www.england.nhs.uk

Developing Robust

Capitated Budgets:

A Year of Care Tariff

Approach Southend LTC Year of Care

Commissioning Early Implementer

Site

Steve Downing, Head of Finance,

NHS Southend CCG

Bill Wood, Business Intelligence Co

leader, NE London CSU

Beverley Matthews, LTC

Programme Lead, NHS England

Monday 11th January 2016

LTC Community of practice

www.england.nhs.uk

LTC Framework

Commitment to Carers

Frailty

Health Ageing Guide

Fire Service as an asset

Care Homes Quick Guides

Care & Support Planning

Navigating Health & Social Care

Self Care

Ambitions for End of Life Care

Our Declaration

Delivery Models

Planning for Change: • Capitated Budget • Contracting • Simulation Modelling

Patient and Service Selection

Planning for Change:

Workforce

Whole Population Analysis; Understanding your population

LTC Dashboard LTC Toolkit

www.england.nhs.uk

Long term conditions resources

Simulation model

Unbundling recovery simulation model

www.england.nhs.uk

7

Using behavioural

change to open minds

#A4PCC – Action for Person-Centred Care

Person with

long term

condition

o Make a declaration at

www.engage.england.nhs.uk/survey/ltc-

declaration

o Tell your teams about our work

o Encourage them to make a declaration

o Ask them to feed back thoughts and

ideas

o Use our hashtag – #A4PCC – when you

see work that is relevant to person-

centred care for people with LTCs

o Let us know of any events, activities or

social media opportunities that we can

join forces with you

www.england.nhs.uk

Date Topic Led by and details of session Venue

15 January

2016

12pm

How a telephone based coaching model

at large scale can help with admission

avoidance and enhance quality of life for

people with LTC

Magnus Liungman & Chris Bound

Health Navigator Limited

Via WebEx

20 January

12.30pm

Implementing the six Quick Guides to

bring clarity on how best to work with the

care sector. www.nhs.uk/quickguides

Nicola Spencer and Emily Carter

NHS England

Guest speakers:

• Angela Dempsey, - Baker Tilly on the

Quest4care tool

• Dawn Moody – North Staffs on MDT

working and a model implemented in a

CCG

Via WebEx

TBC Self-management in the community and

on the Internet

Peter Moore, The Pain Toolkit Via WebEx

TBC The success and impact of lay health

coaches

Anya De Longh & Jim Phillips Via WebEx

LTC Virtual Learning Community Lunch & Learn webinars:

Sharing and Learning …

www.england.nhs.uk

LTC YoC Commissioning - EIS sharing learning...

Date Webinar Led by and details of session

11 January 2016 Southend EIS

Developing robust capitated budgets

Steve Downing,

Head of Finance, Southend CCG

19 January 2016 Leeds EIS

integrated data to support service

redesign decision making

Tricia Cable, LTC YoC Commissioning Programme lead,

Leeds EIS

- The Leeds approach

- How and who...using the integrated data

- Challenges, lessons learned...what next

11 February 2016 Kent EIS

Commissioning Integrated models of

care

Alison Davis, Integration Programme Health and Social Care,

Working on behalf of Kent County Council and South Kent

Coast and Thanet CCG's

- The South Kent model of care (what it looks like)

- Roadmap to delivery

- Contracting models and evaluation.

March 2016 West Hants EIS

Topic TBC

Kate Smith, West Hants CCG

All webinars 12.30pm to 1.30pm unless stated...

Developing a

Year of Care Tariff NHS Southend CCG

Aim of process

• To develop a tariff model that reimburses providers for a year of care

(YoC) for patients with Long Term Conditions (LTC)

• Tariff should facilitate efficiencies through improved care of patients

with LTC

• Tariff should move away from episodic care and towards a single

tariff for a whole year of care across a range of health and social

care services.

8

Building a Model: Collating Data

• Data from available systems has been taken and collated into a

single data system

• SUS – for Acute Care

• EMIS / System One – for primary Care (prescribing)

• _____ - For social care

• Areas not currently include: CHC, Mental Health, and Non-SUS

Acute

• IG guidelines have ensured that this data is only shared where

consent or appropriate s251 arrangements are in place.

• Original analysis occurred prior to prior s251 ending and has

meant it cannot yet be updated.

9

Building a Model: Time Period and Data

• Data from various systems, across two years was

collated into a single dataset

• Years used are 2011/12 and 2012/13.

