World Class Commissioning Panel Report documents/NHS … · commissioning activity for which it remains formally accountable. Ratings were combined to reflect the judgement of the

World Class Commissioning Panel ReportBexley Care Trust

14 April 2010

1

Overview

First, the panel thanks Bexley NHS Care Trust for participating in this round of assessments for World Class Commissioning (WCC)

The panel asks the PCT to accept this report in the spirit in which it is intended: a support tool on the journey to world class commissioning and as a considered view of the organisation’s strengths and weaknesses based on the insight the PCT itself gave the panel into its commissioning approach

The PCT is a clinically driven organisation with a relentless focus on quality improvement

The panel feels that the results from the competencies self-assessments do not match the panel’s perceptions during the assurance test

The panel identified 5 main recommendations that the PCT will need to consider as it positions itself to drive the transformation of health and healthcare in Bexley

2

CommentaryThe panel identifies 5 major areas for consideration by the PCT at this stage on its journey

1. Headline: Strong clinical engagement and alignment of information systemsObservation: Strong clinical engagement and efforts to improve quality and cost effectiveness (e.g., reducing referrals by 20% in one year)through prioritised improvement efforts and especially information systems to enable this. The panel observed a focus on quality improvement that permeated every activity and discussion. The panel observed that the incentive model which helps to drive much of this is biased towards transactions, but that the PCT recognises this and wants to move to a more outcome-based accountability model supported by incentives. Recommendation: (1) Ensure that you preserve a diversity of clinical leadership (including social care practitioners) and preserve relationships with CHS during separation; (2) Continue with your plans to move to a more outcome-based accountability model

2. Headline: Improving relationship with the Local AuthorityObservation: The PCT has worked closely with the local authority (LA) to renew its relationship. In the last few months the PCT created a Borough Directorate that links closely with the LA to strengthen the public health agenda. This should provide an evidence base for use in PBC and other commissioning workRecommendation: Continue to work closely and develop this relationship. Strengthen public health professional input into the PCT and consider how the sector can support with this

3. Headline: Managing the financial challengeObservation: The PCT came out of a financial turnaround successfully in the last few years. Today the PCT faces a more difficult financial climate than ever before. There is a need to shift activity out of acute and into polysystems, and the PCT has done commendable work on clinical engagement and building a culture of improvement. However, the PCT did not produce evidence that there are detailed implementation plans underpinning this Recommendation: The panel recommends that the PCT reflects on its approach to finance to ensure it is able to articulate clearly the financial challenge it currently faces, both to staff and external observers and to ensure that it works closely with providers and monitors at Board level the progress against savings targets and targets for shifting activity without losing the focus in clinical quality

4. Headline: Balancing local innovation with national and regional prioritiesObservation: The PCT demonstrated multiple examples of innovation (e.g., use of MEDE, development of Kite Mark scheme, creating a culture ofimprovement, incentive schemes). Recommendation: Ensure you continue to relentlessly monitor progress on priority outcomes in order to move quickly from Fair to Good in CQC. Ensure you continue to relentlessly monitor progress on priority outcomes

5. Headline: Sharing practiceObservation: The panel notes that the evidence submitted on panel day went far beyond what was submitted in written documentation. The panelalso notes that other PCTs in London are not aware of some of the good practice in Bexley, and Bexley could do more to actively share this. Additionally on panel day and in documentation the Board did not share many examples of what it has learned from other PCTsRecommendation: Share your practice with others and also look for best practice to emulate in your priority areas

3

Potential for Improvement Commentary

PCT trajectory

xx

Commentary

xx

Areas for development

xx

Commentary

xx

Areas for development

Organisational development

• The PCT demonstrated rigorous financial management during its turnaround, which began in 2007. Increase in spend had been driven by acute

• The PCT has worked to strengthen its relationship with LA• Today the PCT demonstrates a rigorous focus on quality

improvement

• The panel acknowledges the good work the PCT has done in the last few years to complete a financial turnaround

• The panel acknowledges the view of the leadership that “success does not just happen, it’s created” and the panel agrees that the PCT has achieved that

• The panel recommends that the PCT reviews its strategic financial position and scenario plans, to ensure that all members of the board can articulate the financial challenge’and closely monitors progress against targets to address it

• Build on the work in progress to revitalise the JSNA process and document

• The panel recognises that the team is new and suggests that it focus in the coming year on understanding the interdependencies in their roles with members about to explain key priorities for areas outside their main remit

• The panel suggests that if the PCT continues on its current path it will improve in its execution against national and regional targets

• The panel suggests the PCT reflects on how it can move from transactional to outcome-based methods (e.g., incentive scheme for GPs)

• The panel suggests the PCT shares its practice with other PCTs in London and nationally and learns from others as well

• The panel recognises that the Care Trust took to heart the feedback from last year and made some changes directly as a result (e.g., recruiting Board members with relevant expertise)

• The panel recognises that the team is relatively young (most here for 1 year)

• The PCT had to make some difficult management cuts due to financial turnaround. The PCT recognised the changing governance landscape and so evolved its organisation with that in mind

• The panel notes that the PCT does not have multiple examples of sharing with other PCTs or learning from them

Overall PCT scores, reflecting sector assessments The WCC process in London reflects the development of sector commissioning. Sectors began to take responsibility for acute commissioning and performance management on behalf of PCTs during 2009/10. Sectors were assessed for specific governance elements and certain competencies most relevant to these responsibilities:

Strategy– Vision and objectives– Initiatives to ensure delivery of strategic goals– Consistency of financial plan with the strategy– Board challenge ownership, ownership and monitoring of strategic plan delivery

Finance– Robustness of planning assumptions

Competencies– Competencies 4 and 7-11

The sector assessment process followed the PCT process – sectors completed self-assessments, these were analysed and sector panel assessments held.

