Commissioning and Prioritising Health Services in Bridgend Local Health Board

Commissioning and Prioritising Health Services in Bridgend Local Health Board

Developing a tool for evidenced based and cost-effective commissioning

Interim Report Jan 2005

Dr Phil Webb, Commissioning & Performance Development Manager, Bridgend Local Health Board, North Court, David Street, Bridgend Industrial Estate, Bridgend CF31 3TP

1. Setting the Scene

This paper seeks to provide a framework for effective service commissioning in Bridgend. As the Local Health Board moves into its third year, the focus of activity has moved to a more proactive approach by establishing a Commissioning and Prioritisation Framework for assessing service improvement. Work is currently in progress to ensure that our commissioning intentions are aligned with National, Local and Ministerial priorities; are evidenced based and benchmarked against best practice; are focussed on a whole systems approach; must promote innovation, reward flexibility and challenge current methodology. In addition, there will be certain priority areas that require collective commissioning strategy and as such there will be a need to ensure a balance between flexibility within the commissioning arrangements whilst maintaining the legitimacy of an LHB focus.

There is currently a paucity of data supporting the implementation of quality into the commissioning process although NHS policy has, for a number of years prescribed an agenda for effectiveness in healthcare [[1], [2], [3], [4]]. Because of this, there have been historical and repeated attempts to provide measures of effectiveness but these have been fractured and non-coherent in terms of joined up processes. More recent attempts have resulted in commissioning methods designed to value health care expenditure via the generation of cost: value ratios [[5]] and mapping assessments of economic utility and geodemographic values. The purpose of the current programme has been to review these approaches to formulate a robust, evidenced-based, needs led approach to commissioning, to determine the most pertinent assessment of health gain (e.g. Quality Adjusted Life Year) and to formulate plans for integration and implementation of these agreed processes (e.g. input from National Public Health Service, Health Economics Groups, care pathways development, information management, partner commissioners, primary care and secondary care providers).

The projected outcome of this would potentially be:

• Single streaming of a comprehensive, whole systems approach to commissioning.
• Development of a Prioritisation and Commissioning Framework that is evidence- based and health needs led, performance managed and monitored by defined health gains.
• Improvements in Information Governance and data flows that concentrate on the production of quality information centred on measuring health gain.

2.Programme Update

The Chief Executive, Director of Health Improvement and Performance, and the Director of Finance and Commissioning have lead responsibility for commissioning services on behalf of the Bridgend Community. As such, effective and efficient commissioning is one of the key strategic responsibilities of the Local Health Board. In order to fulfil its obligations, the Board needs to work closely with its partner organisations to ensure:

• Full implementation of national guidance and ministerial priorities identified in Service and Financial Framework (SaFF), NICE, National Service Frameworks (NSFs), Wanless Action Plan (WAP), and NHS Modernisation is achieved;
• Appropriate policies, protocols and management arrangements are in place to enable evidenced-based investment decisions to be made in accordance with its Commissioning Intentions (Appendix 1), Health, Social Care and Well Being Strategy (HSCWB, Appendix 2), SaFF and WAP;
• The required services are commissioned from the most appropriate provider organisation within agreed financial limits, quality and standards;
• That service are designed on a whole systems approach, focus on the principal of right place, right action, right time and reward and incentivise best practice;
• Demand is managed and that prevention and sustainability are promoted;
• That explicit choices are made on what is achievable;
• That performance is closely monitored and the expected outcomes are achieved;
• A maximisation of new flexibilities across health and social care.

Bridgend Local Health Board has undertaken an evolutionary process involving a series of workshops held during the latter half of 2004. Early developments involved the NPHS working in collaboration with the LHB to facilitate the development of a prioritisation methodology [[6]] (Appendix 3). This involved an exploration of the factors that influence the prioritisation of healthcare and the development of an initial methodology and systems tool.