• Each patient is marked with the specific Long term

conditions that they suffer, based on primary care

registers

• Each patient is also marked with the number of long

term conditions that they suffer.

10

Building a Model: Conditions

• Premise based around the notion that patients care needs are

determined by

• the number of LTCs the patient has

• Specific LTCs that the patient suffers

• 14 unique LTCs were looked at in this model

11

Congestive Heart Failure Cancer

COPD Alcoholism

Dementia Depression

Chronic Lung Disease Smoking

Chronic Kidney Disease Asthmatic

Hypertension Coronary Artery Disease

Diabetes “Other”

Building a Model: Calculations

12

• Model cycled through each divisions of patients based on the

number of LTCs and identifying patients who had a specific LTC

within this bracket

• For example one division of the model looks at patients who have 3

LTCs, one of which is “Coronary Artery Disease”.

• In each division the overall metrics are calculated for the cost across

two years, this includes the following calculations

- Mean Cost

- Median Cost

- Standard Deviation

- Top 10th Percentile

- Bottom 10th Percentile

- Mean excluding top and bottom 10th percentiles

- Median excluding top and bottom 10th percentiles

Building a Model: Summarising Results

13

• With all cycles complete the results were collated and aggregated

into a single table indicating the number of LTCs, and the condition

specified in the division, showing the mean and median annual cost

once top and bottom 10th percentiles were removed.

• Either the mean or median cost can then be used as a proxy tariff.

• There are benefits to using either of these values • Mean – typically considered ‘true’ average as mathematically more understandable. Includes all

known values in calculation. Better for larger samples

• Median – typically considered more reliable as will ignore outlier values – better for smaller samples

or those suffering from outliers.

• Acute NTPS 2015/16 uses mean as basis for tariff calculation from

Reference cost data.

Building a Model: Reviewing Results

14

• Divisions showed a tendency to have a maximum mean cost at 5-6

long term conditions, rather than peaking at the max count of 7(+).

• Example shown for Asthma

• Suspect smaller sample size

leads to bias at this point

Building a Model: Reviewing Results (2)

15

• Number of patients in higher counts of LTC were small, such that

Confidence Intervals are very large

• Example below

Building a Model: Utilising Model Results

16

• Building the model allows for correlation in costs to be assessed

across specific LTCs and the number of LTCs along-side these.

• Majority of divisions appeared to fit a Logarithmic trends, though

some were more linear or even Exponential.

• Thus these trends have been calculated alongside the actual costs

– manually excluding visible outliers – to build a trend.

Building a Model: Utilising Model Results

17

• The next series of charts show the result of this re-modelling

Building a Model: Utilising Model Results

18

• Alcohol

- One point excluded due to low sample size (<10)

Building a Model: Utilising Model Results

19

• Asthma

- No points excluded

Building a Model: Utilising Model Results

20

• Cancer

- No points excluded

Building a Model: Utilising Model Results

21

• Chronic Kidney Disease

- One point excluded as visually an outlier

Building a Model: Utilising Model Results

22

• Chronic Lung Disease

- two points excluded as low sample size (<10)

Building a Model: Utilising Model Results

23

• COPD

- One point as visually outlier

Building a Model: Utilising Model Results

24

• Chronic Heart Failure

- One point excluded as visual outlier

Building a Model: Utilising Model Results

25

• Coronary Artery Disease

- No points excluded

Building a Model: Utilising Model Results

26

• Dementia

- trend indicates exponential curve (red) rather than logarithmic

Building a Model: Utilising Model Results

27

• Depression

- One point excluded as visual outlier, another as small sample

Building a Model: Utilising Model Results

28

• Diabetes

- One point excluded as visual outlier, another as small sample

Building a Model: Utilising Model Results

29

• Hypertension

- One point excluded as visual outlier,

Building a Model: Utilising Model Results

30

• Smoking

- One point excluded as visual outlier,

Building a Model: Utilising Model Results

31

• Other LTCs

- One point excluded as visual outlier,

Building a Model: Utilising Model Results

32

• Full picture (combined model)

Building a Model: Converting to a Tariff

33

• Tariff can therefore be based on number of LTCs and presence of

specific LTCs with higher cost determinant at that banding.

