PbR rewards

Service innovation

•Through the procurement of a Prime Contractor/ Accountable Lead Provider or integrator who will be responsible clinically and financially for the services that the CCG and Local Authority requires

Contractual Innovation

•With better outcomes and improved quality by incentivising a shift of resources to where they are needed most, and a shift in culture so that providers and commissioners work to a common aim

Improved value for money

OBC is a mechanism to drive change, applying a new approach to working with clinicians and stakeholders across the care economy. Central to the approach is engagement with patients and service users to find out what outcomes they want. Outcomes based contracts transfer appropriate risk to providers and create the circumstances and incentives to allow them to innovate and profit from success – provided they manage the costs and deliver the outcomes your population wants. To do so, providers must collaborate, problem solve, and deliver efficient, integrated services. Each OBC covers all care for a given group of people – for example, those with or at risk of mental health problems, or children, or those with musculoskeletal disorders.

8 19 Nov 2013

Introduction and Approach Outcomes based commissioning – the approach so far in Oxfordshire

Oxfordshire Clinical Commissioning Group’s (OCCG) aim is to secure improved outcomes and value for money for patients and the public. In March 2012, OCCG decided to change how it commissions a range of services by introducing an outcomes orientated approach to commissioning and contracting. OCCG decided that Maternity services would be one of the services that would have this new approach.

Stage 1: Defines programme governance,

engagement and programme plans. Defines the broad outcomes for each

service or population segment and an indication of

the budget. Recommends the

route to contracting for these objectives.

Stage 2: Deeper engagement with public, providers

and wider stakeholders. A business case

outlining the case for change,

refined outcomes and incentives

and identifies the service blueprint

or vision.

Stage 3: Formal process to secure

providers to deliver the services. This

stage ends when a contract is signed to deliver these

services.


National Support for OBC This direction of travel - moving away from activity payments to payments for outcomes is supported at a national level. The NHS Outcomes Framework purpose is outlined as ‘providing a national level overview of how well the NHS is performing; providing an accountability mechanism between the Secretary of State for Health and the NHS Commissioning Board; and acting as a catalyst for driving up quality throughout the NHS by encouraging a change in culture and behaviour.’ Importantly from the contractual perspective, the 2014/15 National Tariff Payment System Consultation notice state: “The clear challenge for the health sector is to improve what matters to patients while keeping within a fixed NHS budget. Our teams at NHS England and Monitor are now working together to define a common direction and put in place a coherent national framework to enable this to happen.” The document then goes onto describe ways in which commissioners can move away from PbR to innovate in the way they contract for services.

Work has been underway since Autumn 2011 when with the formation of OCCG in shadow form it has considered changing the way that services are contracted to achieve better value for money and better value for patients. The first stage [Phase 1] of this approach – designing an outline programme governance, and developing the case for change / baseline were completed, offering the CCG a ‘go/ no go’ decision point in January 2013. This business case represents activity undertaken in Stage 2 of the process. The purpose of this document is to outline the benefits of developing a capitated outcomes based approach to commissioning Maternity services in Oxfordshire, and the estimated scale of the potential financial opportunity achievable through this approach.

The OCCG prospectus states: ‘A shift to commissioning for outcomes OCCG recognises there is a need to move away from simply commissioning quantities of activity and instead shift towards measuring outcomes as defined by the patient or service user themselves. We want to radically re-define the basis on which we commission services to put patients experience first. A simple example would be rather than commissioning for a knee operation to take place, we want to commission for an increased level of mobility after a knee operation. Can Mr Jones walk to the shops again?’

Stage 4: Post contract

award is focused on

contract management

and performance.

9 19 Nov 2013

PwC

Case for change Outcomes that matter Blueprint / Service Vision Procurement Process Contract negotiation Run, monitor, improve • Identify population

segments • Map current service

scope for defined population

• Identify current landscape, performance, expenditure, contracts, plans and savings

• Identify the case for making changes to the current arrangements

• Model potential impact of moving to OBC for population group

• Workshops with patient groups to identify outcomes that matter to them

• Test outcomes with clinical reference groups and wider stakeholders

• Develop outcomes hierarchy and measurement

• Map current ability to deliver to outcomes and assess cost

• Understanding of vision and essential components of the desired blueprint

• Design of incentives model

• Market soundings of existing and potential providers

• Assessment of regulatory and contractual considerations

• Ongoing patient, public and clinical engagement

• Recommendation of procurement and contracting options

• Outcome refinement

• Implementation of agreed procurement option

• Agreement of scope and financial envelope

• Vision / blueprint including:

• scope of services to be included

• timing and phasing • payment

mechanisms • Evaluation criteria

agreed • Contract

management arrangements agreed

• Implementation of contract management arrangements

• Evaluation of progress toward outcome goals

• Provider support and on-going collaboration

• Phasing in of new service areas

Key

task

s

• Procurement evaluation of provider proposals for commercial model

• Finalisation of contract

• Contract award• Provider

engagement and co-design of new delivery models

• What is the scope of this work?

• Who is it for? • What are the

challenges? • Is it worth it?

• Can we agree a set of outcomes that matter and are clinically deliverable?

• Is there an outline vision for a service model?

• Are providers able and willing to contract on this basis?

• Can regulatory hurdles be overcome?

• Is there a business case for proceeding?

• Can we assure ourselves that the contracting process will be legal, timely and achieve our objectives?

• Can we let a contract that will deliver for patients and service users?

The end of each step will provide an answer to these key questions:

---------------------------------Phase 2-------------------------- ------Phase 4 ------- ------------------Phase 3-----------------

Introduction and Approach The approach to OBC in Oxfordshire

The below diagram gives an overview of the key activities undertaken during Stage 2 and how this progresses to develop an OBC contract

Business Case - Maternity 10

19 Nov 2013

3. Maternity Services in Oxfordshire - the context today


The purpose of this section is to outline: • Use of maternity services • The provider landscape • Maternity services by location

11 19 Nov 2013

Maternity in Oxfordshire Key Facts

• Female population of Oxfordshire aged 10-49 is 177,307 (2011 census) • Number of live births has increased by 6.4% from 2006 to 2011 • Population for females of childbearing age is projected to decrease by approximately 7,000 by 2021 • It is possible that live births have reached a peak, and will reduce over the next 5 years • 92% of births to Oxfordshire women took place in an Oxfordshire unit or at home.


73%

15%

1%

3% 3%2%

1% 1%

1%

FY11/12 Oxfordshire Births by Location

The John Radcliffe Hospital OUH

The Horton General Hospital OUH

The Cotswold Maternity Unit

Home or en-route

Royal Berkshire Hospital

Wallingford Community Hospital

Wantage Community Hospital

The Great Western Hospital

Other

12 19 Nov 2013

Maternity Services in Oxfordshire Volumes

Cohort size and volumes An analysis of the last year births activity commissioned by CCG has identified 7,206 births having taken place at OUH amounting to c.85% of the total OUH maternity activity. The table below show the breakdown of birth activity between Oxfordshire and other commissioners as per the OUH PASCAL system. The forecast outturn (straight line projection based on 5 months of actual data) estimate the number of OUH births for Oxfordshire residents to be around 6,310 births p.a. in 2013/14.


Maternity Services in Oxfordshire The provider landscape

In Oxfordshire there are two Obstetric Led Units - one at the John Radcliffe Hospital (JR), one at the Horton General Hospital (HGH). There are also four Midwife Led Unit (MLU); one at the JR, and three free-standing MLUs in Chipping Norton, Wallingford and Wantage. Women with low risk pregnancies are cared for by OUHT Community Midwifery Teams. Those with pre-existing medical or psycho-social conditions (“high risk pregnancies”) or complications that develop during pregnancy, are cared for by the Obstetric Team at one of the Units. The intervals at which she is seen are usually the same because they follow nationally determined NICE guidelines. There is also a standard GP protocol for antenatal care which describes what is expected of the GP at different stages. The vast majority of women across Oxfordshire still have their baby at the JR Obstetric Unit (approx. 360 per month). About 130 women per month will deliver at the HGH Obstetric Unit. The MLUs cater for about 100 births per month (with more than half of these giving birth at the integrated MLU Spires Birthing Centre at the JR) and a handful of women (usually between 5 and 15 per month) will have a successful homebirth.

Provider Maternity unit type and location

Oxfordshire University Hospital (OUH)

Consultant led unit – John Radcliffe Hospital, Oxford Consultant led unit – Horton General Hospital, Banbury Integrated MLU (level 7) John Radcliffe Hospital Oxford Midwife led unit MLU – Cotswold Midwife led unit – Wallingford Community Hospital Midwife led unit – Wantage Community Hospital Midwife led unit – Chipping Norton War memorial Community Hospital

Royal Berkshire NHS Foundation Trust (RBF)

Consultant led unit - Reading

Great Western Hospital (GRW)

Consultant led MLU - Swindon

Other Hospitals Home and other


The way in which antenatal care is provided over the following 6 months will differ depending on where the woman lives.

14 19 Nov 2013

Maternity Services in Oxfordshire By location

Each year more than 7,000 Oxfordshire women access maternity services. Usually this begins with a positive pregnancy test at home and a GP consultation within the first two or three weeks. The main point of access to the hospital maternity service is via GP referral to the Oxford University Hospital NHS Trust (OUHT) Community based Midwifery Team, although self-referral is also possible but not common. Once referred to the community midwives, the woman meets the midwife and is assessed and booked into the service (the “booking visit”). Nationally, all women should be “booked” before 13 weeks of pregnancy. In Oxfordshire, about 90% of women are booked by this time. This visit will usually entail a detailed history taking, discussion about options available for antenatal care and delivery, and onward referral for antenatal screening tests. At this point the woman also receives her ‘handheld record’ which will be the main clinical record for her pregnancy and which stays with her at all times. At this point she will also be referred to the Obstetrician if there are clinical reasons for this. Oxford City - In and around Oxford City, some antenatal care will be provided in GP practices by the local midwifery team. Much more care is now provided in local Children’s Centres. Some women will also see their GP during pregnancy. All GPs should be following the local maternity pathway in terms of antenatal care and screening. In low risk pregnancies this will usually mean seeing the GP instead of a midwife for at least two antenatal visits. North - In the north of the county women will often have their antenatal care delivered by community midwives in the Horton General Hospital or in one of two Children’s Centres. Again GP input to antenatal care will vary from practice to practice. North West - The picture is different for women living in the north west of the county. Here women are able to access their antenatal care from the new Cotswold Maternity Unit. This gives them the opportunity to have all their pregnancy care in one place – if their pregnancy is normal. Any pregnancy complications will mean their care is transferred to the Obstetric Team at the HGH and they will receive all their antenatal care (and birth of the baby) in the Obstetric Unit at the HGH.