Methods for the Prioritisation of Healthcare Expenditure in West Norfolk PCT [5] was used as a model. This was originally developed to enable a ‘fair and equitable’ commissioning of health services across the PCT. The method chosen required a sound theoretical underpinning yet had to take into account pragmatic realities such as data availability and time limitations. The West Norfolk PCT framework was based on a multi-criteria utility model. In this model a set of explicit criteria are defined with proposals scored against each criterion. The net cost of the programme is divided by this score to give a crude cost:value ratio. Proposals with the lowest cost:value ratio should be prioritised over those with a higher ratio. This work also featured as a case study in the Modernisation Agency’s National Primary Care Trust Development Programme (

From this seminal work, a draft Commissioning Protocol was presented to the Board 12th August 2004 for comment [[7]]. For the remainder of the year, this draft protocol has been refined over a series of reviews in parallel with the development of a commissioning strategy that is due to come to fruition in March 2005. The draft reassessed criteria, definitions of main and sub-domains and a flow chart outlining the process were refined at a recent Commissioning Sub-Committee Meeting [[8]]. The results of this are now open to all partners for review (Appendix 4).

3.Appeals Process

The facility for Consultees to make an appeal is an integral part of the Board’s process for developing its Commissioning and Prioritisation Framework. All organisations involved in the application process will be provided with the opportunity to make an appeal based on one or more of the following grounds:

• The Board has failed to act fairly and in accordance with the Commissioning and Prioritisation Procedure set out in the Boards Guidance to partners;
• The Board decision is perverse in the light of the evidence submitted;
• The Board has exceeded its powers.

An independent Appeal Panel will consider the appeal and in line with the Boards policies, appellants and stakeholders of the outcome of the appeal will be informed as soon as practicably possible. The Panel will consist of Board members (who have not been previously involved in the appraisal) and representative members of partner organisations. The Board will publish the Appeal Panel’s decision, the details of those who appealed and the members of the Panel who heard the appeal. The Board will produce a guidance document that will be made available to all partners as part of the development of the Commissioning and Prioritisation Framework. Draft guidance can be seen in Appendix 5. Appeals can either be rejected or upheld. If the appeal is upheld, the Appraisal Committee will be asked to revisit the evidence and reconsider the proposal in the light of the Appeal Panel’s findings. If the appeals are rejected the draft decision becomes the final decision and will be published.

4.Potential Constraints: Annual Financial Frameworks

National Finance Agreements detail Local Health Boards and Health Commission Wales revenue allocations on an annual basis. The allocation reflects Ministerial decisions about the distribution of resources under Section 97F of the National health Services Act 1977, the amounts payable to the Assembly in respect of capital charges under section 97F(8) and Section 85 of the Government of Wales Act 1998.

LHBs, Trust and HCW are expected to achieve and deliver the Minister’s annual priorities from within this allocation (with some exceptions detailed in the accompanying Welsh Health Circular). An assessment of the implications of the Financial Allocation will be sent for information to the Boards partners each year as a response document. It is important to note that the Commissioning and PrioritisationFramework will apply as a mechanism as a consistent methodology although the exact financial position of the Board will change from year to year. Clearly, there will always be a considerable emphasis on service proposals that can be funded through:

• Resource efficiencies and process redesign;
• Which clearly integrate the Boards Commissioning Intentions 2005/06.

The revenues allocations year on year will have significant implications on the scope and depth of potential investment. The Financial Assessment 2005/06 will be sent out as a separate document.

1. Capital Project Development: Process and Criteria for Prioritising Investments

The achievement of a modern, integrated, comprehensive and service user centred service is an important objective for Bridgend Local Health Board. The integration and co-ordination of resources to ensure the effective delivery of service is a complex issue that needs to be adequately considered within the Commissioning and Prioritisation process. It is crucial that the process for planning projects encourages a team based approach to develop a service brief from each estate initiative that represents the aspirations of all its potential users including patients and service users. As such, the process needs to deal with all proposals effecting Capital Estate Strategy with revenue implications approached in 2 stages:

• Stage 1: Service Implications. Improvements in service (in terms of assessing impact on current service provision, service redesign or the development of an entirely new service).
• Stage 2: Capital options. Capital optionswill be evaluation using a weighting-based optional appraisal process once Stage 1 has been completed. This process is currently under development but should be in line with the Boards Integrated Strategy for Primary Care Premises (Appendix 7). Examples of the Benefits Criteria for Capital Options Appraisal for Primary Care may include may include DDA compliance, physical condition, function suitability and space utilisation [[9]]. These criteria vary for Secondary Care Estate and a different criteria set will be developed to reflect this.