• For example:

- Patient with 3 LTCs (Depression, Asthma and Dementia)

- Highest valued LTC is Dementia = £3,080.42 annual modelled cost

- Patient develops 4th LTC of Diabetes

- Dementia remains highest valued LTC within 4 LTC group = £3,800.58

• Results in 77 unique tariff levels.

• How does Tariff compare to actual when applied to historic

data?

Applying the Model: Comparison

34

Actual Cost 2011 Actual Cost 2012 Modelled Tariff for

Year of Care

Bottom 10th Percentile £ 883k £ 762k £ 4,713k

1 LTCs £ 229k £ 192k £ 1,059k

2 LTCs £ 354k £ 308k £ 1,923k

3 LTCs £ 192k £ 169k £ 1,106k

4 LTCs £ 71k £ 63k £ 398k

5 LTCs £ 27k £ 24k £ 165k

6 LTCs £ 6k £ 4k £ 41k

7 LTCs £ 4k £ 2k £ 21k

Central 80% £ 7,574k £ 6,551k £ 4,197k 1 LTCs £ 3,080k £ 2,910k £ 1,292k 2 LTCs £ 2,318k £ 1,939k £ 1,426k

3 LTCs £ 1,226k £ 1,072k £ 883k

4 LTCs £ 571k £ 407k £ 374k

5 LTCs £ 219k £ 132k £ 144k

6 LTCs £ 134k £ 73k £ 59k

7 LTCs £ 27k £ 17k £ 20k

Top 10th Percentile £ 7,428k £ 6,532k £ 996k

1 LTCs £ 4,173k £ 3,749k £ 360k

2 LTCs £ 1,788k £ 1,468k £ 308k

3 LTCs £ 957k £ 811k £ 197k

4 LTCs £ 382k £ 338k £ 76k

5 LTCs £ 90k £ 125k £ 36k

6 LTCs £ 17k £ 36k £ 8k

7 LTCs £ 21k £ 5k £ 10k

Grand Total £ 15,885k £ 13,845k £ 9,906k

• Table (right) shows the impact of applying the model to the baseline data

• Total effect is underfunding of £3.9m from 2012 actuals (28%)

• Model overfunds bottom 10th

Percentile by over 500% (2012)

• Model underfunds top 10th Percentile by 85% (2012)

• Model underfunds central 80% by 36% (2012)

Applying the Model: Comparison

35

• Table (right) shows over/under funding ratio

• Looking at central 80%, 1 LTC position has largest under funding.

• Linked to shape of trend line used – which will start below first point.

Over/Under Funding (%)

Bottom 10th Precentile 519%

1 LTCs 453%

2 LTCs 525%

3 LTCs 554%

4 LTCs 534%

5 LTCs 589%

6 LTCs 935%

7 LTCs 736%

Central 80% -36%

1 LTCs -56%

2 LTCs -26%

3 LTCs -18%

4 LTCs -8%

5 LTCs 9%

6 LTCs -20%

7 LTCs 14%

Top 10th Percentile -85%

1 LTCs -90%

2 LTCs -79%

3 LTCs -76%

4 LTCs -78%

5 LTCs -71%

6 LTCs -77%

7 LTCs 73%

Grand Total -28%

Next Steps for revising model:

36

• Update data to 2014/15 or later • Remove patients who died within 12 months from end of data set period. Subject to

use of PHMF (Public Health Mortality File)

• Re-assess or adjust use of logarithmic trend lining, which may account for significant underfunding of patients with 1 LTC.

• Explore potential to add in further patient factors (age, gender etc.)

• Apply modelling process to another area and compare against results seen in Southend CCG.

Issues and Barriers

• Data sharing agreements

- IG issues

- Logistics in getting sign up

• Data sharing and linking data

- Coding issues and using key indicators (NHS number)

- Solution to link data and pseudonymisation

• Organisational sign up

- Ensuring all partners who you want to receive data from have a data

sharing agreement to provide information to your designated data

processor.

37

Other considerations and lessons learnt

• Vehicle/project to use tariff

- Tariff is a means for payment not the solution to commissioning

- Conduit to develop different commissioning models and pathways.

• Commissioning at patient level

- Commissioning at cohort of patients and pathways and not services.

38

Want to know more?

If you would like to discuss any element

of this presentation, please contact our

Essex POD team on:

Tel: 01268 594490

Email: William.wood1@nhs.net

www.nelcsu.nhs.uk