Sector scores for the above governance elements and competencies have been combined with PCT scores to give an overall rating for the PCT. This is to ensure that, as in other parts of the country, a PCT’s score reflects the full range of commissioning activity for which it remains formally accountable. Ratings were combined to reflect the judgement of the panel and confirmed at regional calibration.

The way in which the ratings have been combined, in order to give an overall rating is set out in the next four slides. The rest of the panel report (slide 9 onwards) reflects the panel’s assessment of the PCT. The Sector assessment is available in a separate report.

Overall PCT scores - governance

Finance

Board

Robustness of planning assumptions is the only Finance element for which sectors were assessed and sector and PCT scores have been combined.

The Board scores for the PCT were not influenced by those of the sector. Therefore the 2010 Board scores for the PCT are those from the panel assessment that are found later in this document.

Strategy

Overall score24-30 Green17-23 Amber10-16 Red

Overall score26-30 Green17-25 Amber10-16 Red

Ratings were awarded points on the basis that R=1, A=2 and G=3. For governance areas where Sectors were assessed, the PCT and sector points were combined. For elements where the sectors were not assessed the PCT points were doubled. The total number of points was then converted to an overall RAG rating using the banding scales indicated.

Bexley Care TrustPoints

SELPoints

Combined points

Bexley Care TrustPoints

SELPoints

Combined points

Vision Initiatives FP Board Milesto. OverallA A R A A2 2 1 2 2

A R R A2 1 1 2

A4 3 2 4 4 17

Historic Fin Mgmt Assump Base Scenarios OverallG A R A R3 2 1 2 1

R1

A6 4 2 4 2 18

Overall PCT Scores, reflecting sector assessments (1/2)

Sub-competency Sector score PCT scorePCT combined

score

Competency 4• 4a- Clinical engagement • 4b- Dissemination of information• 4c- Reputation as leader of clin. engage.

• 2.00• 1.00• 2.00

• 3.00• 3.00 • 3.00

• 2.00• 3.00 • 3.00

Competency 5• 5a- Analytical skills and insights• 5b- Understanding of health needs trends• 5c- Use of health needs benchmarks

• 1.00• 2.00• 2.00

• 1.00• 2.00• 2.00

Competency 3• 3a- Influence on local health opinions • 3b- Public and patient engagement• 3c- Improvement in patient experience

• 2.00• 3.00 • 3.00

• 2.00• 3.00 • 3.00

Competency 2• 2a- Creation of LAA based on joint needs• 2b- Effective partnerships• 2c- Reputation as active, effective partner

• 3.00• 2.00• 2.00

• 3.00• 2.00• 2.00

Competency 1• 1a- Reputation as local leader• 1b- Reputation as change leader• 1c- Employer of choice

• 2.00• 3.00 • 2.00

• 2.00• 3.00 • 2.00

CompetenciesSectors were assessed for competencies 4 and 7-11 and so for these the Sector and PCT scores have been combined to give an overall PCT

score.• For competencies 4a, 7a, 7c, 9, 10 and 11 the competency must be achieved for all services. Hence the lower of the two levels achieved by

the PCT and Sector was taken as the overall score. • For competencies On items 4b, 4c, 7b and 8 the competency does not need to be achieved for all services. Hence the higher of the two

levels achieved by PCT and Sector was taken as the overall score.

The final score for 2010 WCC is in the column at the far right, highlighted in grey.

Overall PCT Scores, reflecting sector assessments (2/2)

Competency 7• 7a- Knowledge of provider capacity• 7b- Alignment of capacity and needs• 7c- Creation of effective patient choices

• 1.00• 1.00• 1.00

• 1.00• 1.00• 1.00

• 1.00• 1.00• 1.00

Competency 8• 8a- Identification of improvements• 8b- Implementation of improvements• 8c- Collection of quality information

• 2.00• 1.00• 2.00

• 2.00• 3.00• 2.00

• 2.00• 3.00• 2.00

Competency 9• 9a- Understanding of provider economics• 9b- Negotiation of contracts• 9c- Creation of robust contracts

• 1.00• 1.00• 1.00

• 1.00• 2.00• 1.00

• 1.00• 1.00• 1.00

Competency 10• 10a- Use of performance information• 10b- Performance discussions• 10c- Resolution of contract issues

• 1.00• 1.00• 1.00

• 2.00• 1.00• 2.00

• 1.00• 1.00• 1.00

Competency 11• 11a- Measuring efficiency, effectiveness• 11b- Identifying opportunities to maximise• 11c- Delivering sustainable efficiency

• 1.00• 1.00• 1.00

• 1.00• 1.00• 1.00

• 1.00• 1.00• 1.00

Competency 6• 6a- Predictive modelling skills and insights• 6b- Prioritisation of investment• 6c- Incorporation of priorities into invest.