South In the south of the county about 10 women per month chose to have their care provided by the Royal Berkshire Hospital Foundation Trust (especially if they live around the Henley overlap area where access is easier). The vast majority, however, still chose to receive care from the OUHT Community Midwifery Team. Women living in the south (east and west) can chose to receive much of their antenatal care in one of two MLUs – Wantage or Wallingford. They can also choose to have their babies delivered in one of these units or indeed can chose to return to the JR Unit for their baby’s birth. Antenatally Antenatally, the foetal anomaly screening is provided at the main hospital sites, as is the Early Pregnancy Service (where problems are referred in the first trimester (first three months e.g. bleeding) and the Maternity Assessment Service (when problems develop in later pregnancy e.g. reduced foetal movements). The remaining antenatal screening is provided in the community. Again, access to and staffing of these services differs from the JR to the HGH. Out of Hours, most pregnancy related problems will be referred to the on call midwives and if necessary be referred on to the Maternity Assessment Service at one of these hospitals. Postnatally Postnatally the care received becomes more diverse again with some women having additional support from support workers to establish breastfeeding, and some women (especially those who have had a normal delivery and/or a previous baby) receiving a short period of postnatal care (less than one week) At two weeks postnatally, the maternity service care ends and the family receives a Primary Birth Visit from a health visitor who will now be responsible for the delivery of the national Healthy Child Programme until the child goes to school. At this time the health visitor will also assess the woman’s mental health and if necessary refer on to the Infant Perinatal Service at Oxford Health. At six to eight weeks the woman should have a postnatal examination by her GP, unless there is a particular reason for this to be undertaken at the Obstetric Unit. In addition, the baby will have a 6-8 week examination by the GP and the first vaccination will occur in a local baby clinic, Children’s Centre or GP surgery. Business Case - Maternity 15 19 Nov 2013

4. The Case for Change


The purpose of this section is to outline: • The policy context for changing service provision • The financial envelope • Services in scope • Potential savings

16 19 Nov 2013

Why OBC for maternity services

Having a baby is the most common reason for admission to hospital. Overall outcomes for women in Oxfordshire are good when compared nationally but when things go wrong the consequences are very serious for the woman, baby, her family. Maternity services in Oxfordshire are currently contracted under a national Payment by Results system under a single multi-million pound contract for all OUHT services. Payment for services is based on the activity the Trust generates and is not related to women’s experience or outcomes of the services they receive. Maternity services are monitored alongside a huge range of other unrelated services provided by the OUHT such as trauma services, emergency departments and diagnostic services. It is unclear how the money the commissioner pays for maternity services, translate to the money actually spent on local maternity services, because of the nature of the current contract. There is no reconciliation between the investment in services and the outcomes or experience of the family. The current way of delivering ‘maternity’ services is based on a traditional maternity model and change in services is hampered by both the complexity of the contractual system and the limitations of just looking at the ‘maternity episode’ of pregnancy, birth and immediate postnatal period. At present the commissioner will focus on performance against the measures that are easily available rather than the measures that matter to women and their partners. Indeed it is clear that under the new NHS commissioning arrangements, there is no one organisation that holds all the information about local maternity services. This lack of clarity is replicated nationally around reporting of the Maternity Minimum Data Set. It is clear that maternity services are highly regulated services. All NHS Trusts must comply with Care Quality Commission standards. However, recent experience shows that the regulatory approach does not always ensure high quality safe provision. Local commissioners are well placed to analyse a combination of ‘soft’ and ‘hard’ information and work with providers throughout the year, across a wider set of domains to ensure safe, high quality services. In summary the current system of contracting and service delivery can act as a barrier to innovation and improvement in services. This business case proposes a single outcome based contract for maternity services that should: • Remove disincentives, financial and managerial • Remove barriers for change and innovation • Be driven by women and their partner’s experience not activity and interventions • Incentivise ownership of outcomes even before pregnancy and up to a year after the baby is born


The case for change Why change service provision – the Policy Context

Based on the premise of modern health reform which aims ‘to develop a patient-led NHS’, the identification of service users’ needs is a vital step in commissioning services effectively and efficiently. For maternity services this means providing services that are both ‘women focused and family friendly’. The National Service Framework (NSF) for Children, Young People and Maternity Services (2004) stated that all women should ‘have easy access to supportive, high quality maternity services, designed around their individual needs and those of their baby’. It recognised the importance of addressing the needs of women and their families before, during and after their pregnancy and child birth especially those of disadvantaged women and families. The NSF also recognised the importance of involving partners in the pregnancy and birth as a key opportunity to engage partners at an early stage in the care and upbringing of children. Maternity matters: choice, access and the continuity of care in a safe service (2007) built on the commitments established in the NSF and established a programme to improve choice, access and continuity of care based on a strategy that identified the need for women and their families, especially those from the most disadvantaged communities, to be placed at the heart of maternity services.

Responding to Department of Health objectives for maternity care: • to improve performance against quality and safety indicators; • for mothers to report a good experience; • to encourage normality in births by reducing unnecessary

interventions; • to promote public health with a focus on reducing inequalities; and • to improve diagnosis and services for women with pregnancy-related

mental health problems. • Woman’s overall experience • Providing safe care and reducing unnecessary interventions (Clinical

negligence rates; Maternity care accounted for a third of the clinical negligence bill in 2012-13, which highlights the importance of improving safety)

• Continuity of care (Women’s experiences relating to continuity of care are mixed; midwife to birth ratio graph)

• Choice • Commissioning arrangements (It is unclear how local commissioners

are monitoring the performance of the providers of maternity services and holding them to account)

• Efficiency of local providers of maternity services (e.g. managing capacity)

Efficiency and Effectiveness gains: • Single contract (management) • Reduce/eliminate handover points Respond to user needs and wants (engagement feedback)


The policy context National Audit Office Report

18 19 Nov 2013

Case for change The mother and baby programme

The case for change from a traditional ‘maternity service’ to a longer and broader mother and baby programme is supported not only by users and stakeholders, but also by the evidence base around healthy mother and healthy baby, parenting and seamless services. What happens before, during and after pregnancy has lifelong impact on the health of both the mother and her baby. Poor parenting and poor maternal behaviour will impact strongly on a baby’s health outcomes. The case around the danger of drug and alcohol use is well documented. There is new and increasing evidence that psychosocial stress is linked to ADHD and schizophrenia in children. Mental illness in pregnancy is linked not only to maternal suicide, as a major cause of maternal death, but to mental illness in young adolescents.

In a large county like Oxfordshire the performance data countywide masks some significant variations in both the experience and outcomes for pregnant women. For example women in the north of the county are much more likely to have a caesarean section than women in Oxford City. Women delivering at the HGH are less likely to start breastfeeding their baby than women who deliver at the JR. There is no evidence that this variation is a result of clinical factors, they are simply variations in how care is provided from one part of the county to another. The mother and baby programme will be able to address variation and improve quality through innovation so that women get the same high quality services no matter where they access them.


Pregnancy is also shown to be a critical ‘window of opportunity’ when parents are especially receptive to advice and support. Intervening early in pregnancy to support parents can improve a baby’s life chances in terms of better education, increased employability and reduced offending behaviour. Conversely it is also the period when many women first experience domestic abuse and it is shown that a foetus or baby exposed to maternal stress (such as domestic abuse) can have their responses to stress distorted in later life. In the UK babies are still disproportionally vulnerable to abuse and neglect. In Oxfordshire three of the seven last Serious Case Reviews (where a child is killed or seriously harmed) involved babies under a year old. More than half of children on the Child Protection Register in Oxfordshire are under 5 years old and half of those are on the register for reasons related to neglect by parents/care givers.

Similarly deprivation and poverty affect small but significant pockets of the population (appendices) The CCG is committed to reducing health inequalities and providing a healthy start in life is a key commitment in the Oxfordshire Health and Wellbeing Strategy. In Oxfordshire there are 15,200 children (13%) aged under 16 living in poverty (defined as living in a household with 60% less than the average household income). This is low compared to the national average of 20%, and slightly below the regional median for the South East of 15%, but again there are significant variations between parts of the county. Deprivation is linked to poorer outcomes in terms of teenage pregnancy, maternal obesity, smoking and breastfeeding.

Having a mother and baby programme that is responsible to supporting effective parenting, not just in terms of birth and care of the new-born makes sense locally.

The new mother and baby programme will have the flexibility to address these needs through very local models of provision and through alliances with other organisations, especially the voluntary and community groups.

19 19 Nov 2013

The case for change Mother and Baby OBC Financial envelope

Financial envelope – overall system cost OBC recognises that in order to understand the financial cost of achieving the required outcomes it is important to consider the overall system cost that impacts on the woman’s journey, regardless of the setting in which they take place and / or the commissioner responsible.

As a result, in order to define the OBC financial envelope we have looked at all the services required to achieve the desired outcomes whilst recognising that some services are without doubt in scope and it is relatively easy to see how they would transition to OBC in the first phase. The services however require further analysis to understand if and how they impact on the outcome and whether it is possible to include them in the financial envelope at a later phase of the contract. This may require a change in commissioning arrangements in order allow inclusion.


Mother and Baby Care Programme to 1 year The traditional maternity pathway starts with a visit to the GP and then the first antenatal (booking) appointment and ends approximately 2 weeks after delivery. However, when we ask the public and other stakeholders what outcomes they want from the services they describe outcomes that can only be met by significantly expanding the scope of services currently provided – they can’t be delivered by the current pattern of service. Consultations with users and clinicians have shown that for the outcomes to be achieved the mother and baby care programme needs to start at pre-conception and end 1 year after delivery.

Building the scope of services In order to deal with this complexity the cost of the current services has been allocated to one of the following categories (table on next slide): • Initial scope – these are services that are clearly within scope

and within the contracting authority of the CCG and or the County Council

• Influenced – these are services that are considered to be key to the future service delivery model and hence the provider will be incentivised to influence however the funds sit currently outside the commissioner’s budget, e.g. Primary care, Health Visiting

• Out – these are services that are currently not relevant to the proposed scope and will continue to be commissioned outside the OBC programme. Based on the above the total annual plan spend for Mother and Baby services that could affect the outcomes has been estimated at £54m from which £25.3m will be included in the initial OBC financial envelope. The out of scope services may be revisited during the contract term and re-evaluated as appropriate. The commissioners will look at how those services identified as ‘influenced’ may be brought into scope during the contract term.

20 19 Nov 2013

Case for change Forecast spend and potential impact of OBC


• The total OBC financial envelope for maternity is estimated to be c£25.3m from which c£24m relates to OUH and c1.2m to other non-OUH maternity activity.

• Following the introduction of tariff in FY 13/14 the cost of maternity services has been forecasted to increase by c10.6 % from £27m to £31.5m giving an affordability gap of £4.5m from which £1.5m has been absorbed by the provider to give an agreed budget of £30m.

• A review of the number of births at month five has indicating a fall of c12% in the number of births giving a revised forecast for FY13/14 of c£24m.

• The introduction of OBC is not expected to see a significant reduction in the service provision cost however better integration and improved patient outcome are expected to release cost inefficiencies and allow for better care to be provided within the same financial envelope of £25.3m (£24.1m OUH activity plus additional £1.2m of non-OUH activity).

19 Nov 2013

The case for change Services in Scope

The scope of services to be included has been driven by the impact the services have on each of the four outcomes. It is proposed that in order to meet the four outcomes the service is described as the mother and baby programme of which traditional maternity services are one (large) part. This would also align the outcomes with the Healthy Child Programme (0-5 years) and the Healthy Child Programme (5-19 years). This means that the scope of the new proposed mother and baby programme would include the period from before pregnancy to a year after the baby is born. This is considered to be the optimum timeframe in order to maximise the impact of the four outcomes. It does not mean that the mother and baby programme will deliver all the service in this period but it does mean that the programme will be responsible to outcomes that begin before and extend after what is traditionally described as maternity.


The following services are in scope: • Preconception services • Antenatal screening • New-born screening and examination • Early pregnancy service • Antenatal care • Intra-partum (birth) care • Breastfeeding and infant feeding • Antenatal education

The following services are not in scope: • Sexual health services • Termination of pregnancy services • Specialist (commissioned) services e.g.

Neonatal cots • Gynaecology services • Paediatric services

The following services are not in scope but are influenced by and can influence the services in scope: • GP antenatal services • Health visiting and Family Nurse

Partnership services • County Council’s Children’s Services • Perinatal mental health services

22 19 Nov 2013

The case for change Mother and Baby OBC financial envelope


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�� FY�2013/14� ��

Activity�description�

Estimated�spend�£'000�

Initial�Scope�£'000�

Influence�£'000�

Out��£'000� Comments� �

Maternity�Other�

5,142� 247� 0� 4,894�

Includes�OUH�activity�for�other�commissioners�(c15%�of�overall�OUH�contract�value�for�maternity).�CCG�to�discuss�with�the�commissioners�appetite�for�inclusion�of�their�activity.�Financial�value�is�based�on�an�activity�forecast�of�6,310�number�of�births�and�a�case�mix�as�@M5.�Value�to�change�in�line�with�activity.�Initial�scope�includes�the�Horton�activity.��

�

OUH�Maternity�

24,108� 24,108� 0� 0� OCCG�activity�ate�OUH.�Financial�value�is�based�on�FY�13/14�tariff,�activity�and�casemix�as�at�end�of�Month�5�pro-rated�for�12�months.�Values�will�be�adjusted�in�line�with�any�activity�increase/decrease� �

RBFT�Maternity� 986� 986� 0� 0�

Estimated�plan�value�for�FY�13/14�based�on�2�months�of�actuals.�Scope�inclusion�is�subject�to�confirmation�with�RBFT� �

Postnatal�Mental�Health�

119� 0� 119� 0�Estimated�plan�value�in�block�contract� �

Health�visiting�

7,000� 0� 7,000� 0��Estimated�plan�but�currently�commissioned�by�Area�Team� �

Sexual�Health�

7,000� 0� 0� 7,000��Excluded� �

FNP� 790� 0� 790� 0��

�Estimated�plan�but�currently�commissioned�by�Area�Team� �

Termination� 756� 0� 0� 756� �Excluded� �

Children�centres�

8,500� 0� 0� 8,500�Excluded,�currently�subject�to�OCC�review� �

Total� 54,401� 25,342� 7,909� 21,150� ��

The maternity values shown below are indicative and subject volume changes. The OUH share has been calculated by applying the actual case mix percentage as at month 5 to the forecasted number of births at FY 13/14 using the current maternity tariff rates.