6.The Way Forward

The strategic engagement of commissioning partners in the development and ownership of the Commissioning and Prioritisation Process, subsequent policy development and monitoring of local services is vitally important. Paramount to the success of this programme is the need to develop a culture of partnership and collaboration across organisational boundaries to develop shared ownership and responsibility in commissioning. The issues, methodology and process need to be consulted as widely as possible to set the strategic direction for commissioning and pace of implementation for 2005-06 and for future years.

6.1Recommendations

Partners are invited to:

• Consider the terms of the attached DraftCommissioning Intentions (Appendix 1), Commissioning and Prioritisation Protocol (Appendix 3), Draft Appeals Guidance (Appendix 5) and the draft format of Business Cases (Appendix 6). Comments on this documentation are requested by 9th Feb 2005. This is to assist in the development and intent of the commissioning criteria, methodology and process in-line with the challenging timescale (Appendix 8).
• Maximise opportunities for interactions between Bridgend Local Health Board and its partners (e.g. via Partnership Board, joint Executive Team Meetings).
• Note that until the protocol has been formally accepted by the Board and its partners the executive aspects of the commissioning process will continue to be handled under existing arrangements through the Executive Commissioning Team, the meetings of the Executive teams of the LHB and Bro Morgannwg NHS Trust (as the LHB’s main provider organisation) and the regular LTA meetings that take place between the LHB and its provider Trusts.
• Note that reports from the Director of Finance and Commissioning outlining progress on SaFF negotiations and ongoing LTA performance will continue to be placed on the agenda for public Board Meetings.

7. Appendices

Appendix 1:Draft Commissioning Intentions 2005/06

Appendix 2:Health, Social Care and Well Being Action Plan 05/08

Appendix 3:Prioritisation Background Information

Appendix 4: Draft Commissioning Framework: Reassessed criteria, definitions and main and sub-domains and flow chart for potential submissions

Appendix 5:Draft Appeals Guidance

Appendix 6:Draft Business Case Template

Appendix 7:Draft Integrated Strategy for Primary Care Premises

Appendix 8:Timeline

Appendix 1.Draft Commissioning Intentions: Mapping Macro-Level Priorities to Local Commissioning

1.Context

Bridgend Local Health Board is now in its second year during which time it has delivered against its stated objectives especially in relation to:

•Establishing governance arrangements

•Establishing effective partnership working

•Securing and providing primary and community health care services including the first stage implementation of the new General Medical Services contract

•Producing the Health Social Care and Well Being Strategy

•Securing secondary care services

•Ensuring effective financial and performance management arrangements

•Discharging all statutory functions delegated to the LHB

As the LHB continues to develop, its focus of activity has moved to developing a more proactive approach to service improvement. This will guide the work of the Local Health Board in conjunction with its partners in 2005/06 and for future years. In particular commissioning must be:

•Aligned with our vision developed through these Commissioning Intentions, Health Social Care and Well Being and Service and Financial Framework

•Evidenced based and benchmarked against best practice

•Must be focused on a whole systems approach

•Must promote integration

•Must challenge current methodology, promote and reward flexibility and innovation

•Must manage demand and create sustainability

•Must determine and prove health gain

•Must make difficult but explicit choice about what can and cannot be achieved

2.Scope

The scope of the commissioning continuum is shown in Figure 1. Local Health Board commissioning should not be considered in isolation from other approaches, as it is part of a broader continuum from which different and complementary options can be selected. Such choice should be guided by the local environment and service configuration. Indeed recent research has suggested that multiple approaches need to be integrated to produce more effective commissioning Table 1.

Table 1. The advantages and disadvantages of single commissioning processes [[10]]

Patient choice / Single Practice Based / Multi practice based / Joint or horizontally integrated / LHB / Lead LHB/HCW / National
Choice, contestability, responsiveness / / / / / /
Budgets and financial risk / / / / / / /
Transaction costs / / / / / / /
Clinical
Engagement / / / / / / /
Need and inequalities / / / / / / /
Clinical
Quality / / / / / / /

Key

/ Effective / Ineffective / Ambiguous or context specific

Figure 1A Commissioning Continuum [1]

In recognising that the commissioning framework must be cross-sector and that its scope is extremely comprehensive (including for example the development of care pathways to support the patient journey, managing demand and ensuring clinical quality and clinical excellence) this paper seeks to map the commissioning requirements contained in national, local and ministerial priorities; assess these requirements in relation to existing expenditure via Programme Budget and identify key commissioning priorities for 2005/06 via limited marginal investment opportunities.