• 1.00• 1.00• 1.00

• 1.00• 1.00• 1.00

Sub-competency Sector score PCT scorePCT combined

score

National medianWorstvalueStrategic priority

Bestvalue

00 100

th percentile

Nat

iona

l Lo

cal

0.5M: 83.7

-3.723.6

-2.40.95

22.11573.4

n/an/a

n/an/a

M: 73.2

M: 15.6

83.2

0.56

241.9

n/a

n/a

8. COPD prevalence

2. Life expectancy (Males) & Life expectancy (Females)

1. Health inequalities (Males) & Health inequalities (Females)

3. Under 18 conception rate

4. Proportion of children who complete MMR immunisation by 2nd Birthday

5. Smoking quitters

6. Stroke deaths within 30 days

7. For IAPT proportion of people completing psychological treatment assessed as moving to recovery

-2.8

-0.2

n/a

3.2M: 4.0 M

F-2.7

0.75

0.92

0.01

0.54

0.86

0.03

M

0.5 F

F: 10.7 F: 1.4

F: 78.1 F: 87.8

9. Diabetes controlled blood sugar

10. CHD controlled blood pressure

M

F MF

FMF

M

information not available

information not available

8

Strategy

A

Finance

A

Board

A

GOVERNANCE

Local leader of NHS

Collaborates with partners

Patient and public engagement

Clinical leadership

Assess needs

Prioritisation

Stimulates provision

Innovation

Procurement and contracting

Performance management

Ensuring efficiency and effectiveness of spend

Bexley Care Trust COMPETENCIES

Level 4

Level 1

Overall PCT position, reflecting sector assessment

Current TimePeriod

01/01/2004 -31/12/2008

01/01/2005 -31/12/2007

01/01/2004 -31/12/2006

01/04/2008 -31/03/2009

01/04/2008 -31/03/2009

N/A

N/A

01/04/2008 -31/03/2009

01/04/2008 -31/03/2009

01/04/2008 -31/03/2009

Health outcomes and qualityOutcomes Selection Date: 2009/10

PCT Rate of Change

Previous

Current

9

Governance – Panel assessment on Strategy

1. Vision and goals2. Initiatives to ensure delivery of strategic goals and the PCT’s

programme of change 3. Consistency of financial plan with the strategy4. Board challenge, ownership and monitoring of strategic plan

delivery5. Achievement of milestones to date

A

Red Amber GreenMeasureAssessment

Last year’s rating This year’s self-ratingPanel Assessment

Rationale for scoring

Recommendations going forward

1. Vision links to national content and main health needs, e.g., CHD, sexual health, MH. The PCT described how it engages clinicians in the vision and in focussing on core areas like end of life care. Not all outcomes have measurable targets and timelines in the CSP (e.g., mental health IATP had no milestones and diabetes has no interim milestones), but the PCT states that it has milestones for some of its roundtable groups

2. 13 initiatives address overall vision and priorities. Initiatives like COPD will address health inequalities although it will not lead to financial savings. Impact of initiatives on health outcomes not always clear (e.g., MH). Initiatives mapped to HfL pathways. Timelines for impact of each initiative on each outcome not evident in documentation (e.g., mental health dementia initiative). The submission stated polysystem plans would be more developed in March 2010, but on panel day there was limited discussion of this

3. Dis-/investments including timelines against initiatives over 5 years provided. There is one person in charge of the business cases and reviews these before they go to the resources committee. However, impact against each initiative insufficiently described in documentation. Link between dis-/investment decisions and health outcomes unclear. Planned surpluses increase to a reasonable amount of £3.5m in 2013/14 (FP) and contingencies cover quantified risks

4. Clinical leaders have been instrumental in the development of the strategy. It was not evident in the board minutes that there is regular and robust challenge of the strategy by the NEDs. On panel day the NEDs described how they fed into the strategic discussions (e.g., MMR and changes at Queen Mary’s) and their toughest Board issues (provider externalisation and coding issues in acute). In documentation it was not evident that progress against initiative milestones was discussed at Board meetings, however it will have a scorecard going forward

5. The PCT has a history of meeting milestones (e.g., progress on financial turnaround), and a history of exceeding some milestones (e.g., smoking). Not clear from documentation if past performance against milestones was thoroughly reviewed to identify causes of non-delivery and drivers of success. On panel day the PCT articulated some of its lessons learned (e.g., from the decommissioning in community gynaecology; from the primary care front end on the A&E, which was not efficient). The PCT reflected that ongoing engagement, information systems and sound processes are instrumental in the areas where it has successes

• Ensure you set milestones and interim targets for improvement of outcomes• Ensure there is a link between dis-/investment decisions and health outcomes

10

Governance – Panel assessment on Finance

1. Historical financial management2. Robust financial management3. Robustness of planning assumptions4. Sustainable financial position as ‘base case‘5. Sustainable financial position under different financial scenarios

A





1. The PCT paid off £17m in debt in the last 3 years. The PCT outturn for 2008/09 was £130k surplus which was in line with SHA expectations. The PCT outturns for 2006/07 and 2007/08 were £8.5m deficit and £52k surplus respectively.

2. Monitoring is robust and there is a financial report at each board meeting where the board reviews the PCT’s progress against key national finance targets (e.g., board minutes 13/01/09). There is evidence of a better payment practice code in excerpt from accounts where % of bills paid by NHS creditors in 2008/09 was 98% (p.36). The information dashboard for GPs picked up the issues in acute, the PCT acted and took £10m of activity out. The PCT helped lead APOH to match capacity and demand

3. Inflation assumptions do not seem to align with SHA guidance (acute A&E attendances and planned same day procedures are forecast to grow only circa 0.9% year on year; population assumptions are not mentioned). Contingencies from 2011/12 onwards are well above SHA guidelines of 0.5% (e.g., 3.5% in 13/14). Initiative delivery plans lack detail. The Board stated there are only £1m more in productivity improvements they can make

4. The PCT forecasts operating surpluses of circa 1% for 2011/12 - 2013/14 (in line with SHA expectations of 1%), however, forecast surplus for 10/11 is £1k (1% different from SHA expectations). Initiative plans are not detailed, with high level milestones, only some metrics and little evidence of targets. Detailed polysystem plans to be ready by March 2010.

