Transcript Document

KPA DAY
2015
Commissioning specialised
services – back to the future
or break the mould?
28th March 2015
www.england.nhs.uk
Introduction to Specialised Commissioning
The commissioning of specialised services is a prescribed direct commissioning
responsibility of NHS England as set out in the Health and Social Care Act 2012.
145 different services contracted with 300 healthcare providers, managed through
1 national, 4 regional and 10 sub-regional teams, with national clinical leadership and
stakeholder engagement organised through 6 Programmes of Care responsible for 73
Clinical Reference Groups
A wide range and diversity of health and care needs are met - from renal dialysis and secure
inpatient mental health through to treatments for rare cancers and life threatening genetic
disorders
Specialised services account for approximately 10% of the total NHS budget, spending circa
£14 billion per annum in 14/15 with the 15/16 allocation rising to £14.6 billion
Before the 2012 Act, the services defined as specialised were less than half the value
of the current portfolio.
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2
Challenges we face
•
Many of the services operate at the cutting edge of science and
innovation with new treatments and procedures being developed
and introduced all the time. These offer real benefits for patients but
put significant pressure on NHS resources.
•
Whilst many specialised service providers offer fantastic care that is
the envy of the world, specialised services in some parts of the
country sometimes fall short of what is expected for patients on
quality. Examples include cancer outcomes, vascular outcomes and
access to appropriate mental health services for children.
•
Where commissioning responsibility moves between NHS England
and Clinical Commissioning Groups (CCGs), care can become
fragmented with patients feeling they have ‘fallen in the gap’.
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Impact of Innovation on Specialised commissioning
Each year, medical innovation drives a £400 – 500m increase in spend in specialised services
•
A significant portion (>40%) is due to innovation in equipment, devices and procedures
•
The financial impact of innovation is likely to be highest in specialised services, but is by no
means the only area where this will be felt
The four types of innovation are each subject to different approvals processes
•
Pharmaceuticals have the most stringent approvals process, including safety and clinical efficacy
•
New devices, equipment and procedures undergo tests for safety during regulatory approval
•
Following approval, most new technologies are available through the NHS with no further
assessment
Currently, only ~25% specialised technologies (by spend) are subject to assessment by NICE
•
Up to 40% drugs evaluated by NICE, but a much lower proportion of new equipment and devices
•
After NICE approval, commissioners are legally obliged to resource the technology within 3
months
•
Even when NICE does not 'recommend' a drug, may still be possible for patients to access it via
the NHS (e.g. through the Cancer Drugs Fund)
The current deployment model results in a variety of challenges
•
New technologies are approved for NHS reimbursement before sufficient evidence is available
•
Lack of control in the adoption of new technologies post approval
•
No mechanism for removing technologies and procedures that have less value
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Natural growth in Specialised
Commissioning
Natural drivers will lead to annual growth in spend of 7.2% over the 5 years
• Includes both growth in activity (3%) and growth in cost per patient (4.2%)
• Fastest growing components are staff costs and drugs costs, contributing 3.6%
and 2.0% respectively
On this trajectory, specialised services will have a funding gap of £5.1B by
2019/20 (~25% of budget)
• This is the current 'momentum case' if no further action is taken to reduce growth
in spend, compared to a continued funding profile of flat, real-terms growth
Individual services have varying growth rates, which should inform approach
to interventions
• Six services will account for >50% of growth in spend over the next five years:
• Chemotherapy; Secure MH; Renal Dialysis; Neurology; NICU; Neurosurgery
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Six services account for ~50% spend
growth to 2019/20
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End stage renal failure is affecting 6,891 new pts per
year
End stage renal failure
(ESRF)
is an irreversible, long-term
condition as a result of
chronic kidney disease
Renal Replacement
therapy (RTT) prolongs and
improves life for the
majority of people at ESRF.
Incidence rate: 108 pts
per million population
6,891 new patients
per year in the UK
Source: UK Renal Registry 16th Annual Report
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RRT incidence rates in the countries of the UK 1990–2012
The number of patients on Renal Dialysis is
increasing
Growth in prevalent patients by treatment modality
at the end of each year 1997–2012
Despite the reduction
in incident rate, the
total number of
patients on RRT,
both dialysis and
transplantation is
increasing
This is due to
increased survival
rates and an increase
in transplant
population
Source: UK Renal Registry 16th Annual Report
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Establishing consistent national specifications has been a major
achievement whilst identifying significant
change needs
25 providers had no services which yet
Almost every provider had at least one
service not yet meeting standards
meeting standards, whilst 106 were fully
compliant
Number of services offered by provider
Number of providers
100
150
Services in derogation
Compliant services
All 25
providers that
derogate on
100% of
services offer
just 1 or 2
services
80
On average,
~20% of
services for
each provider
in derogation
60
100
106
89
56
40
50
25
20
9
0
0
Major providers of specialised services1
100
%
5075%
2550%
125%
0
%
Proportion of services in derogation
Derogation = time limited permission to continue to provide services which do not yet fully
meet specifications provided they are safe
1. Excludes providers offering less than 10 services, for illustration only
Note: Only includes provider derogations (i.e. derogations where it is within the provider's remit to be compliant); does not include commissioner derogations
Source: NHS England, Introduction to nationally consistent specifications for prescribed specialised services; NHSE Provider database
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Lack of commissioner capacity, fragmented pathways and
misaligned risk reduce the value of specialised services
1
Problem
Symptoms
Lack of
commissioner
capacity
• Provider dominance
• Limited understanding of
service quality and cost
• Managing contracts rather than
managing services
• Overspending
• Limited ability plan and
commission highest value
services
• Variable outcomes for patients
• Incentives shift costs from
CCGs to NHSE