23 19 Nov 2013

Maternity Services in Oxfordshire Potential savings

Savings and affordability forecast The biggest challenge of today’s overall commissioning is to secure appropriate health and social care provision for a population with increasingly complex needs without additional funding For maternity, the commissioner is looking to incentivise providers to work together and improve outcomes, integrate services, ensuring complex cases are managed more effectively and develop the pathway further. It is expected that this will release cost inefficiencies and allow for better care to be provided within the same financial envelope Any additional savings within the contract term, will be shared between commissioner and provider and re-invested in the maternity care programme in services as appropriate. Areas identified for potential efficiency savings include: • Improving performance against quality and safety indicators (reducing the clinical negligence bill) • Reducing unnecessary interventions such as Caesarean sections • Earlier contact with women in order to reduce complications in pregnancy • Being accountable for either providing all services (e.g. Glucose Tolerance Testing) or paying another provider to do it (e.g. new-born

examinations) • Working with the public to agreed to optimal configuration of services that spans from before pregnancy • Ensuring the optimal configuration of services to deliver cost effective and affordable care • Clarifying the role of primary care in the pathway • Reduction in % of deliveries with complication through better care coordination and prevention • The new born examination (paid per case through Local enhanced services) is expected to be absorbed in the long term in the main maternity

tariff and finance through provider efficiencies generated through integration and better care coordination. • Reduction in excess bed days • to a year after birth. Service Map It can be seen from the service map on the next page that there is a dominant NHS provider but it is also clear that the OH and Social services have an important role in the effective delivery of mother and baby services. Users of the services are keen that the services are more closely integrated particularly in the following areas: • Screening • Health visiting • Breastfeeding • Weight management • Smoking cessation


The case for change Service provision in scope by Commissioner and Provider:


MOTHER AND BABY: CURRENT SERVICE PROVISION

MONTH -18 -15 -12 -9 -6 -3 BIRTH 3 6 9 12 15 18 21 24

ServiceCommissioned by: Provided by:

Annual Cost £K:

INTRA-PARTUM

FNP TVAT OH 790

Maternity OCCG OUH 30,469 43%

Maternity OCCG RBHT/GWHT 1,000

GP Primary Care TVAT Antenatal in GMS contract

GP Enhanced Services OCCG 68

Mental Health OCCG OH 119

Health Visiting TVAT OH 7,000

Childrens' Centres OCC SS 9,500

Child Health OCC Small Grants/SLAs 500

TOTAL 49,446

PRE-CONCEPTION ANTENATAL POSTPARTUM EARLY YEARS

51% 7%

19 Nov 2013

Maternity Services in Oxfordshire OBC driving transformation

CONTRACTUAL transformation • Working with a lead provider or integrator to lead the provision of

maternity services and manage the overall maternity pathway and programme budget.

• Promoting service integration and reducing fragmentation. • Aligning incentives for organisations with the goals of the system (i.e.

better outcomes and better value). • Using a contract duration that promotes investment up front, to enable

shifts in working practices to deliver savings and efficiencies over longer term.

• Reducing the number of KPIs to that necessary – with a focus on outcomes.

• Ensuring that NHS Terms and conditions are maintained, but that the contract reflects the new way of working – if we just continue with block contracts we are not commissioning.

CULTURAL transformation • Leaving behind the old PCT culture of an adversarial relationship between

commissioner and provider, and shifting to an approach that is more collaborative, and one of shared problem solving.

• Building a different relationship with the public - patient organisations and representatives involved in maximising value as well as campaigning for more resources.

• Releasing innovative potential in providers, with clinicians taking responsibility for maximising value from the allocated programme budget, and delivering the outcomes the people of Oxfordshire want.

• Facilitating a culture of collaboration and integration between providers across the health and social care economy.

• Doing something different that proves the CCG is different from the PCT, and that encourages providers to “sit up and take notice”


FINANCIAL transformation • Delivering better value, sustainable services, and removing barriers to a

more integrated approach.

• Providing savings to commissioners across both health and social care.

• Incentives aligned with responsibility to deliver the outcomes that are needed.

• Preparing the system for wider transformation - recognising that this contracting model could be applied to all programme budget areas in the future, delivering the same or similar proportions of savings.

OPERATIONAL Transformation • Working with patients/carers and the public to derive meaningful

outcomes. • Increasing clinical engagement in innovation and service design and

improving the use of evidence and information. • Placing greater emphasis on prevention with incentives to work in

partnership. • Aiding the ability to design population based systems and networks. • Working closely with partners across the health and care economy to

ensure they are able to deliver this model in the future for other services

A capitated outcomes based approach will reinforce and supplement this work, incentivising providers to make its delivery a reality.

OPERATIONAL T f ti

OBC driving change for Mother and Baby

26 19 Nov 2013

5. Outcomes that matter


The purpose of this section is to: • Outline the outcome model

• Outline the approach to developing the outcomes including stakeholder engagement • Outline the process and methodology followed by OCCG in developing Outcomes Based

Commissioning • Show the outcomes and indicators selected to take to develop in Stage 3 • Model how these will be incentivised in Stage 3

27 19 Nov 2013

Outcomes that matter Understanding the outcomes model

What is an outcome? An outcome is defined as a health and/or social gain experienced by a person with an illness, as defined from the person’s, rather than the system’s or the clinician’s, perspective. Crucially, outcomes are not the same as processes. Outcomes are the things that meaningfully impact a person’s life – for example, reducing premature mortality, achieving gainful employment, being able to live in stable housing. Outcomes should not be confused with process measures or outputs such as time taken from GP referral to treatment or the use of a mental health assessment tool. An evidence-based approach The COBIC approach for OBC organises outcomes into a hierarchy following that devised by Professor Michael Porter, Harvard Business School. Porter’s hierarchy is an evidence-based approach to improve outcomes that has already been successfully applied to international health systems to inform value-based scorecards. Porter has developed an outcomes hierarchy that has three tiers of outcomes: health status achieved or retained, process of recovery and sustainability of health. Outcomes for the full cycle of health and care To ensure sustainability of health, it is necessary to develop outcomes relevant to the full cycle of healthcare, from an initial problem through to recovery. Developing the outcomes and indicators that providers will be contracted to deliver has been a key part of the OBC work, all providers will share responsibility to deliver the outcomes in the contract. The outcomes should be fixed for the duration of the contract (and beyond), but indicators may evolve and change over time. All outcomes should also be consistent with NICE and national standards.

TIER LEVEL

Tier 1 Health Status achieved or retained

Survival

Degree of health/recovery

Tier 2 Process of recovery

Time to recovery, maintenance of/return to normal activities

Disutility of the care or treatment process – diagnostic errors and ineffective care, treatment related discomfort, complications, or adverse effects, treatment errors and their consequences in terms of additional treatment

Tier 3 Sustainability of health

Sustainability of health/recovery and nature of recurrences

Long term consequences of therapy e.g. care induced illnesses


al

28 19 Nov 2013

Outcomes that matter History of engagement with users, stakeholders and the public

A history of engagement and involvement in maternity services For the past 10 years commissioners, providers, users (past and present) and other key partners such as children’s centres, have worked together to inform the planning, commissioning and delivery of maternity services. The Oxfordshire Maternity Services Liaison Committee (MLSC) was chaired by a paid user representative and focused on promoting normalisation of birth and breastfeeding for Oxfordshire women. The MSLC was the forum that first shaped, debated and agreed the outcomes that have been proposed in this business case. The outcomes, as described were not necessarily new or different because they represented the culmination of user and stakeholder engagement work over many previous years. At a large event in January 2013 an invited audience of women from different social groups (e.g. young mums) and with different experiences (e.g. women with substance misuse problems), joined the existing MSLC members to share their views on the outcomes that matter to them. These outcomes were also checked against the National Maternity Survey carried out by the Care Quality Commission (CQC) in every NHS Trust (2007; 2010 and 2013). This measures women’s experience of maternity services and has been used extensively to inform the outcome indicators. (Results of 2013 CQC survey yet to be published.) A year of engagement with professionals A wide range of professionals have always been involved in the MSLC. Following the workshop in January there was a specific ‘Clinical Reference Group’ established. This group was engaged in developing and refining the outcome indicators, the vision and the service model for the future. As well as ‘virtual’ engagement through group email there were two one day workshops specifically for members of the Clinical Reference Group to get together to develop the next phase of the project. The Health and Wellbeing Board’s engagement The Children and Young People’s Board (as a sub-group of the Health and Wellbeing Board) has endorsed the direction of travel and outcomes on two occasions in the last year. The work is seen as a key vehicle for delivering the commitments in the Health and Wellbeing Strategy around a healthy start in life. Business Case - Maternity 29 19 Nov 2013

Outcomes that matter Stakeholder engagement

Guiding principles of engagement Amongst the principles identified within the CCG’s Communications strategy is the need to use a range of engagement approaches to ensure that the work to develop commissioning based on patient-centred outcomes is underpinned by the views of patients, service users and carers. In taking forward the work, the COBIC team has also adopted the following additional principles that outcomes and indicators must be: • evidence based – informed by both quantitative and qualitative

research • developed iteratively, supported by robust local engagement

processes involving patients, carers and clinicians


All the engagement activities on outcomes for maternity services have taken place in the context of broader programme-wide stakeholder engagement throughout 2013. This spans from a high profile exploratory event in January, through on-going liaison with Localities to the current survey of member practices, and encompasses informal dialogue across the health economy as well as formal provider engagement sessions happening this Autumn. These wider initiatives have influenced a growing awareness of the COBIC approach, and several have also informed the detail of our work on maternity services. The approach to developing outcomes and indicators The Lead Commissioner for Children Young People and Maternity Services has engaged with stakeholders across the health economy throughout the process, as illustrated by a recent presentation to members of the Oxfordshire Children and Young People’s Board. A key theme that has emerged is the requirement for greater integration. This has been strongly voiced by users who are looking for greater integration between services and organisations that support screening and health visiting (Area Teams of the NHS England) and breastfeeding, weight management, smoking cessation (Local Authority)

Talking Health Survey A Talking Health web survey and discussion forum invites people that have used maternity services in Oxfordshire (or will be using these shortly) to have their say on what outcomes they think are most important for the patient when using good maternity services. Due to close on 8th November, this has been publicised via Healthwatch, mumsnet, the Public Involvement Network, Localities, relevant groups listed on OCC’s website, Oxford University Hospital NHS Trust’s patient database and the staff intranet. 124 people had participated at 29th October 2013 The survey gathered feedback on four key areas: • Are the 4 proposed outcomes the right outcomes for maternity

services in Oxfordshire? • Have we got our measures right for these outcomes? • What else should we include and why? • Are there any other comments that you would like to make?

Healthtalkonline An analysis of Healthtalkonline interview collections on Pregnancy, Antenatal Screening, Caesarean section, Infertility. Breastfeeding The outcomes identified are largely supported by data from HTO interview collections that were explored for this analysis. Some gaps were identified in relation to • Ensuring that service planning and delivery is culturally sensitive and

appropriate for each individual • Ensuring inclusion of outcomes that relate to circumstances such as

miscarriage, termination of pregnancy, stillbirth or death soon after birth due to abnormality or health condition.