5. The PCT forecasts operating surpluses of circa 1% for 2011/12 - 2013/14 (in line with SHA expectations of 1%). However, as in base case, a surplus of only £1k is forecast for 2010/11 (agreed with the SHA). There is no mention of upside scenario. There is little explanation of how plans will adjust in a downside scenario besides “BCT is only able to maintain its financial health if it manages its performance with the acute sector well and contains growth and activity within planned amounts” (CSP 51)

• The panel recommends that the PCT reflects on its approach to finance to ensure it is able to articulate clearly the financial challenge it currently faces, both to staff and external observers, and to ensure that it works closely with providers and monitors at Board level the progress against savings targets and targets for shifting activity

11

Governance – Panel assessment on Board

1. Organisation2. Risk3. Information4. Performance5. Delegation6. Board interaction

A





1. The PCT had to undertake restructuring in recent years due to resource constraints. The PCT eliminated the DPH, but has a newly formed Borough Directorate from which it gets analytical and health needs insights. In future it expects much PH capacity will be at the sector. The organisational development plan references staff engagement, however, there is no mention of a staff survey. The PCT explained its priority areas for staff processes (e.g., linking outcomes to appraisals, tracking sickness and absence electronically). There is no mention of refreshing values in light of the separation of community health services

2. The governance framework states that the Board will take an active interest in the management of significant risks, however no risks from the risk and Governance team have been discussed in the minutes that have been submitted. On panel day the Board described its top 3 risks as managing acute over-performance, capability gaps and delivering APOH, however, they lacked detailed mitigation plans

3. The performance reports submitted provide consistent and actionable data that is timely and accurate, however , there is no evidence that board and quality reports do the same (e.g., the threshold for Hospital Acquired Pressure Ulcers is zero however, 68 were reported in July - how was this discussed). MEDE informatics is used for primary care. The PCT acknowledges CHS data could improve

4. Financial performance indicators are reported at each Board meeting, however, there is no evidence that quality, clinical or service indicators are reported consistently across all major care settings (CHS, MH specifically). On panel day the Board explained how it was alerted to over-performance at SLHT and as a result of actions eliminated £10m in activity. The PCT is not delivering on Vital Signs for stroke, immunisation and teenage conception commitments, and has prioritised these on the outcomes list

5. The PCT submitted a series of tables to illustrate the proposed structures of organisations with delegated responsibility including CSL, however, they do not clearly show roles, responsibilities or accountabilities. On panel day the Board described how it has joint commissioning arrangements with the LA for mental health. The PCT has supported the development of the sector and planned with this vision in mind

6. The Board has played an active role in shaping strategy from the early stages, however, there was no evidence in documentation that shows their role in prioritising investment or making investment tradeoffs. On panel day the Board described trade-offs like investing in COPD and teenage pregnancy even though the savings would not be realised until many years down the line, however examples were limited

• Ensure the Board is focussing on managing the financial risk in areas beyond over-performance (e.g., savings) • We note the PCT did a review of SLHT and we encourage the PCT to continue to be vigilant in working with the sector on this• Focus on robustly arranging and monitoring LA agreements• This is a new team and they need to ensure they understand each other’s roles and areas that have inter-dependencies (e.g., Finance, and LA)

121 3 year period where available – please see appendix for variations where applicable for some indicators4 Top decile defined as the PCTs with the largest rate of improvementSOURCE: Team analysis

Outcomes

Bexley Care Trust health outcomes and qualityOutcomes Selection Date: 2009/10

Previous

Current

Newly SelectedUpper QuartileLower Quartile

Top quartile rate of improvement

x

Bottom quartile rate of improvement

x

Changes in outcomes from last year• The PCT has 10 outcomes and deselected 5 (i.e., infants

breastfed, hypertension, 4hour A&E, screening for diabetic retinopathy, and proportion of deaths that occur at home). They added 5 outcomes (i.e., under 18 conception, IAPT, COPD, diabetes controlled blood sugar and CHD). These changes were based on a prioritisation process (CSP 55,56)

• An example of challenge from stakeholders during outcome selection is the inclusion now of child health, and the development of three initiatives to support this

• The 8 selected outcomes are in line with the key health needs (i.e., CHD, sexual health and MH). Elderly and maternity outcomes were not included in this priority list because they are already business as usual and incentivised

Performance over last year• The PCT exceeded its target for smoking quitters• The PCT specifically selected outcome targets on which it is low

and expects to improve them over the next year

Recommendations• Look to other PCTs who have best practice in your areas of focus• Ensure you are addressing the issues of underlying data

availability and quality in IATP, COPD prevalence and stroke• Prioritise improvement in CHD controlled blood pressure