1. Mapping Priorities

Table 2 maps the targets identified in the Service and Financial Framework 2005/06, Health Social Care and Well Being strategy 2005/06, National Service Frameworks, NICE, Wanless Action Plan, Health Gain Targets and costed plans. As can be seen from the Table, elements from all these high level strategies can be integrated into Domains shown in the left hand column in Table 2. These domains are not discrete and there is a degree of both vertical and horizontal integration between each document and domain as expected. When this data is cross-mapped into the Programme Budget for 2003/04 Table 3, a crude proxy of current spend can be developed as shown in Figure 1. This will be further broken down into primary care vs secondary care elements that will allow for an analysis of relative spend in high priority areas. The relationship between primary and secondary care services, community services, social services and voluntary sector and a perception as to the scope of potential change related to financial spend is currently under consideration. From this, preliminary high level commissioning intentions and predictions in change of direction in spend can be seen in. The LHB’s response to the SaFF Targets 2005/06 can be seen in Table 4.

Table 2.Commissioning Priority Indicators: Mapping Domain, High Level SaFF [[11]], HSCWB [[12]], NSF/Care Programme, Wanless, NHS Modernisation, NICE Guidence, NHS Health Gain Targets and Costed Plans

Domain / SaFF Target / HSCWB / NSF/ Care Programme / Wanless Action Plan /

NICE Guidance

/ NHS Health Gain Targets / Costed Plan/Potential Resource

Domain 1: Older People

/ Action 1 (Breast Cancer Screening), Action 24 (Stroke Pathways) / Screening services, older people, older people with mental health, Physical activity, Nutrition, diet and obesity, Disability Services, Carers, Immunisation/vaccination / NSF Older People (Mid 2005), Stroke Sentinel Audit 2004, National Breast Screening Programme / Avoiding Falls and Fractures / Alzheimer’s Disease (No. 19), Falls (CG21), Breast Cancer (CSG), Breast Cancer (No.23, No. 30, No. 34, No. 54, No. 62), Flu (No. 58, No. 67), Hip Disease 9No. 2, No. 44), Knee Joints (No. 16), PDT (No. 68), / To reduce the European Age Standardised Rate (EASR) for stroke mortality by 20% in 65-74 by 2012; to reduce the EASR for hip fractures in >75 by 10% by 2012; to increase the present rate of moderate-to-vigourous exercise taken by people 50-65 to 30 minutes on five days a week by 2012
Domain 2: Children and Young Persons / Action 2 (NSF), Action 3 (CAMHs),
Action 9 (Sexual Health) / Children and Young People, Physical activity, Nutrition, diet and obesity, Disability Services, Carers, Immunisation/vaccination / NSF Children, Young persons and maternity services / Children and Young Person Framework partnership, Childrens Oral Health / Epilespy (children) (No. 79), ADHD (No.13), Asthma (Childern under 5) (No. 10), Asthma (Older Children) (No. 38), Arthritis (Juvenile idiopathic) (No. 35), Flu (No. 58, No. 67), Leukaemia (No. 29, No. 70) / To eliminate sustained person-person spread of measles, mumps and rubella by 2015, To reduce child (0-14) pedestrian injuries by motor vehicles by 35% by 2012 / CAMHS 05/06
National funding through Cymorth, Communities First
Domain / SaFF Target / HSCWB / NSF/ Care Programme / Wanless Action Plan / NICE Guidance / NHS Health Gain Targets / Costed Plan/Potential Resource
Domain 3: Disease Specific (Mental Health, Stroke, Diabetes CHD) / Action 3 (CAMHs),
Action 12 (Cancer),
Action 13 (Coronary Heart Disease), Action 14 (Call to Needle Time), Action 17 (Crisis resolution and Home Treatment), Action 18 (Mental Health), Action 19 (Mental Health: Delayed Transfer of Care), Action 24 (Stroke Pathways) / Mental Health Services, Older people with mental health problems, LD services, Smoking cessation / NSF Cancer, NSF Coronary Heart Disease, NSF Diabetes,
NSF Renal, Diabetes National Audit 2004, Crisis resolution and Home Treatment, Tidal or Re-focusing Model, Integrated Day Opportunities / Diabetic care, investment in training and education, specialist diabetic nursing and therapy services; Cardiology, management of referrals through outpatients and diagnostic screening services, COPD, Delayed Transfers of Care / Adult Head and Neck Cancers (CSG), Breast Cancer (CSG), Familial Breast Cancer (CG14), Breast Cancer (No.23, N0. 30, No. 34, No. 54, No. 62), GIST (No. 86), Lung cancer (No. 26), Ovarian Cancer (No. 28, No. 45, No. 55), Anxiety (CG22), Depression (CG23), Depression and anxiety CCTB (No. 51), Bipolar Disorder (No. 66), Epilepsy (CG20), Epilepsy (adults) (No. 76), Epilespy (children) (No. 79), ECT (No. 59), Diabetes (CG15, CG10, H, F, E), Asthma (Childern under 5) (No. 10), Asthma (Older Children) (No. 38), Acute Coronary Syndromes (No. 47), Angina and MI (No. 73), MI (No. 52) / To increase the mean Mental Component Summary Score (MCS) for Wales to 50 by 2012; to reduce the EASR from suicide at all ages by 10% by 2012; to increase the mean MCS score for carers by one point by 2012; To reduce Coronary Heart Disease (CHD) mortality EASR in 65-74 to 400.0 in 2012; To Improve CHD mortality in all groups and at the same time for more rapid improvement in deprived groups; to reduce Cancer EASR <75 by 20% by 2012; to improve cancer mortlaity in all groups groups and at the same time for more rapid improvement in deprived groups / Cardiac, Cancer,
Mental Health costed plans, change agent investment, Dementia Services, Chronic Disease Management