A complementary questionnaire to seek the views of parents and partners living in Oxfordshire on maternity services has also been developed and distributed by the Public Involvement Network. This probes views, clarifying attitudes, expectations and preferences to help gain a better understanding of the support that parents value and feel they need, and importantly to help define outcomes.

30 19 Nov 2013

Outcomes that matter Talking Health Survey summarized

Overall strong support was given for the four proposed outcomes that have been identified for maternity services in Oxfordshire. No-one disagreed with any of the proposed outcomes. The outcome that respondents agreed with the most was ‘Healthy baby’ with 83% of people choosing ‘strongly agree. The outcome that had the lowest rating was ‘Healthy family’ with 49% of people choosing ‘strongly agree’.


Breastfeeding support – a missing outcome? Greater support for breastfeeding and the need for monitoring of breastfeeding rates was a key issue that was consistently raised in response to the questions throughout the survey as well as in the online discussion forum. It was felt that this issue had been omitted from the four proposed outcomes. Stakeholders suggested it should be listed as either a separate outcome and/or used as one of the key measures for other outcomes. Adequate staffing – particularly midwives The need for adequate staffing levels and in particular the need for more, well-trained midwives was highlighted by many stakeholders as something that was missing from the proposed outcome measures for maternity services. Midwives and midwife related services are clearly valued by patients, and this was reflected in the feedback. However some patients disagreed with the measure for Outcome 4: Experience of Care entitled ‘Having a named midwife caring for you throughout pregnancy’ as they indicated that this was impractical due to holidays, illness, availability of appointments etc. Instead they felt that having a small team of good, well-trained midwives that understand your needs was more important and that continuous/named one-to-one care is more important when in labour. Choice Many respondents highlighted the need for choice with regards to both choice of care and choice of birth option. It was stressed that this choice needs to be a properly informed choice with better communication between professionals and patients to enable this to happen. Use of complex terminology was also mentioned as an additional and confusing issue when patients are asked to make a choice. More and better postnatal care When asked to add any additional comments about the proposed outcomes and measures for maternity services, the strongest theme that emerged was around the need for more and/or better postnatal services. Comments that people shared indicated that for some people the current patient experience of postnatal care is poor and many respondents gave personal experiences as examples. Education for parents Take-up of antenatal and postnatal education for both parents was raised as a suggestion for measuring Outcome 3: ‘Healthy Family – fit and capable to be the parent you want to be’. Issues around the need for better access to this education and the need for support and guidance around inoculations, breastfeeding, and what to expect in the first year were also identified. Involvement of the father Outcome 3: ‘Healthy Family – fit and capable to be the parent you want to be’ received a lot of comments from respondents saying that involvement of the father should be included as a measure. This included involvement both antenatal and postnatal, with suggestions that fathers should be included in measures for education and care of the baby, and that there should be more consideration of the mental health/wellbeing of the father. SMART measures Respondents highlighted the need for SMART measures for each of the proposed outcomes and also indicated that a number of the measures were either too late e.g. measured after 1 year, or that measures needed to be taken at regular intervals throughout pregnancy and after birth to give an accurate picture of success. Other issues raised Other issues raised included: concern around the potential closure of children’s centres and the impact this would have on families; the need for better transition between different maternity services and for better consistency of care/trained staff; and also a number of concerns were raised about the impact of isolation/lack of family support on the parent(s).

31 19 Nov 2013


Healthy Mother Healthy BabyFit and capable to be the parent

you want to be

Experience continuous and seamless care through

pregnancy and birth and throughout the postnatal period

% of women readmitted within 28 days of delivery Stillbirth rate % of parents who feel confident as parents at 6-8 weeks

% of women who felt that they received consistent advice and support/encouragement in first 2 months after delivery

% of women undertaking preconception assessment (incentivise to target risk groups)

Prematurity rate % of parents who feel confident as parents at end of year 1

% of women with a named midewife during pregnancy

Median gestation at first contact Low birth weight (<2500g) % of vulnerable parents that have a positive outcome from a parenting intervention

% of women receiving continuous support during labour

% of women who are pregnant in the flu season, receiving flu vaccination

Perinatal mortality rate % of first time parents that receive parenting education

% of women who felt adequately supported during the postnatal period

% of women breastfeeding at 2 weeks after birth Infant mortality

% of obese women (BMI >30) who reduce their BMI to at least 2kg/m2 in the first 12 months after childbirth

Proportion of live birth at term (>=37 weeks gestation)

% of women assessed for Wholley at booking and at transfer to primary birth visit

% of unexpected neonatal unit (NNU) admissions

Evidence that every woman with a pre-existing mental illness has a documented & implemented care plan for antenatal, perinatal and postnatal care

% of women breastfeeding at 6 months

Desired Outcomes

Outcomes that matter The outcomes that matter and illustrative indicators

32 19 Nov 2013

Outcomes that matter Incentivisation of contracts - sharing risks and benefits

Current contracting arrangements do not promote cross working between settings and providers as in many cases there are strong financial dis incentives. Removing financial constraints allows closer cooperation between different providers so they are able to focus on common outcomes. Clinical professionals drive this focus for reasons of patient benefit, but this is reinforced by the commercial arrangements to ensure that managers no longer have a disincentive built into their contracting arrangements. For this reason it is proposed that the outcomes will carry financial rewards in return for enhanced levels of patient care and outcomes through the implementation of an incentivised contract. A number of factors need to be considered when developing an incentivised contract so that: • it effectively supports and enables good quality outcomes for patients • it is as simple as possible to manage • contract management is not disproportionately cumbersome Pace of Change The proposed incentivised outcomes framework is developed for a “steady state” position, however it is recognised that information and data for some indicators may not be immediately available. As a result, a phased approach for implementation of each indicator will be agreed as appropriate. This avoids the need to change indicators over time as data is available and maintains focus on the overall goals for steady state. For example, year one may be about data collection, year two may have a small performance improvement targeted and the weighting of outcomes changed. The table below illustrates how this may be achieved: As these contracts are envisaged to be offered for a longer than usual period of time, there will need to be a change mechanism which allows for the improvement of outcomes and indicators as necessary in light of new evidence. Changes will be made through agreement of the parties.

Indicator Selection - indicators selected clearly demonstrate achievement or otherwise of the desired outcomes and promote joined-up working across providers. They need to be meaningful for providers and commissioners to monitor and report on. They should aid the provider in managing their operations.

Number of Indicators –limited to ensure focus on monitoring if the desired outcomes are on track. Other measures can still be monitored and reported to aid operational and contract management. Balance required to ensure that monitoring does not utilise a disproportionate resources.

Avoiding portfolio effect - Monitor’s work to develop a pricing strategy showed that small incentive amounts across many indicators produce a portfolio effect, where providers effectively choose which indicators to focus on whilst being rewarded year on year with a broadly similar financial value.

Incentive Quantum - The financial value and proportion of the overall contract value that is ‘at risk’ through Incentivisation needs to be meaningful and material to the provider without destabilising the provider or the wider health economy. Different outcomes and indicators can carry different weightings to allow for flexibility and to recognise complexity of delivery.

Indicator Thresholds - a baseline of performance is established ensuring that the performance is an improvement on current provision with an associated threshold reflecting adequate performance. Performance above this attracts the potential financial reward, further split for good, improved and excellent performance. For some indicators a pass/fail approach will be more appropriate.


Selecting and incentivising indicators

YearAnnual 'Incentivisation Pot'% of 'pot' for each threshold Good Improved Excellent Good Improved ExcellentOutcome 1 9% 18% 40% 18% 25% 50%Outcome 2 0% 0% 0% 10% 25% 50%Total 9% 18% 40% 28% 50% 100%

Year 1 Year 2£1m £3m

33 19 Nov 2013

Outcomes that matter The incentivisation structure for Maternity

Incentivisation In order for incentivisation to work, there needs to be a sharing of any benefits, which can then be reinvested for further development and or delivery of healthcare services. The share will be negotiated in advance between the contracting parties. It is the intention of the CCG to effectively utilise all of the incentivisation budget each year to provide better healthcare for the local population, irrespective of whether or not the providers achieve the performance levels required. To this end, in the event that providers do not receive the full value of the incentivisation ‘pot’, the CCG will look to direct the unpaid monies into specific healthcare services within Oxfordshire.


Next steps Subject to this business case being approved, the following decisions will be taken to move towards the delivery and implementation of an incentivised outcome based contract. Whilst all of elements will be finalised through negotiation with the successful providers, the CCG will need to have a working proposition from which to begin initial provider discussions: • The overall percentage / value of the total annual contract value

that is ‘at risk’ through the incentivisation • The weighting between each of the outcomes • The weightings for each indicator within each outcome • The weightings between ‘good, improved and excellent’ where

appropriate • The speed at which each indicator and the incentivisation takes

affect

34 19 Nov 2013

6. Vision for Mother and Baby Maternity Service


The purpose of this section is to: • Present the Vision for Maternity services – Mother and Baby Maternity Service • Outline the key components to this vision

35 19 Nov 2013

Vision for Mother and Baby Maternity Service

• Having a baby is a natural process that will not involve the woman necessarily becoming a ‘patient’ of the NHS but will involve her and her partner being given the skills and confidence to have the pregnancy, delivery and early start in life that they chose.

• This service will address the needs of women who are thinking of becoming pregnant and who find themselves pregnant. We know that the earlier services can become engaged with women, the better the outcomes for her and her baby.

• Women and their partners will be treated with dignity, compassion and respect and will be able to feedback their experiences easily and will know that their feedback will make a difference.

• There will be many points of access into the Mother and Baby service but we will know that there will be the same high quality of care wherever that contact happens.

• The Mother and Baby Service will have detailed knowledge about their local communities and will have local delivery plans that meet the needs of (very) local communities. This acknowledges that some communities/groups/individuals will need more or different inputs in order to get the same outcomes as other groups/individuals. Local plans will be published and will form the local ‘offer’ to women in that area.

• All women will have access to a named professional in order to develop a trusting therapeutic relationship. The job title of that professional will be less important than the skills set they hold to engage with an individual woman and her partner.

• From conception to the end of the first year of the baby’s life, the woman and her partner will have access to support and education in order to give them the confidence to raise their baby in a loving and secure environment. This will address the physical and emotional aspects of parenthood as well as looking at infant care and nurturing.

• Those families who are assessed to have difficulties or additional challenges will be able to access evidence based services which promote parent-baby interaction.

• The Mother and Baby Service will develop technological solutions to the challenges of keeping women and their partners informed, sharing information across agencies, managing care closer to home and delivering care in community based settings.

• The mental health needs of a woman will be of equal importance to her physical health needs and she will be able to access support according to her needs and where necessary will be able to access specialist perinatal mental support.

• Expectant parents will receive all the information they need to make an informed decision as to how to feed their baby and will be supported in the choices they make. Mothers will be given every support and encouragement to breastfeed their baby. Consistent advice and support on weaning will be available to all mothers at a local level.

• Where problems do arise at any point in the planning, pregnancy or postnatal period, women can expect to be involved in agreeing an individual and integrated care plan that is delivered in collaboration with the woman and her partner.

• The service will be an ‘integrator’ in that it was ensure all parts of the system from primary care to Children’s Centres and voluntary sector providers, are supported to provide a seamless service for women and their partners.

• The service will provide ‘assurance’ that the quality of service remains consistent wherever care is accessed.