Aspirations• Ensure you have interim milestones for outcomes and also

granular targets for specific geographical wards

Strategic priority

Nat

iona

l Lo

cal

8. COPD prevalence

2. Life expectancy (Males) & Life expectancy (Females)

1. Health inequalities (Males) & Health inequalities (Females)

3. Under 18 conception rate

4. Proportion of children who complete MMR immunisation by 2nd Birthday

5. Smoking quitters

6. Stroke deaths within 30 days

7. For IAPT proportion of people completing psychological treatment assessed as moving to recovery

9. Diabetes controlled blood sugar

10. CHD controlled blood pressure

PCT

PCT aspiration (CAGR)ONS cluster Top decile 4National

3 year historic rate of improvement (CAGR, %) 1

0.5 0.5

-3.7 -3.7

-2.4 -0.6

22.1 10.1

n/a n/a

n/a n/a

-2.8 0.4

-0.2 0.9

n/a n/a

3.2 1.7M

-0.7F

0.0

-5.1

7.2

n/a

n/a

0.3

0.5

24.0

0.0

0.0

5.0

0.4

0.0

-0.4

3.0

n/a

n/a

-1.0

1.0

n/a

0.8

1.2-2.7

0.8

-6.2

5.4

22.1

n/a

n/a

3.1

1.7

n/a

-3.9

-9.4

M

0.5 0.5 0.00.3 0.6F

13

Overview – Competencies

Competency

Locally lead the NHS

Work with community partners

Engage with public and patients

Collaborate with clinicians

Manage knowledge and assess needs

Prioritise investment

Stimulate market

Promote improvement and innovation

Secure procurement skillsManage the local health system

Ensuring efficiency and effectiveness of spend1

1.

2.

3.

4.

5.

6.

7.

8.

9.

10

11

1 Competency added this year, hence last year’s rating not available

Level

1 2 43

This year’s self ratingLast year’s ratingPanel Assessment

Topline introduction• Bexley Care Trust provided

evidence to meet their self-assessment on competencies 4 and 11

• The PCT did not show evidence to meet their self-assessment on the remaining competencies

14

Competency 1 – Panel assessment

• Reputation as the local leader of the NHS

• Reputation as a change leader for local organisations

• Position as an employer of choice

Last year’s rating This year’s self-rating

Level321 4Measure

Are recognised as the local leader of the NHS

Panel Assessment

Competency



• Key stakeholders agree the PCT is recognised as a local leader of the NHS (score of 5.16 out of 6). There is evidence the PCT actively participates in the local health agenda. (e.g., PCT and PBC practices driving new commissioning initiatives leading to new service - outreach outpatient clinics in cardiology, gynaecology, weight management), CSP 71. There is no clear evidence in the CSP (e.g., survey data) to confirm that the local population agrees the local NHS is improving services. There is evidence the PCT understands and acts upon patient experience and reputation levels (e.g., clinically-led process with informed patient engagement resulted in improvements to the MSK pathway)

• Key stakeholders agree that the PCT significantly influences their decisions and actions (score 5.16 out of 6). There is evidence the PCT is working with key partners and stakeholders (Strategic Health Partnership, LiNks, Voluntary and 3rd sector) in developing new service for Bexley residents (e.g., Bexley A&E data-sharing model rolled out to local partners to assist them to target their resources to reduce A&E admissions). The PCT has supported sector development and was the first to contribute staffto the sector. Bexley was a leader in the APOH programme

• Feedback survey indicates that 67.8% of all commissioning staff have received job-relevant training, learning or development in the last 12 months (SHA score 75.2%). There is evidence the PCT has identified capacity and capability gaps and has a detailed action plan to address gaps in skills and capabilities (OD plan, 34, 40), however, the OD plan does not reference the staff survey. At panel day the Board explained that it aspires to improve in staff appraisals and electronic systems to monitor sickness and absence. The PCT received a Silver Award for investment in the development of its finance staff. The PCT has undertaken a programme to train graduate doctors as GPs

• The panel observed that the PCT’s good work (e.g., referral reduction) has often gone un-noticed in other PCTs in London and nationally. The panel suggests that the PCT shares its practice with others and also looks for best practice to emulate in its priority areas

• The panel notes that the PCT was close to a level 3 on 1a, however they did not show evidence of the population agreeing that the PCT is improving services

15


• Creation of Local Area Agreement based on joint needs

• Ability to conduct constructive partnerships

• Reputation as an active and effective partner

Level321 4Measure

Work collaboratively with community partners to commission services that optimise health gains and reduce health inequalities and deliver increased productivity


Competency



• There is evidence the LAA targets were refreshed in March 2009. There is evidence the PCT priority outcome indicators are aligned to the findings in the JSNA (e.g., teenage conception rates identified as an urgent priority). PCT and LA are jointly accountable for LAA targets. Every quarter the council’s performance team produces a performance report for submission to the Joint Management Board and Partnership Core Group

• Key stakeholders somewhat agree that the PCT proactively engages their organisation (score 4.96 out of 6). The PCT has worked with the Borough Council to produce a JSNA (September 2008) which identifies the health needs of the population. The PCT is undertaking a review of the JSNA to reflect current needs and has done further local analysis. It is not clear if the PCT regularly evaluates partnership effectiveness, however, in the last few months the health partnership board was rejuvenated. The PCT has a joint post children’s commissioning post. They have just agreed a business case for joint mental health commissioning. The PCT role in the specialised commissioning agenda is outlined in the ‘Proposed London PCT Collective Working Arrangements and Proposed Establishment Agreement for the London Specialised Commissioning Group document. CE and Chair meet with the CE and chair of LA monthly

• Key stakeholders agree that the PCT is an effective partner (score 4.57 out of 6). There will be joint commissioning of mental health. The PCT in partnership with the Strategic Health Partnership Board and LiNks has worked together to redesign services (e.g., redesign of MSK, cardiology and diabetes pathways) CSP 70-71. The PCT has worked with partners to start to deliver APOH and worked with the LA on child obesity and smoking

• Continue to create strong relationships with partners, building on the progress made in the last year• Continue to review and update the JSNA document and involve stakeholders in the process