Domain

/ SaFF Target / HSCWB / NSF/ Care Programme / Wanless Action Plan / NICE Guidance / NHS Health Gain Targets / Costed Plan/Potential Resource

Domain 4: Primary care

/ Action 20 (Quality and Outcomes Framework), Action 21 (Enhanced Services), Action 22 (NHS Dentistry), Action 23 (Pharmacy Contract), Action 27 (Prescribing) / Primary care and community services, oral health / WAG Enhanced Services, Pharmacy Contract, Dental Contract, Intermediate Care Strategy, Medicines Management Programme, Chronic Disease Management / Oral Health, Childrens Oral Health / Anxiety (CG22), Depression (CG23), Dental Recall (CG19), Wisdom Teeth (No. 1) / nGMS Contract, Pharmacy contract, NHS Dental contract, Intermediate Care Model,
Domain 5: Access and secondary care services / Action 4 (Inpatient waiting 12 months), Action 5 (12 months outpatients), Action 6 (4 months angiogram), Action 7 (6 months cardiac revascularisation), Action 8 (Cancer), Action 9 (Core Sexual Services),
Action 10 (within 24h Emergency Access to GMS), Action 11 (Ambulance Response Times), Action 26 (15% reduction Delayed Transfer of Care) / Sexual health, Hospital Services / 2nd Offer, Waiting List Initiatives / Sexual Health, Delayed Transfer of Care, Maximising Acute Capacity via Efficiencies, Redesigning and modernising services, Reducing Admissions / Infection Control (CG2), Obesity (No. 46), Pregnancy (No. 41), Renal failure (No. 48), Renal transplant (No. 85), Rheumatoid Arthritis (No. 36, No. 72), Sepsis (No. 84), Trauma (No. 74) / 2nd Offer
Domain 6: Pervasive
Emergency Pressures, Performance / Action 15 (4h A&E), Action 16 (5% reduction in emergency admissions), Action 25 (Unified Assessment), / Community Development, Community Safety, Education and lifelong learning, Employment, Physical Activity, Nutrition Diet and Obesity, Alcohol and Substance Misuse, Prison Health / Personal Care Plan, Individual Placements, Vulnerable Persons, Community Safety Strategy / Promoting independence and managing demand, optimising service delivery, Unified Assessment / Obesity (No. 22, No. 41, No. 46) / Inequalities in Health Programme, Grants for specific projects, Health Alliance Funding, Communities First Funding, Delivery Unified Assessment

Table 3:Mapping Domains to Identyfiable Elements of Programme Budget Spend