VISION 1


VISION 2


7. Commercial and contractual options The purpose of this section is to:

• Demonstrate this approach adheres to Monitor’s principles and guidance • Considers the market options for the route to contract • Outlines the risks and benefits associated with the potential routes to contract • potential critical success factors to consider in the selection of providers in Stage 3 • The contracting form and content • The outline milestones for each route to contract


Commercial and Contractual options Current position

Having a baby is the most common reason for admission to hospital. Overall outcomes for women in Oxfordshire are good when compared nationally but when things go wrong the consequences are very serious for the woman, baby, her family. Payment by results not outcomes Maternity services in Oxfordshire are currently contracted under a national Payment by Results system under a single multi-million pound contract for all OUHT services. Payment for services is based on the activity the Trust generates and is not related to women’s experience or outcomes of the services they receive. Monitoring performance Maternity services are monitored alongside a huge range of other unrelated services provided by the OUHT such as trauma services, emergency departments and diagnostic services. It is unclear how the money the commissioner pays for maternity services, translate to the money actually spent on local maternity services, because of the nature of the current contract. The current way of delivering ‘maternity’ services is based on a traditional maternity model and change in services is hampered by both the complexity of the contractual system and the limitations of just looking at the ‘maternity episode’ of pregnancy, birth and immediate postnatal period. At present the commissioner will focus on performance against the measures that are easily available rather than the measures that matter to women and their partners. Indeed it is clear that under the new NHS commissioning arrangements, there is no one organisation that holds all the information about local maternity services. This lack of clarity is replicated nationally around reporting of the Maternity Minimum Data Set. It is clear that maternity services are highly regulated services. All NHS Trusts must comply with Care Quality Commission standards. However, recent experience shows that the regulatory approach does not always ensure high quality safe provision. Local commissioners are well placed to analyse a combination of ‘soft’ and ‘hard’ information and work with providers throughout the year, across a wider set of domains to ensure safe, high quality services.


Commercial and contractual options Principles and adherence

In summary the current system of contracting and service delivery can act as a barrier to innovation and improvement in services. This business case proposes a single outcome based contract for maternity services that should: • Remove disincentives, financial and managerial • Remove barriers for change and innovation • Be driven by women and their partner’s experience not activity and

interventions • Incentivise ownership of outcomes even before pregnancy and up to

a year after the baby is born Moving forward, it is desirable for the sector, that commercial arrangements support and are aligned to the outcomes, whilst also ensuring that the optimum value for money is achieved for both users of the service and taxpayers with an appropriate risk transfer. The following commercial terms have been developed to support this. An Alternative Payment Mechanism To enable the providers to have the flexibility to deliver the services in the manner they determine is most appropriate to achieve the desired outcomes, the traditional method of payment (block and or activity based payment) is not appropriate and therefore an alternative approach is required. Monitor’s stated long-term aim is to improve the payment system to support delivery of good quality care for patients in a sustainable way. Their proposals are designed to help commissioners and providers address the strategic challenges facing NHS care in three ways: • by offering more freedom, to encourage the development of new

service models; • by providing greater financial certainty to underpin effective

planning; and • by maintaining incentives to provide care more efficiently.

Under the Health and Social Care Act 2012 it is possible to make” local variations” to pricing where “..adjustments to prices, currencies or payment approaches is in the interests of patients to support a different service mix or delivery model. This includes cases where services (with or without national prices) are bundled..”. It also requires that such variations are disclosed to Monitor and published to assist Monitor in facilitating the sharing of experience around new payment approaches. This is expected to help enhance system wide incentives such as prevention, integration, improved outcomes, improved patient experience. Payment approaches might include pathway, capitation or outcomes based payments. Monitor’s consultation document proposes a set of overarching principles to support local price variations. OCCG’s approach supports these to date and will need to continue to do so throughout the contracting process: The principles are: Local agreements must be in the best interests of patients. They must maintain the quality of health care now and in the future, support innovation where appropriate, and make care more cost effective and allocate risk effectively Local agreements must promote transparency and accountability. They should make commissioners and providers accountable to each other and to patients, and facilitate the sharing of best practice Providers and commissioners must engage constructively with each other when trying to reach local agreements. This should involve agreeing a framework for negotiations, sharing relevant information, engaging clinicians and other stakeholders where appropriate, and agreeing appropriate objectives.


Monitor have a clear expectation to see more widespread development of new services, particularly services which give better and more sustainable support to growing patient groups with multiple care needs, such as the frail and elderly and people with long-term conditions. They are also keen to encourage innovation in service design around integrated care. As a result, they are looking to give commissioners and providers’ greater freedom to experiment with new payment approaches to support the new models of care as they develop.

41 19 Nov 2013

Commercial and contractual options Adhering to Monitors guidance

These principles have been further expanded to provide an indication as to what Monitor will be looking for as evidence to support adherence to them.


We have also spoken directly with Monitor (Competition Policy Department) to update it on the progress to date, the approach and proposed actions following approval of the business case. Monitor have confirmed that this approach is consistent with the draft consultation which is expected to be finalised in the near future.

The approach which OCCG is following in determining the financial envelope and the process which will be adopted in negotiating with the provider will adhere to the above principles.

42 19 Nov 2013

Commercial and contractual options Market Options the route to contract

In taking the decision to proceed to Stage 3 OCCG are bound by central policy and guidance, their own standing financial instructions and national and EU procurement legislation. OCCG have stated throughout this process that, given the provider geography, it is likely that current incumbents would continue to be involved in the service delivery in some form. In deciding the appropriate method by which to implement this contract, a number of factors need to be considered. Current policy and guidance The awarding of contracts is subject to significant guidance, policies and legislation. Monitor, the healthcare regulator, has recently issued a consultation document regarding their guidance for commissioners in terms of procurement. Whilst this document is currently only at the consultation stage, it provides an indication as to Monitor’s approach and interpretation of the Health and Social Care Act 2012. The guidance makes it clear that commissioners are expected to act in a way that achieves the following whenever they are procuring NHS healthcare service, irrespective of the process by which they identify the most appropriate provider: • Securing the needs of health care service users • Improving the quality of services • Improving the efficiency with which services are provided Furthermore, commissioners must: • Act in a transparent, proportionate and non-discriminatory way • Procure services from providers most capable of achieving the

overarching objectives including value for money • Consider appropriate ways of improving services including services

being provided in a more integrated way.

The guidance from Monitor refers to circumstances where 'a commissioner carries out a detailed review of the provision of particular services in its area in order to understand how those services can be improved and, as part of that review, identifies the most capable provider or providers of those services'. In these circumstances it may be appropriate to proceed without running a competitive procurement. (page 23 of its draft Substantive Guidance on the Procurement, Patient Choice and Competition Regulations 2013). Monitors website states: "The guidance makes it clear that the regulations do not force commissioners to go out to tender for every service, but equally commissioners should not simply roll-over existing contracts without first asking how good the service is, and whether it could be improved to give patients a better deal. If so, the next steps might be evaluating alternative providers if there are any and if not negotiating a better arrangement with the existing provider. These are matters for commissioners to consider in exercising their duties……..” Available Market Given the wide ranging nature of the proposed outcome based incentivised contract, a number of providers will need to participate. Across Oxfordshire’s health economy, there are a number of providers currently delivering elements of the existing Maternity services. OCCG considers that it is hard to envisage how the service can be provided without at least some of these incumbent providers. That said, their role in the future service delivery model would be need to be determined. OCCG held a provider event on 5th November 2013 to provide an opportunity for the wider provider market to hear about their plans and to understand the potential interest. The event was attended by 14 NHS organisation representatives, 14 Voluntary Sector representatives and 17 private sector representatives.


Commercial and contractual options Route to contract - options

Approach There are two approaches which OCCG could use to identify and appoint providers to deliver the incentivised outcome based contract, taking into account Monitor’s guidance and the objectives which they are looking to achieve: 1. Through existing providers via a service review exercise 2. Via a procurement process such as competitive dialogue Whilst the competitive dialogue approach is well established and the steps which need to be completed are clearly documented, the service review approach is not. OCCG, would through this service review approach, be seeking assurance from the providers of their understanding, capability and appetite to work with the CCG in developing and implementing the new commissioning approach within the required timescales. Irrespective of the approach selected, OCCG need to ensure adherence to the Monitor guidelines. Each is not without its risks of challenge and therefore consideration needs to be given to provide clear evidence of how the decisions have been taken and why, and importantly, the impact on patients.

It is therefore critical that OCCG can clearly demonstrate and evidence adherence to the above in deciding how to source and identify the most capable provider for the service. This will be achieved irrespective of which route is taken. A thorough evaluation of options, decisions and rationales will be undertaken and documented. The needs of the patient is put at the forefront throughout. Recommendation If OCCG were to select Option 1: With existing providers via a service review exercise it is recommended that a staggered twin track approach is taken. By this process a milestone would be identified at the mid-point of the service review. At this milestone point if, OCCG has concerns as to the successful outcome of the process and or the providers indicate that they are unable or unwilling to continue, initial preparation activity should be undertaken to enable them to go to the wider market subsequently if appropriate. In undertaking this at the midpoint this will also put some competitive tension in the process. There should not be any activity with the wider market itself, until such time as the service review process has been completed and the OCCG have taken the decision regarding whether or not to competitively tender the contract. This approach does and should not predetermine the outcome of the provider assessment, but instead looks to limit any delay in implementing the contract should OCCG decide to utilise the competitive procurement route. This is outlined in the timelines later in this section.


We have also spoken directly with Monitor (Competition Policy Department) who we have updated on progress to date, our approach and our proposed actions following approval of the business case. They have confirmed that OCCG’s approach is consistent with the draft consultation which is expected to be finalised in the near future.

44 19 Nov 2013

Commercial and contractual options Benefits and Risks


Option Benefits Risks

1. Proceed with existing providers via a service review exercise

• Less likely to destabilise • Understand the local health economy better • Closer relationships with commissioners • Can be quicker and less bureaucratic • Shows OCCG is collaborative • A smoother and more streamlined process • Flexible approach permitted, unconstrained by formal

procurement processes • Reduced risk of destabilising service provision • Reduced risk of issues arising from service

transition/mobilisation

• Lack of competitive tension to get providers to go further; faster’ • Entrenched views hard to overcome • Current culture not conducive to change • Harder to confirm value for money and that you have indeed got

‘the most capable provider’ • Risk of challenge from providers not involved in process • Tells wider market that OCCG is not ‘open for business’, making

subsequent procurements slightly harder • Risk of challenge that OCCG should have undertaken competitive

procurement in order to comply with the 2013 Regulations • Untested approach in new environment under the 2013

Regulations. Lack of clarity around precisely what evidence is required to identify 'the most capable provider or providers’

• Risk of being able to demonstrate best value for money in the absence of competitive tension

2. Proceed to procurement process such as competitive dialogue

• Sets clear signal to market that OCCG means business • Get more responsive providers • Better demonstration of value for money • Less risk of challenge • You are assured of getting the best providers (*better due

diligence) • Shows OCCG is professional and open to innovation • Provides a safe environment for providers to innovate • Gives third sector and not-for-profit organisations more chance

to get involved. • Should ensure full compliance with the procurement regulations • Maintains competitive tension amongst a number of providers

until quite late in the process - arguably delivering better value for money

• Competitive dialogue may identify solutions not previously considered or identified

• Can take time and is often bureaucratic • Incumbents will feel threatened (but this can be mitigated) • Harder to manage multiple expectations if wider procurement

used • More expensive (but better Return on Investment than

alternative route above) • Risk of insufficient market interest to generate a genuine

competition • Risk that incumbent providers will be able to determine the

composition of stronger/successful consortium

45 19 Nov 2013

Commercial and contractual options Sample criteria for service review

Area Critical Success Factors

Patients/Carers (not providers) are the focus

Will this model result in clear, measurable deliverables to patients? Is there development of a performance and feedback process actively engaging with patients/carers?

Consortium strength Will the breadth of organisations provide the delivery solution? A clear map of the strategic fit of each of the provider organisations?

New working relationships are accommodated in the arrangements

Does the new structure and governance support the key changes required, e.g. integrated top team, systems, shared identity, What are the contractual relationships with all providers Does the alignment of organisations objectives to meet the desired outcomes

Outcomes v outputs A delivery mechanism that works toward patient outcomes and not volumes of activity or inputs

Financial Assessment Demonstration of the investment and savings plan, confidence of achievement. Realistic interaction demonstrated between financial planning and the implementation plan

Prioritisation of objectives and decision-making on workloads and resourcing can take place

Does the structure enable clarity around the strategic objectives to deliver the outcomes? Are their linkages demonstrated across the providers? Is there clarity about who is accountable for what? Are there supporting processes that manage potentially conflicting priorities?

Individuals are clear about their responsibilities and accountabilities and can act in an empowered way.

Does the structure enable application of a performance management system? Can individual and team development needs be identified and resourced to meet desired outcomes?