16

• The PCT has effective strategies for communicating with the public and patients including seldom heard groups (e.g., Patient Participation Group, ‘WoW’ – Wellbeing on Wednesday; Healthy Futures:– a project involving children and teenagers). Key stakeholders only somewhat agree that the PCT proactively shapes the health opinions and aspirations of the public and patients,(score 4.36 out of 6). There is evidence the PCT has clear success stories of delivery (e.g., LTC – services such as virtual ward, care navigation teams, community nurses link care between the hospital and home, reducing the need to admit or stay in hospital;diabetes – community provision of care, self management and education to be rolled out in 2010/11). The panel did not see evidence of the PCT proactively shaping public health behaviours

• There is evidence the PCT knows the impact of public and patient involvement and engagement and can demonstrate engagement has led to improved health and service experience, e.g., APOH consultation – delivery of UCC, Maternity Choice project, dental and optometry services changed in response to approach by patient groups. There is evidence that seldom-heard groups are involved in service review (e.g., Healthy Future:– a project involving children and teenagers, SMILE – oral health, recommissioning of a mental health service from local provider). There is evidence the PCT gathers information from patients andthe public. There is evidence the PCT captures patient/public views which have affected commissioning plans. The public has some confidence in the local NHS (score of 63.3 out of 100)

• The PCT has focus groups and surveys and also finds out what patients think via everyday encounters through the ‘make us better’ comment scheme, patient experience through quantitative (such as GP surveys) and qualitative methods (PALS, complaints). There is evidence the PCT collects patient experience, PALS queries and complaints and can demonstrate how this information has led to improvements in quality care, e.g., community cardio clinics supplemented by diagnostics in local surgeries; Crisis and home treatment services. Patient experience built into PBC kite mark plans. The PCT has DEAN (diversity, equality, and action network) which recently undertook a mapping exercise to ensure the right groups are involved


• Influence on local health opinions and aspirations

• Public and patient engagement• Improvement in patient experience

Level321 4Measure

Proactively build continuous and meaningful engagement with the public and patients to shape services and improve health


Competency



• Ensure that in addition to listening and engaging with patients and the public, the PCT is proactive in communicating the impact of public engagement to the public as well as making them aware of current and potential health initiatives.

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• Clinical engagement• Dissemination of information to support

clinical decision making• Reputation as leader of clinical

engagement

Level321 4Measure

Lead continuous and meaningful engagement of a broad range of clinicians to inform strategy and drive quality, service design, and efficient and effective use of resources


Competency



• The ‘NHS Bexley’ approach involves clinicians, allied health professionals and PBCs (CSP 70). There is a clinical cabinet that advises on policyand a clinical executive (made up of GPs) that advises on nuts and bolts (e.g., contracting), and a PEC. There is also a graduate practice based commissioning scheme for younger doctors. Clinical leadership is emphasised across many pathways (e.g., diabetes and cardiology). The Bexley Diabetes Practice Development Team is comprised of local clinicians and a diabetologist from Queen Mary’s Sidcup. The PEC is no longer dominated by doctors (the head is an optometrist and there are many nurses as well) and there are additional roundtables (e.g., Mental Health), which facilitate links between acute and primary sector, as well as having secondary care programme directors to advise on commissioning and supervise quality

• Bexley have introduced a MEDE system which provides trust data at patient level and enables the management of service delivery in line with best practice, and the sector is planning to roll this out across SEL. The Map of Medicine programme is being installed in every practice. While there was only 1 PBC response to the survey, the quality, format and frequency of information were all rated ‘very good’. Each GP gets an online statement each month that includes information about spend in acute and the most expensive patients. This allows for follow-up discussions about excess bed days, etc. There is evidence that budgets are agreed. One example is of redesign is in cardiology, which has focused on the more deprived areas where CHD is most prevalent. There has been a 20% reduction in referrals to secondary care in the last three years. The PCT has taken action to get rid of poor-performing GPs

• Pathways and service areas have been prioritised for redesign. Cardiology and diabetes have been early areas of focus. PBC governance arrangements: issues with business case agreement have been resolved and there was evidence of a robust process for addressing conflicts of interest. Survey results indicate that stakeholders agree the PCT proactively engages clinicians (scoring 5.29 vs. SHA average 4.69). Ethical framework for clinicians in management developed and has been through a probity review. A separate PBC company has been established

• The panel observed that the incentive model which helps to drive much of this is biased towards transactions, but that the PCT recognises this and wants to move to a more outcome-based accountability model supported by incentives. Ensure that you build on good work to preserve a diversity of clinical leadership (including social care practitioners) and preserve relationships with CHS during separation

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• Analytical skills and insights• Understanding of health needs trends• Use of health needs benchmarks

Level321 4Measure

Manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements


Competency



• The JSNA was written together with the LA but it is the 2008 version and is currently in the process of a refresh. There is evidence in documentation that a consistent methodology is used to understand health inequalities within the PCT by pathway and disease group (e.g., JSNA 35). The key JSNA findings are reflected in the PCT’s strategic priorities, however, there is little evidence of theJSNA assessing the unmet needs of Bexley, although this work has been undertaken separately. The panel did not see sufficient evidence of regular review of needs assessment, in particular with partners

• The JSNA’s findings of major health risks are by demographic and disease group (e.g., JSNA 12, 22). The JSNA considers past data trends (e.g., JSNA 19-20). There is little evidence to suggest that insights from public, patients, clinicians and other stakeholders were considered, other than Bexley residents’ opinions on what would make their area a better place to live (JSNA 65). On panel day the Board described the robust prioritisation process for their outcomes undertaken with patients and clinicians

• The PCT benchmarks itself against London and national disease prevalence (e.g., JSNA 21, 31). Initiatives are in place to improve Bexley’s performance relative to London and the UK (e.g., CSP 58), however plans are very high level. The MEDE system disseminates information to providers and a bi-monthly stakeholder newsletter informs the public