• Incentives to shift costs from
providers to commissioners
• Inability to influence referrals
• Overspending
• Opportunity costs for investing
in upstream services
• Variable outcomes for patients
between areas or regions
• Confusion amongst
commissioners
• Lack of accountability
• Difficulty in planning end-to-end
service
• Poor patient experience
• Risks to quality and safety
• Inability to reshape pathways
and to invest differently across
and between them
2
Misaligned
financial risk
3
Fragmented
pathways
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Source: Stakeholder interviews (June 2014): Birmingham and Black Country, South Yorkshire and Bassetlaw area teams
Consequences
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New commissioning structures to drive new provider models,
underpinned by the use of incentives and pricing mechanisms
Case for change…
…emerging solutions
1
1
Lack of commissioner
capacity
Enabling
New commissioning
models
2
2
Misalignment of
financial risk and
incentives
New provider
contract models
3
3
Fragmentation of care
pathway
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Underpinning
Use of incentives
and pricing
Population/place based planning & accountability
CCGs and local authorities fund a defined
local population at all care providers they
use regardless of where they are based
Specialised Teams fund a total hospital
service for all patients in England who use
it regardless
of where they live
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Population/place based planning & accountability
Provider Catchment
Population / Place Based
Strengths:
Strengths:
• Total view of entire provider service
• Focus on nationally consistent policies and standards
• Equity in eligibility for access to care & standard
service requirements highly valued by patient groups
(no ‘post code lottery’)
• Strong provider service benchmarking capability
• Full view of population level access to and spend on
services relative to health needs
• Ability to see impact of decisions upstream and
downstream of specialised services
• Potential to allocate and align incentives
• Tailoring to local priorities and different health needs
Challenges:
Challenges:
• Perverse incentives when patient flows change to
different providers in a different region
• No way to assess variation in population access
relative to health needs
• Needs informatics enhancement to integrate a view
across end to end pathways and population use of all
services.
• Risk to equity in eligibility for services
• ‘Out of area’ provider management tends to be poor
• Planning footprints remain at different scale to local
health economies: Specialised catchments need
alignment of a large number of organisations (1
specialised catchment to 20 CCGs and 10 health &
wellbeing boards)
How do we realise the major benefits of place based
commissioning without losing the achievements from
provider based commissioning?
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New provider models
Individual Provider
Contracts at specific site
Contracted Networks of
providers for a service
Contracting individual
services by activity
Contracting wider
services by outcomes
Commissioner demand
risk
Provider shared
population accountability
Tariffs drive pay to
provider
Tariffs inform resource
allocation internally
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Collaborative Commissioning
Principles of Collaborative Commissioning
To improve pathway integrity for patients
• To help ensure that specialised care is not
commissioned independently from the rest
To enable better allocation or investment decisions
• the ability to invest in upstream or more effective
services
To move towards population accountability
• To lay the groundwork for ‘place based’ or
population budgets and clearer accountability
To improve financial incentives over the longer
term
• Avoiding specialised care where appropriate and
reducing unwarranted variation
To focus NHS England on services that are truly
specialised
• Helping improve focus and the quality of
specialised commissioning
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Approach to setting up Collaborative
Commissioning
• The new collaborative arrangements will be codesigned with CCGs;
• CCGs will be able to choose how much involvement
they have in collaborative arrangements;
• CCGs will not be required to invest significant resource
in setting up or delivering the new arrangements;
• NHS England will provide a range of development
support to support CCGs to implement arrangements.
• National Service specifications and policy will remain
to ensure quality and consistency is maintained.
The key roles of the collaborative committees
• Priority setting for service change including developing
a priorities plan and monitoring delivery against this
plan;
• Leading service reviews, including engagement and
consultation;
• Enabling greater CCG clinical input into national policy,
standards and specification in order to ensure wider
service models and pathways are aligned;
• Developing commissioning proposals on service
changes, new pathways and reconfiguration;
• QIPP development and delivery.
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There is the opportunity to influence and improve
the value that patients receive from renal services
Exemplar service
specifications
National service
specifications that will be:
• Common across CCGs and
ensure that services are of
high quality in all regions
• Guide for collaborative
commissioning committees
but allow freedom in certain
areas, for alterations to
meet the local population
needs
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Quality improvement
Coordination and liaison
with other bodies
Better use of data
• Define quality indicators
that can be used to monitor
provider performance
• Collect national data on
these indicators for
comparison
• Publish public “State of the
Nation” reports
• Inform and advice
collaborative
commissioning committees
consortia regarding failing
providers
Via financial levers and
service improvement
Renal Dialysis is only one
part of the renal pathway.
• Renal Dialysis is only one
of the treatments for end
stage renal disease that
has many causes
• Different parts of the
pathway are commissioned
in different levels
• Many different bodies have
an interest/responsibility for
different part of the
pathway
• Coordination is necessary
to ensure the best possible
outcome
Key themes to take away
•
Shifting the mindset from managing contracts to managing services
and patient outcomes, with better and more transparent information,
including patient insight
•
Collaborating to commission the full range of services for a
population across the whole pathway to address inequality and
make upstream investments
•
Addressing unwarranted variation in quality and efficiency by
making the case for consolidation, centres of excellence, and new
models of provision such as prime contractor, network delivery and
population accountability
•
Opportunity and support for those who want to try breaking the
mould
www.england.nhs.uk