Timescales/Mobilisation Proposed route map to achieve outcome based Incentivised contract along with patient outcomes and financial benefits

The purpose of this service review is for the commissioner to be assured that the providers have the understanding, capability and capacity to deliver their vision for Outcomes Based Commissioning. Engagement and dialogue throughout the process leading to the contract award is an important lever in OBC which will enable the providers to take greater ownership of the delivery of the service. The commissioner should to be assured through this approach and in the specification of the contract, evidence and plans that the provider will have in place a successful programme to implement and manage the transition to OBC. Criteria for assessment evaluation Critical success factors will be discussed as part of the process. The table provides some potential high level criteria which would be developed further in advance of commencing this exercise. The critical success factors will be applicable to both option routes in determining the successful providers. The success factors have taken into account research evidence highlighting a successfully integrated care service (See Appendices) • The desired outcomes must shape the form that enables them to

happen • Making time and effort to understand each other’s agendas. • Have the right people with the right level of decision-making

power together • How to integrate processes as well as services. • Keep the service user at the heart of the process of change with a

strong focus on achieving better outcomes. • Pay attention to issues in procurement early on, whether they are

about how to integrate different legal and planning processes or address issues around building design and IT infrastructure.


Commercial and contractual options Contracting form and content

Contract Form and Content The final contract form will be based on the latest NHS Standard Contract for Clinical Services. Additionally, to reflect the incentivised, outcome based approach, several additional components will be included:


Contract duration to facilitate effective changes in the service delivery model, a longer term contract is required. This approach supports the providers in developing and implementing their new operational models, and provides an opportunity for the expected benefits to be achieved. A contract length of 5 years with a potential extension of up to 2 years is proposed. There will be appropriate break clauses during the contract period to facilitate a change in provider if required due to unsatisfactory performance.

Change Mechanism this is required to enable flexibility for both the commissioner and provider so that as the service is developed, the indicators reported and feedback from patients is received, changes can be made as appropriate in a non-cumbersome manner.

Gain share arrangement to ensure that providers look for efficiencies as well as meeting patient outcomes, a gain share arrangement is required. Whilst the principles of this can be set out upfront, the details will need to be subject to negotiation with the successful provider.

Greater emphasis on patient / carer feedback

direct patient and where appropriate carer feedback on the service being delivered will form part of the incentivised performance framework to ensure satisfaction and provide an on-going opportunity for improvement suggestions.

Incentivised performance framework

this is part of the heart of the contract to ensure the focus remains on outcomes

Back to back arrangements where there are material subcontractors (in terms of value and or contribution), the contracting provider will be required to have in place back to back legal arrangements to provide OCCG with further assurances that the contract will be delivered as expected. Greater transparency of data and information – this is required to facilitate better partnership working between the contracting parties to deliver changes across the system and better care and outcomes for the patient.

Conditions Precedent prior to the contract going live and at appropriate stages of the implementation process, there will be check points. For the provider to continue with the implementation of the clinical service, they will have to demonstrate to OCCG that they have satisfied agreed preconditions for service commencement.

47 19 Nov 2013

Commercial and contractual options Option 1&2: Milestone Plans


A high level milestone plan for the above recommendation, incorporating both approaches has been developed and is summarised below, along with a brief explanation around the activity required, this is expanded in the Appendices. A full plan would be developed as a first task in Stage 3 depending on the route selected.

48 19 Nov 2013

Commercial and contractual options Milestone Plan outline


Activity Area Key Activities / Purpose

Project Management and Governance Ensures that appropriate Governance and reporting arrangements are in place to oversee timely delivery of the project and that any issues and risks which arise are identified and managed in an effective manner

TUPE Clarify TUPE related implications for each option, understanding the activities required to support this and incorporate this into the overall plan

Communication and Engagement Develop and execute the stakeholder communication and engagement plan, ensuring consultations are undertaken where necessary and that all engagement is held at an appropriate time in the overall process

Transition of Renewable Contracts As individual service contracts come up for renewal from November 2013 onwards, their new terms will take into account the move to outcome based contracting. Relevant indicators, data collection and outcomes will be included to aid the transition to a common set out of outcomes and a single contract.

Service Review Process by which OCCG will seek to be assured as to the understanding, capability and appetite of local incumbent providers to participate in the delivery of the incentivised outcome based contract. Providers have the opportunity to share with OCCG their high level service delivery model which they believe would deliver the specified outcomes for the local population

Negotiation – Willing Provider In the event that the OCCG Governing body are assured that existing providers are able to deliver an effective service delivery model that will achieve the desired outcomes, then a process of negotiation will be undertaken. This will include the finalisation of contractual key commercial terms such as indicator thresholds, risk and gain share, and the financial envelope

Procurement Execution – Competitive Dialogue

Should the OCCG decide to go to the wider market via a procurement exercise, a competitive dialogue approach would be adopted. This enables providers to work with the commissioners to some degree, in developing the final delivery model. There are a number of stages within this and timescales are determined through EU procurement legislation

Mobilisation / Implementation Following the successful appointment of providers, they will work with OCCG to finalise and agree the mobilisation and implementation plan. Progress against this will be then be monitored

Contract Go Live / Contract Management The final stage of mobilisation will be to confirm that the provider has put in place those things which were agreed to be critical to the successful delivery of a clinically safe service. At this point, the contract will go live and OCCG, in conjunction with the CSU and the provider, will deliver, monitor and manage the contract

49 19 Nov 2013

8. Risks and Mitigations


The purpose of this section is to: • To consider the implications of the change management programme required: • Outline the risks and mitigations

• Provider specific • Commissioner specific • General

50 19 Nov 2013

Risks and Mitigations Change Management – implications for commissioners and providers

OBC has a number of risks attached to it including: • A relatively new concept although consistent with OCCG and national

strategy • The route to contract – the process of transition is currently

restricting potential progress as until OCCG decides to implement this approach some stakeholder groups will remain ambivalent at best or wary of investing resource unnecessarily. The experience of Bedfordshire was that provider behaviour changed dramatically once the decision was made to proceed.

A change management programme OBC requires organisational development for the CCG and the providers as it represents a shift in the traditional dialogue and relationship between commissioner, provider and the patient/carer. More fundamentally it will require the providers to lead and be accountable for a significant change management programme in order to reconfigure how they deliver services together. This section focuses on the change management required by providers and how the commissioner can support and influence this change. OCCG have stated that they wish to minimise destabilising providers and there are a number of steps that could reduce the risks inherent in a change management process. In our engagement to date patients/carers clinicians and health and social care practitioners have welcomed the opportunity to design how services are provided to deliver OCCG’s vision. This shift in practice will however require different working relationships, accountabilities as well as structural and systematic changes.

The commissioner, through the route to contract process (service review or procurement) can support, facilitate and enable change by: • Support and open communication throughout • Discussion and agreement with the providers to agree KPIs that

recognise the change management required, particularly within the first year of the contract

• Including questions relating to managing change as part of the critical success factors in selection of the provider.

Open communication Whilst it will be the provider’s responsibility for leading the change management process within their organisations, commissioners should provide support for this. This process should be agreed at the beginning of the next stage of OBC development and could include: • Agree communications with a principle for early, open

communication so that providers can manage and control communication through their own channels to their stakeholders and staff

• Regular executive and board level engagement to ensure top-level commitment to the change across the provider organisations

• Joint commissioning/provider workshops to support the process


Impact on Commissioners This approach similarly needs to be applied to the commissioning team as they move to a new relationship with providers. This will have implications for communications within the CCG but also to identify appropriate learning and development required in moving to: • Conducting service review/procurement • Contract performance monitoring and review • Joint commissioning with OCC in an OBC approach

For maternity there are a number of risks: • Limited competition in the market • Lack of drivers for change in some areas (e.g. very good current provider;

in top decile nationally on RCOG measures) • Political ‘noise’ • Difficulties in changing existing services • Restrictions on ability to move away from PBR

51 19 Nov 2013

Risks and Mitigations Potential unintended consequences

Rationale for impact assessment The proposals for service transformation set out in this business case will, if implemented, have a significant impact on those who provide and use NHS services, and the public. The impact will differ depending on the route to contract selected. As such, following the Governing Body decision regarding the future direction of travel, the CCG should consider an impact assessment is carried out to ascertain the impact of this decision on providers’ sustainability and costs. This assessment will add to the wider analysis of costs and benefits for service users and the public. Undertaking a robust impact assessment of providers will also contribute to the ongoing programme of engagement and will better enable incumbent providers to mitigate risks where necessary. It is particularly important that this assessment takes place in order to identify any unintended consequences and ensure that services outside of those contracts confirmed to be in scope in the next Phase remain stable. The nature of cost structures and co-dependencies across services mean that changes in contracting patterns could affect the sustainability of local providers. Scope of impact assessment The scope and structure of the impact assessment will be informed by national Provider Sustainability Guidance. The key components of the impact assessment could include: • Defining the objectives of the agreed

programme of service transformation • Assessing impact on incumbent

providers: costs and quality • Assessing impact on incumbent

providers: unintended consequences • Benchmarking • Broader health objectives


In addition to risks regarding the process we have identified potential unintended consequences of this process. There are risks attached to the development of an outcomes based contract – particularly as Oxfordshire is among the first tier of CCGs nationally to develop this approach. Importantly however, these risks can be mitigated through the delivery of the approach itself. A full risk assessment is included in the appendices.

52 19 Nov 2013

9. Options for decision The purpose of this section is to: • Outline the options for Maternity for discussion and decision


Decision tree

19 Nov 2013 Business Case- Maternity 54

OCCG has requested the following flowchart used to assist the decision to proceed to Phase 3.

Options for Decision The business case


Area Phase 2 activity Phase 3 activity

Defined outcomes Over the past 18 months there has been a process for describing, testing and checking the outcomes that matter for women and their partners. The four outcomes that have been agreed have strong consensus. An incentivision model has been applied to all indicators.

Further testing of outcomes and indicators with providers (in both routes to contract). Review of data availability and collection

Financial envelope and services in scope

The financial envelope has been identified with analysis of contracts in scope now and those with potential to be included later.

Further refinement with providers and development of incentivisation and risk transfer model

Potential for improvement

The financial model demonstrates potential impact of OBC compared to PbR. Identifies potential areas where savings could be achieved.

Providers required to demonstrate how they would work together to deliver efficiencies

Clinical Vision A clinical vision has been developed outlining the transformation required and what needs to be different with OCCG leads influenced by the service scope and engagement sessions with the OCCG leads for Maternity. This has extended the scope to 12 months after birth.

Providers required to demonstrate how they can change working practices to achieve vision

Contractual options Options for route to contract have been outlined with risk assessment, milestones and criteria that could be selected

Negotiation with providers risk transfer, Incentivising to develop a contract structure that deliver the requirements.

The business case. Does the business case demonstrate the following sufficiently to move to Phase 3 activity? • defined outcomes • financial envelope and services in scope • potential for improvement • clinical vision

55 19 Nov 2013

Options for decision Considerations

Having a baby is the most common reason for admission to hospital. Overall outcomes for women in Oxfordshire are good when compared nationally. Maternity services in Oxfordshire are currently contracted under a national Payment by Results system under a single multi-million pound contract for all OUHT services. Payment for services is based on the activity the Trust generates and is not related to women’s experience or outcomes of the services they receive. It is unclear how the money the commissioner pays for maternity services, translate to the money actually spent on local maternity services, because of the nature of the current contract. The current way of delivering ‘maternity’ services is based on a traditional maternity model and change in services is hampered by both the complexity of the contractual system and the limitations of just looking at the ‘maternity episode’ of pregnancy, birth and immediate postnatal period. At present the commissioner will focus on performance against the measures that are easily available rather than the measures that matter to women and their partners. Indeed it is clear that under the new NHS commissioning arrangements, there is no one organisation that holds all the information about local maternity services. This lack of clarity is replicated nationally around reporting of the Maternity Minimum Data Set. It is clear that maternity services are highly regulated services. All NHS Trusts must comply with Care Quality Commission standards. However, recent experience shows that the regulatory approach does not always ensure high quality safe provision.