• Use local and national data to support your analysis of local health needs and ensure that this analysis informs your decision making and prioritisation process

• Ensure JSNA document clearly assesses unmet needs

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Competency 6 – Panel assessmentLevel

321 4Measure

Prioritise investment of all spend in line with different financial scenarios and according to local needs, service requirements and the values of the NHS


Competency • Predictive modelling skills and insights to

understand impact of changing needs on demand

• Prioritisation of investment and disinvestment to improve population’s health

• Incorporation of priorities into strategic invest-ment plan to reflect different financial scenarios



• Not evident in the written documents if activity or quality has been modelled under the best and worst case scenarios, however, financial activity is modelled under the 3 scenarios (CSP 46-53 and FP). There was no evidence in the documentation provided of predictive modelling by care pathways

• As per the CSP, ‘clear procedures are in place for prioritisation of investments, linked to national and London strategy, and the approval of business cases’, however no evidence of defined criteria in the written documents (CSP 48). Patient and public engagement includes public consultation during April 2009 (CSP 37), however, it is unclear how this influenced the development of dis/investments. The dis/investment proposals include predicted improvement in health outcomes and impacts on health inequalities (e.g., diabetes controlled blood sugar outcome to improve to 71.39% by 2014/15), however, they are not systematically done (e.g., no predicted improvement for the stroke outcome). Decommissioned a gynaecology project which did not hit targets and was peripheral to priorities. The PCT consulted with key stakeholders including clinicians and as a result included child health as a priority

• There is some alignment between the gaps, current initiatives to address those gaps, and the strategic investment plan (e.g., teenage conception). Priorities include dis/investment as appropriate (e.g., COPD in CSP 62). Unclear in written document if dis/investment decisions are evaluated and reprioritised based on the three different financial scenarios or of clear and robustassumptions (CSP 51). Enabling strategies have been identified (e.g., IT, estates), however, unclear if prioritised and evaluated for their overall impact

• You should seek to implement a modelling process that enables you to map across care pathways and care settings• The panel notes that the PCT was close to a level on 2 on 6b, however, did not show evidence of predicted improvement on

outcomes and health inequalities as a result of investments and/ or disinvestments• Utilise three different financial scenarios to ensure that planning builds on best case impacts

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321 4Measure

Effectively stimulate the market to meet demand and secure required clinical and health and wellbeing outcomes


Competency

• Knowledge of current and future provider capacity and capability

• Alignment of provider capacity with health needs projections

• Creation of effective choices for patients



• The PCT has appointed an Interim Director, Strategy & System Management who has relevant industry experience. The PCT identifies a range of providers in mental health, ophthalmology, dentistry (Cliniceta and In-health for diagnostics; MIND in Bexley for IATP). During 2010 BCT will launch a ‘Kite Mark’ scheme, which in tandem with a scorecard, will give practices accreditation in line with agreed quality and service standards. The CSP states that the MEDE informatics programme gives PCT information about quality and feedback today, but it is not clear if this has been used to assess practices regularly

• The MEDE informatics system gives the PCT snapshot information about primary care, but there is no mention of a model for demand projections. The PCT states that it will work closely with PBC and other clinicians to ensure that its services are configured in a way that “meets the needs of our population”. The CSP does not clearly identify remaining gaps in the market, although it mentions how it filled some in the last year (e.g., MIND for Bexley winning the tender for IATP)

• HfLrequired the PCT to review provision and marketplace, however, it is not clear from documentation that the PCT has a strategyfor creating choice (beyond the example of commissioning a GP led health centre). The CSP describes referral processes for ophthalmology but with GPs the PCT states that “Work is also ongoing with the Practice Based Commissioning (PbC) consortia regarding referral patterns and challenging historic practices.” 50% of patients surveyed in 2009 said that they were “offered a choice of hospital for your appointment”, down from 55% in 2008. The Maternity Choice project introduced in 2009 gives all women a choice about where they wish to book for antenatal care. Approximately 60% of the women self-refer at present

• Whilst the PCT has made improvements in some aspects of choice, further work needed to extend the approach to understanding of the market in primary care to community and mental health services.

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• There is evidence the pathway redesign is based on national and international best practice of the pathways (e.g., cardiology pathway – reporting against clinical and operational benchmarks; service was a finalist at the PBC Vision awards in 2009). It is not clear which specific interventions are required at each point in the pathway and the criteria for moving patients along the pathway, the focus appears to have been on aspects that make the biggest impact. The PCT has introduced Map of Medicine in its practices to support clinicians in decision making on the pathways. There is no evidence that the PCT aggregates GP system data to undertake a risk analysis and target patients

• The PCT’s quality approach is not clear from documentation, but was explained on panel day. There is evidence the PCT has implemented improvement techniques in service or pathway redesign (e.g., eye care pathway:– reduction in the number of patients seen in a hospital setting by working with providers; glaucoma refinement scheme is being used as a model by other national PCTs as an example of best practice). On panel day the PCT described how the round table groups generate ideas and then clinicians develop a business case. Improvement efforts have led to a 20% reduction in referrals to secondary care in the last three years.