Over the past 18 months there has been a rigorous process for describing, testing and checking the outcomes that matter for women and their partners. The four outcomes that have been agreed, emerged very early on in discussions with users and have changed little over time. Indeed there has been a huge consensus from users, the public, clinicians and other stakeholders that the following outcomes are right for maternity services In summary the current system of contracting and service delivery can act as a barrier to innovation and improvement in services. This business case proposes a single outcome based contract for maternity services that should: • Remove disincentives, financial and managerial • Remove barriers for change and innovation • Be driven by women and their partner’s experience not activity

and interventions • Incentivise ownership of outcomes even before pregnancy and

up to a year after the baby is born


Options for Decision Route to contract


ROUTE TO CONTRACT Is there potential for the incumbent provider market to deliver the outcomes. Given the wide ranging nature of the proposed outcome based incentivised contract, a number of providers will need to participate. Across Oxfordshire’s health economy, there is one provider currently delivering most of the existing Maternity service. OCCG considers that it is hard to envisage how the service can be provided without this incumbent provider. That said, their role in the future service delivery model would be need to be different to deliver the new mother and baby service.

There are two approaches which OCCG could use to identify and appoint providers to deliver the incentivised outcome based contract. These take into account Monitor’s guidance and the objectives which they are looking to achieve. The routes are expanded in Section 7: Commercial and Contractual Options, they are : 1. Through existing providers via a service review exercise 2. Via a procurement process such as competitive dialogue

Wider provider market. OCCG held a provider event on 5th November 2013 to provide an opportunity for the wider provider market to hear about their plans and to understand the potential interest. The event was attended by 14 NHS organisation representatives, 14 Voluntary Sector representatives and 17 private sector representatives. The feedback from the providers was very positive regarding holding an event at this stage and all sectors, particularly third sector providers expressed a keen desire to be involved further. Over the last year a number of CCGs have started to work in this way and some have already progressed to the procurement stage. Bedfordshire has let a £120m contract for musculoskeletal services and Cambridgeshire and Peterborough CCGs are in the middle of procuring a lead provider to deliver older people services and provide integrated acute and community pathways in a 5 year contract worth £1bn. Other CCGs include Northumberland CCG, Bexley CCG, Croydon CCG, Herefordshire CCG and Sheffield CCG.

It is recommended that if OCCG decide to follow route 1 via a service review exercise a staggered twin-track phase is followed. In this method if OCCG has concerns as to the successful outcome of the process and/or the providers indicate they are unable or unwilling to continue, initial preparation activity should be undertaken to enable them to go to the wider market if appropriate without a significant impact on the timeline.

National Interest and Support There is significant interest nationally in the decision OCCG is taking. OCCG have engaged nationally with NHS England and No. 10 in this approach. Monitor are very interested in the outcomes of this. Public Health England are keen to support development of integrated services across health and social care.

57 19 Nov 2013

10. Appendices Inclusions:

Assessing the benefits of OBC Commissioner mechanisms to drive savings Case Study References Evidence from case studies on integration Childhood Deprivation Option 1 milestone detail Option 2: milestone detail Potential provider contractual models Risk


Appendix: Assessing the benefits

A capitated outcomes based approach to commissioning maternity services will drive value across the system in a number of ways. The following approach has been used to outline this value, indentifying the potential benefits achievable through the approach in Oxfordshire

Financial benefits Quantifiable savings achieved

through similar approaches

Financial benefits Associated quantifiable and

non-quantifiable financial benefit(s)

The financial benefits identified from similar approaches will show the scale of the potential benefits achievable in Oxfordshire, and will be triangulated with the benchmarking analysis to act as a check on achievability in Oxfordshire. The non-financial benefits evidenced from similar approaches, and best-practice case study examples, will give an indication of the typical activities/ benefits which commissioners can incentivise through the approach. Where possible, the financial benefits associated with best practice provider behaviours (including benchmarking) will be triangulated with savings achieved from similar approaches, to assess the scale of the potential opportunity.

The quantifiable financial benefits identified from ‘best practice’ behaviour will be used to assess the scale and range of benefits achievable, providing an indication of the savings that specific interventions could make in Oxfordshire

Nec

essa

rily

inte

rrel

ated

Assessment of the scale of

potential benefits using evidence from similar

approaches (i.e. capitation, outcomes based mechanisms

etc.) both nationally and internationally

Identify typical ‘best practice’

behaviour which can be incentivised through a capitated outcomes based approach (and

the mechanisms available to enable commissioners to do so)

Outline how a capitated

outcomes based approach can reinforce the transformational work already underway within

Oxfordshire, helping to make its delivery a reality

Non-financial benefits Quality, outcomes,

patient/staff experience etc.

Non-financial benefits Quality, outcomes,

patient/staff experience etc.

Risk benefits Relating to the risk of

delivering planned QIPP

Delivery benefits Relating to the speed at which

planned QIPP can be achieved

Type of benefit What will these benefits tell us?

The benefits related to risk and delivery will give an indication of how an outcomes based approach will reinforce the transformational work already being undertaken across Oxfordshire – showing how the value of the approach relates to existing schemes.

Draft.


The level of savings achievable in Oxford can be driven by Oxfordshire CCG itself, with a number of mechanisms to drive provider value enabled through an outcomes based approach.

10% 12.5% 15%

less

less

no

high

<3 years

lower

traditional

less

more

more

yes

lower

5+ years

higher

proactive

more

Saving Indicator How will the largest savings be achieved?

Degree of competition introduced through tender process

Capitated budget allocation to prime provider

Work with new entrants through competitive dialogue to bring innovation

Specificity of tendering documentation (i.e. service design)

Length of contract

Gainshare model – split of savings shared between provider(s) and commissioner(s)

Contract management technique

Stimulation of market

Providers tend to respond better to threat of loss of income through competition

More budget translates into more freedom to innovate

If incumbents only used, less change is possible as less potential for innovation

More innovation is possible with looser specifications – joint problem solving

Longer contracts allow investment in early years to release savings later

The higher % of identified savings shared with providers incentivises improved

performance

NHS standard Ts and Cs plus proactive contract management to secure ongoing

provider performance

More engagement and flexibility offered to providers - more savings possible

Degree of saving achievable

Draft.

Appendix: Commissioner mechanisms to drive savings


Case study reference list (1)

Cawston T et al, 2012, ‘Healthy Competition’, Reform, available at: http://www.reform.co.uk/resources/0000/0364/Healthy_competition.pdf Cochrane et al, 1998, ‘Senior surgeons and radiologists should assess emergency patients on presentation: a prospective randomised controlled trial’, J Roy Coll Edin: 43:324-7. Curry N and C Ham, 2010, ‘Clinical and service Integration: The route to improved outcomes’, The King’s Fund, available at: https://www.kingsfund.org.uk/sites/files/kf/Clinical-and-service-integration-Natasha-Curry-Chris-Ham-22-November-2010.pdf European Observatory on Health Systems and Policies, 2009, ‘Capital Investment for Health: Case Studies from Europe’, available at: http://www.sfes.info/IMG/pdf/capital-investment-for-health.pdf#page=27 Corrigan P, Hicks N, 2012, ‘What organisation is necessary for commissioners to develop outcomes based contracts? The COBIC Case Study’ Available at: http://www.rightcare.nhs.uk/downloads/RC_Casebook_cobic_final.pdf Imison C et al, 2012, ‘Older people and emergency bed use: exploring variation’, King's Fund. Johri M et al, 2003, ‘International experiments in integrated care for the elderly: a synthesis of the evidence’. International Journal of Geriatric Psychiatry, 18(222–35). Klein S, 2011, The Veterans Health Administration: Implementing Patient-Centered Medical Homes in the Nation’s Largest Integrated Delivery System’, The Commonwealth Fund.

Appendix: Case Study references


Case study reference list (2)

KPMG, 2013, ‘Buurtzog Community Nurses, Holland’, available at: http://www.kpmg.com/global/en/issuesandinsights/articlespublications/value-walks/pages/netherlands.aspx Mitchell F et al, 1996, ‘Intermediate care: lessons from a demonstrator project in Fife: J Integrated Care 2011:19 (1) McCarthy D et al, 2009, ‘Geisinger Health System: Achieving the Potential of System Integration Through Innovation, Leadership, Measurement, and Incentives’, The Commonwealth Fund. NHS Confederation, 2011, ‘The search for low-cost integrated healthcare: The Alzira model – from the region of Valencia’, available at: http://www.nhsconfed.org/Publications/Documents/Integrated_healthcare_141211.pdf Torbay Care Trust, 2009, ‘Integrating health and social care in England: Lessons from early adopters and implications for policy’. Journal of Integrated Care: 17 (6). Turning Point, 2010, Benefits Realisation: Assessing the evidence for the cost benefit and cost effectiveness of integrated health and social care, available at: http://www.turning-point.co.uk/media/23642/benefitsrealisation2010.pdf Weatherly H et al, ‘Financial integration across Health and Social Care: Evidence review’, The Scottish Government Social Research, available at: http://www.scotland.gov.uk/Resource/Doc/303234/0095107.pdf White et al, 2010, ‘Impact of senior clinical review on patient disposition from emergency department’, Emergency Medicine Journal: 27:262-5 Young et al, 2007, ‘Post-acute care for older people in community hospitals: a multicenter randomized controlled trial’. J Am Ger Soc: 55: 1995-2002.

Appendix: Case Study references


Appendix: Evidence from case studies on integration


Evidence Base Large Scale Change Outcomes for patients

Evaluating integrated and community-based care: how do we know what works? Bardsley, M et al Nuffield Trust. (2013)

That planning and implementing large- scale service changes takes time. Pay attention to the process of implementation as well

as outcome. There is a need to be explicit about how desired outcomes will arise and to use interim markers of success.

From the Ground Up: A report on integrated care, design and delivery. Institute of Public Care, Oxford Brookes University (2010)

Clearly map the strategic fit of each of the partner organisations to identify opportunities as they arise. Have the right people with the right level of decision making power together around the table.

Have trust and confidence in each of the partners and recognise that all are working to the same outcomes. Keep the service user at the heart of the process of change with a strong focus on achieving better outcomes. For a successfully integrated care service, the outcomes must shape the form that enables them to happen.

Making integrated care happen at scale and pace. Ham, C, Walsh, N. The Kings Fund (2013)

Find common cause with partners and be prepared to share sovereignty and develop a shared narrative. Develop a persuasive vision to describe what integrated care will achieve Establish shared leadership Build integrated care from the bottom up as well as the top down Pool resources to enable commissioners and integrated teams to use resources flexibly. Recognise that there is no ‘best way’ of integrating care Set specific objectives and measure and evaluate progress towards these objectives Innovate in the use of commissioning, contracting and payment mechanisms and use of the independent sector

Identify services and user �groups where the potential benefits from integrated care are greatest. Support and empower users to take more control over their health and wellbeing

Joint Commissioning in Health and Social Care: An exploration of definitions, processes, services and outcomes.Dickinson, H et al National Institute for Health Research, Service Delivery and Organisation Programme (2013)

The study confirms the findings of numerous previous studies of patient and public involvement; that it is difficult, time consuming and fragile in the face of radical organisational or policy change.

The value of joint commissioning as a concept is seen as inherently good and able to deliver against a range of issues that health and social care organisations struggle with e.g. involving the public and service users in the design and delivery of care services.

Commissioning in health, education and social care: models, research bibliography and in- depth review of joint commissioning between health and social care agencies. Newman et al

• Trusting relationships between commissioners, and how these are built up over time by continuity of staff.

• Clarity over responsibilities and legal frameworks, particularly in the context of any shared or pooled financial arrangements.

• The importance of coterminosity between organisational geographical boundaries; the development of clear structures, information systems and communications between stakeholders. 63 19 Nov 2013

Appendix: Childhood Deprivation


Appendix: Option 1: Milestone detail


Appendix: Option 2: Milestone detail


Appendix: Potential Provider contractual models

This section outlines the contractual models.

Alliance Contract The principle of the contract is to incentivise a number of

providers to collaborate in order to deliver a specific service. Typically the commissioner would hold a single contract with a number of providers. The providers would share a

common performance framework and measures. Each provider would maintain their own internal controls as well

as have collective accountability for the delivery of the services. This means that the providers are reviewed against

their performance as collective rather than as individual organisations. Risk and reward is shared.