• It is not clear what specific quality and outcome metrics are included in both national and locally agreed contracts across caresettings (contract processing form indicates there are quality KPIs for primary and acute contracts). The process for agreeing metrics with relevant stakeholders is not clear from the documentation. The monitoring frequency and reporting arrangements withmajor providers are not clear in documentation but on panel day the PCT described how it monitors quality in CHS and mental health


321 4Measure

Promote and specify continuous improvements in quality (e.g., CQUIN, IQI) and outcomes through clinical and provider innovation and configuration


Competency

• Identification of improvement opportunities

• Implementation of improvement initiatives

• Collection of quality and outcome information



• Make use of data from all care settings to pursue improvement opportunities• Clearly embed your approach to change throughout your organisation• Implement a process for the collection and collation of quality and outcome information

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321 4Measure

Secure procurement skills that ensure robust and viable contracts


Competency

• Understanding of provider economics

• Negotiation of contracts around defined variables

• Creation of robust contracts based on outcomes



• The PCT does not evidence an understanding of provider economics or provider market dynamics. It states in its CSP that it needsto deliver a step change in understanding the market and identification and deployment of levers to manage performance or deliver new services (CSP 82). The PCT monitors some quality of care and productivity as shown in the Bexley Care Trust Performance Report, but this shows no patient experience data. The primary care contract “Negotiation” section demonstrates compliance with PRCC. It states “ongoing work with the provider as adjustments to services (to best meet the needs of residents) have to be negotiated based on unambiguous outcome requirements whilst recognising the commercial impact on the provider.”

• Clear identification of locally defined negotiation variables are not evidenced in the contracts that were submitted. The primary care contract mentions BATNA, however, it does not show rigorous preparation for contract negotiations. There is no evidence in documentation of negotiation strategy or negotiation team roles, but on panel day they described this (sector and PCT)

• There are no clearly specified quality and service metrics or cost productivity and activity expectations. No arbitration process is described (Dental Contract, Negotiation section). The Dental Contract specifies that access, clinical quality and value for money inform the negotiation process, and the PCT now uses a scorecard approach covering quality as well as performance. The primary care and dental contracts are signed in advance of activity commencing, however, the start date of the acute contract was 1/4/2008 and the signing date was 14/3/2009. Have developed a specific service specification for mental health, currently under negotiation

• Understanding of provider markets dynamics and provider economics will strengthen your ability to negotiate and performance manage. You could look to colleagues across the sectors or PCTs to utilise best practice that has been developed in this area

• The utilisation of CQUIN and KPIs in contracts to give you greater leverage over performance will support you in improving your rating for this competency.

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321 4Measure

Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvement in quality and outcomes and value for money


Competency

• Use of performance information

• Implementation of regular provider performance discussions

• Resolution of ongoing contractual issues



• The Board has full visibility of regular performance information, and efforts are now being made to prioritise this in meetings. Data is shared with providers when requested. For primary care the PCT is about to introduce a Kite Mark scheme measuring certain indicators, for practices. Local Area Agreement monitoring includes some Tier 2 Vital Signs (Q2 performance report), however, these are not clearly aligned in the contracts that have been submitted. Bexley is sharing MEDE with the sector (that plans to roll it out) and London via CSL

• Performance reports are generated for the PCT, however, there is no evidence of requirement in contracts for this to be producedby major providers. Regular performance discussions are not evidenced in the contract submissions or the performance reports. On the panel day the PCT described that it does have regular performance discussions with QMS for both formative and summative assessment meetings. The PCT describes the management of data on quality access, patient feedback or workforce in the ODP (7), however, there is no evidence of analysis underpinning this

• The dental contract states that if contract terms are breached it will carry out an investigation, evaluate and audit the evidence as necessary, issue breach notice and remedial notices as appropriate up to termination. Contract compliance management is in place in the primary care contract. The PCT has learned from the community gynaecology decommissioning experience (during which there was double-running for a bit)

• The panel recognises that the PCT has made progress in improving performance discussions. In order to get a level 2 the panel recommends the PCT does risk analysis on quality, access and workforce

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321 4Measure

Ensuring efficiency and effectiveness of spend


Competency

• Measuring and understanding efficiency and effectiveness of spend

• Identifying opportunities to maximise efficiency and effectiveness of spend

• Delivering sustainable efficiency and effectiveness of spend



• There is little evidence of an understanding of patient levels by pathway. The PCT understands their provider spend levels for LTC, e.g., (Prov Perf I 8 ). While there is an understanding of the £ per unit spent there is no evidence of the output per £ spent. There is evidence of the PCT monitoring cardiology outcomes against clinical and operational benchmarks but little evidence of output efficiency benchmarking. As a result of a pilot, the PCT understands that patients prefer diabetes treatment in the community rather than acute but understanding of the optimal economics of this pathway not demonstrated

• Bexley plans to offer high risk CVD patients 1:1 health check assessments in 2010. Cardiology pathway redesign removed initial referrals with a registrar or specialist nurse. Bexley has adhered to HfL’s ‘Framework for Action’ model by implementing polysystems to move care closer to home (CSP 72). The PCT considered operational efficiencies in the finance function (CSP 53) but decided its efficiency was above London average and therefore did not pursue. There is little evidence of capital efficiencyopportunities identified. There is an understanding of procurement options (CSP 86) but little evidence of identified opportunities

• The PCT has met with LIFT co. regarding the development of the polyclinics. There is little evidence of delivery risks or mitigation plans or of how the impact of polysystems will be measured. The PCT performance manages providers (e.g., Kite Mark) but there is no indication as to how polysystems will be performance managed. Bexley does not indicate which person is accountable for their delivery, although they state it is clinically led (CSP 72)

• The PCT recognises it is at the beginning of its journey in this area. The panel suggests that the PCT works closely with partners on efficiency and savings and pursues a programme management approach to support the creation and management of risk and mitigation plans in this area

Documents

World Class Commissioning Panel Report documents/NHS … · commissioning activity for which it remains formally accountable. Ratings were combined to reflect the judgement of the