Prime Contracting A contracting model which enables commissioners to transfer the responsibility and risk for the delivery of

specific services to a single provider. The commissioner holds a single contract with a prime contractor, who then

subcontracts aspects of the service to other providers. The prime contractor is a single point of contact for the

commissioner. The prime contractor has responsibility for the delivery of the full service and so coordinates the

delivery of the services amongst the subcontractors and manages their performance.

Integrator Contract An integrator contract is differentiated by the fact that the

contracting authority (who subcontracts to all other providers) is not a care deliverer – rather an external organisation typically expert in logistics and care co-

ordination. In addition, this model gives the commissioner limited provider engagement – they mainly contract with the integrator, who in turn subcontracts to the necessary providers; thus the integrator engages with the providers,

and the commissioner primarily engages with the integrator alone.

Separate Legal Entity It is possible that a number of provider organisations could form a separate legal entity for the delivery of this service

which would then contract with OCCG. This approach does not require subcontracting however it is costly for

individuals and consequently may discourage some organisations from participating.


Risk management is an important part of the programme management. Anticipation and mitigation ensuring the programme delivers the transformation required. The risks have been categorised as using the methodology shown below with risk assessments undertaken before and after the recommended mitigations.

Risk Score Risk Rate Score – Automatic calculation [Severity/Impact] multiplied by [Likelihood]. Will show green for scores between 0 and 6, amber between 7 and 15, red between

0 - 6 Green 16 and 25.

7. - 15 Amber Severity / Impact Severity Impact Descr Likelihood Likelihood

Descr Likelihood Detail

16. to 25 Red

1 Insignificant 1 Rare Condition currently well managed or no evidence to support effectiveness of treatment, or the event is not expected to occur apart from in exceptional circumstances.

2 Minor 2 Unlikely Satisfactory (average when compared to other comparators), or the event could occur some time.

3 Moderate 3 Moderate Some management of condition, or the event should occur at some time.

4 Major 4 Likely Poor management of condition (higher than other comparators), or the event will occur in most circumstances.

5 Catastrophic 5 Certain No or ineffective management of condition, or the event is expected to occur in most circumstances.

Appendix: Risk methodology


There are risks attached to the development of an outcomes based contract – particularly as Oxfordshire is among the first CCGs nationally to develop this approach. Importantly however, these risks can be mitigated through the delivery of the approach itself.

Oxf

Risk�Number1

2

3

4

5

6

7

8

ordshire�CCG�-risks�associated�with�Phase�3�implementation

Group Risk�Description

Severity�/�Impact��(1-5)

Likelihood��(1-5)

Risk�Rate�Score�(severity�x�likelihood�) Controls/Mitigations Impact Likelihood Risk�Score

Engagement Wider�OCCG�staff�and�teams�are�not�as�engaged/enthusiastic�about�OBC�as�programme�sponsors

3 4 12 Agree�a�formal�cascade�process�for�senior�OCCG�managers�to�disseminate�information�to�their�teams�routinely.��Ensure�the�support�required�to�implement�OBC�is�included�in�individual�and�team�performance�objectives.��Lead�managers�for�each�workstream�to�draft�a�monthly�highlight�report�outlining�progress�against�agreed�milestones

2 1 2

Engagement Political/external�interest�and�pressure�due�to�innovative�nature�of�programme

3 4 12 Key�external/political�stakeholders�continue�to�be�engaged�throughout�process,�ensuring�the�process�remains�at�all�times�within�national�guidance.

3 1 3

Engagement Local�health�economy�concerns�about�major�changes�to�commissioning

4 4 16 It�is�important�to�clearly�articulate�the�difference�between�the�changes�arising�from�contracting�and�those�arising�from�the�provider�driven�blueprints�and�service�vision.�It�is�essential�that�communication�and�engagement�processes�are�developed�within�the�provider�organisations�to�ensure�staff�uncertainties�are�proactively�managed�through�existing�communication�channels�such�as�team-briefs�to�ensure�accurate�and�timely�information�is�given�to�affected�staff�to�minimise�uncertainty.�The�OCCG,�CSU�and�providers�will�need�to�establish�a�joint�communication�plan�for�this�engagement.

2 2 4

Project�Governance Challenging�timeframe�for�project�delivery�and�risk�of�attempted�escalation�of�the�timeline�to�achieve�early�savings

4 4 16 Detailed�plan�with�clear�escalation�framework�and�regular��highlight�reports,�to�outline�any�blockages�which�put�the�programme�timeframe�at�risk.�A�review�of�the�project�team�for�delivery�is�required�to�ensure�the�right�skills�are�available�to�support�the�project�managerially,�technically�and�clinically.�Early�visibility�of�the�benefits�of�strategic�change�v�short-term�QIPP�must�be�effectively�communicated�from�the�Phase�2�business�case.

2 2 4

Project�Governance Failure�to�make�key�decisions�in�clear�and�timely�way�leading�to�delay�and/or�failure�to�progress�the�programme�to�completion.

4 4 16 Robust�governance�and�programme/project�management�arrangements�will�identify�key�decisions�and�when�they�need�to�be�made.�Decision�will�be�primarily�around�the�selection�of�a�lead�contractor�for�the�contract.

2 3 6

Project�Governance Failure�to�understand�information�governance�requirements�leading�to�a�commercial�/�contract�proposal�that�cannot�be�delivered

4 3 12 Working�closely�with�the�CSU,�adherence�to�Information�Governance�Policies�will�be�a�central�theme�to�the�development�of�candidate�indicator�monitoring�and�data��flows�and�that�contractual�and�operating�proposals�take�them�into�account.�

2 1 2

Project�Governance Ability�of�CSU�to�support�OCCG�and�project�with�sufficient�pace,�drive�and�commitment.

5 3 15 It�is�important�that�from�the�start�of�Phase�3�that�the�CSU�identify�those�individuals�with�key�responsibilities�to�work�closely�with�the�OCCG�to�support�the�information�management,�financial�&�engagement�strands�of�the�project.�Both�delivering�on�the�milestones�within�the�project�plan�but�also�'mainstreaming'�the�work�so�that�it�is�embedded�in�the�management�processes�going�forward.

2 2

4

Project�Governance Insufficient�dedicated�managerial�and�clinical�resource�and�leadership�delivering�the�project�from�within�the�CCG�and�CSU�and�liaising�constructively�with�potential�providers�to�shape,�guide�and�implement�the�changes

5 5 25OCCG�and�CSU�dedicated�time�and�resource�has�been�limited�in�Phase�2�due�to�other�conflicting�pressures�and�a�lack�of�alignment�with�other�OCCG�core�deliverables�and�strategies.�This�must�be�fully�resolved�when�moving�into�Phase�3�delivery.

2 2

4

Risk�Rating�after�mitigations

Appendix: Risks and mitigations (1)


Oxf

Risk�Number

ordshire�CCG�-risks�associated�with�Phase�3�implementation

Group Risk�Description

Severity�/�Impact��(1-5)

Likelihood��(1-5)

Risk�Rate�Score�(severity�x�likelihood�) Controls/Mitigations Impact Likelihood Risk�Score

Risk�Rating�after�mitigations

9

10

11

12

13

14

15

16

17

Project�Governance Insufficient�access�to�capital�to�support�the�pump�priming�of�capital�developments�underpinning�system�changes

5 3 15 Early�sight�of�provider�plans�is�key�to�understanding�the�planned�investment�requirements�and�enabling�the�OCCG�and�their�advisors�to�facilitate�access�to�investment�funding�supported�by�robust�financial�plans

2 3 6

Providers Incumbent�providers�are�not�engaged�and�/�or�are�sceptical�about�programme�and�resist�potential�change�to�the�status�quo

3 4 12 Engage�with�and�involve�providers,�throughout�the�programme�so�they�are�informed�at�each�step.��Ensure�executive�team�are�responsible�for�liaising�with�senior�provider�staff�on�a�regular�basis.��Continue�to�engage�with�other�providers,�hopefully�bringing�incumbents�into�the�conversation�whilst�also�mitigating�risk�of�service�interruption�should�incumbents�leave�or�fail�in�their�bids.��The�OCCG�need�a�Governing�Body�that�is�supportive�of�the�OBC�approach�to�stand�firm�against�incumbent�providers�resisting�change�and�potential�loss�of�control

3 2 6

Providers Failure�to�adequately�develop�the�prime�provider�market�resulting�in�no�willing�capable�provider(s)

4 3 12Working�with�providers�(both�incumbent�and�external)�identifying�their�capacity,�capability�and�willingness�to�undertake�significant�change�has�been�an�important�element�of�Phase�2�and�this�will�continue�into�Phase�3.��The�selection�of�the�appropriate�procurement�strategy�is�fundamental�to�this�process.

2 2 4

Providers Letting�a�contract�that�destabilises�existing�providers�risking�security�of�provision�of�other�services�to�the�population�of�Oxfordshire

4 4 16 The�process�of�selecting�a�lead�contract�holder�will�include�an�assessment�to�ensure�their�transition�plans�properly�consider�the�impact�of�changes�to�service�provision�and�the�impact�on�patients�and�staff;�supported�by�a�realistic�delivery�plan�with�a�clear�scale�and�pace�of�change.��The�final�agreed�transitional�plan�will�be�mapped�into�the�outcomes�based�contract�to�that�the�delivery�of�the�changes�are�as�incentivised�as�the�final�vision.�It�is�anticpated�that�providers�will�be�encouraged�by�the�proposed�longer�terms�contracts�offered�by�an�outcomes�based�approach.

2 2

4

Providers Lack�of�vision�from�provider(s)�only�proposing�marginal�change�and�therefore�the�potential�that�the�innovation�and�integrated�working�envisaged�by�the�OCCG�and�OCC�will�not�be�delivered.

4 4 16 It�is�important�to�adhere�to�the�outlined�process�of�provider�assessment�and/or��competition�to�ensure�that�there�is�a�continued�motivation�for�providers�when�considering�service�options�to�remain�focused�on�delivering�the�blueprint�for�change�outlined�by�the�OCCG.�If�incumbent�providers�are�unable�to�persuade�the�Governing�body�that�they�are�able�to�drive�the�necessary�system�changes�then�the�market�could�be�opened�to�new�entrants�to�potentially�work�alongside�the�existing�organisations.�This�process�can�be�suported�by�the�sharing�of�best�practice�examples�and�facilitating�new�partnerships.

2 3

6

Scope Failure�to�include�a�sufficiently�wide�range�of�services�within�the�agreed�contract�scope�to�enable�the�outcomes�to�be�achieved

4 4 16 It�is�evident�from�Phase�2�that�there�is�a�clear�correlation�between�the�scope�and�contract�envelope�and�the�influence�on�the�outcomes�for�a�patient�cohort.�If�the�final�scope�is�too�restricted�then�the�lead�contractor�will�find�it�difficult�to�achieve�the�outcomes�that�matter.�It�is�important�that�the�relationship�between�scope�and�outcomes�is�maintained�and�further�developed�over�the�contract�term.

2 3

6

Scope Risk�of�overly�complicating�the�definitions�and�outcomes 3 3 9 The�approach�must�start�and�remain�as�simple�as�possible�with�exclusions�from�the�capitated�approach�being�limited�and�only�where�essential�to�maintain�the�widest�scope�for�the�agreed�population�cohort.

2 3 6

Outcomes�and�indicators Outcomes�are�challenged�by�providers�during�the�process 3 3 9 It�is�expected�that�the�outcomes�and�indicators�will�continue�to�be�developed�in�conjunction�with�the�provider�.�However�the�work�undertaken�in�Phases�1�and��2�has�tested�that�the�outcomes�are�those�that�matter�and�therefore�it�is�not�expected�that�too�much�deviation�will�occur.

2 36

Outcomes�and�indicators Data�is�unavilable�to�measure�the�indicators 4 5 20 �It�is�expected�that�in�moving�to�an�outcomes�approach�new�datasets�will�be�required�and�new�ways�of�collecting�data�will�have�to�be�established�over�the�contract�life.�It�is�important�that�this�transition�plan�is�articulated�in�provider�plans�with�clear�milestones�linked�to�the�outcomes.

2 36

Appendix: - Risks and mitigations (2)
