1. Commissioning for Value

2. Five Key Ingredients: 1.Clinical Leadership 2.Indicative Data 3.Clinical Engagement 4.Evidential Data 5.Effective processes 1 key objective + 3 key phases + 5 key ingredients = COMMISSIONING FOR VALUE 2 OBJECTIVE - Maximise Value (individual and population)

3. 3 Granularity Where to LookHow to Change SDM Care Planning Manage care out of hospital CfV Pack Atlas Programme Budgets Populations Systems What to Change Individuals Deep Dive Path- way Provider

4. Reducing unwarranted variation to increase value and improve quality The NHS Atlases of Variation Awareness is the first step towards value – If the existence of clinical and financial variation is unknown, the debate about whether it is unwarranted cannot take place

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6. 6 Clinical & Financial Variation When faced with variation data, don’t ask: How can I justify or explain away this variation? Instead, ask: Does this variation present an opportunity to improve? Deep dive service reviews support this across whole programmes & systems and deliver Phase 2: What to Change

7. 7 Mechanism Decision Process Service Reviews Clinical Policy Development and Decommissioning GP Member Practices Public Engagement Partners and Stakeholders Miscellaneous (e.g. Commissioning Annual Plan) Governing Body Full Business Case Clinical Executive Group Case Outlines Reform Proposals Contracts Primary Care Development Procurement Diagnostic Research Ideas Decision Group Reform Ideas Implementation NHS RIGHTCARE HEALTHCARE REFORM PROCESS

8. 8 CURRENT SERVICE FUTURE OPTIMAL SERVICE Fit for Purpose Efficiency and market options Supply and capacity options No/ low benefit Step 1 – define: Step 3 – categorise : Step 2 – define: Redesign, Contract, Procure Contract, Procure, Divest Step 4 – recommend : Maintain Divest Service Review Pathway – Diagnostic steps Fit for Purpose Efficiency and market options Supply and capacity options

9. 9 Number of Circulatory indicators in the bottom quintile of the practice cluster Note, some of the data are based on small numbers. Statistical significance has not been tested and should not be inferred. The data are presented to identify potential areas of improvements rather than providing a definitive comparison of performance. Each coloured bar represents a different set of indicators e.g. dark blue is prevalence. The specific indicators are then shown in the table on slides 21-27 for the 3 practices with the highest total number of indicators in the bottom quintile 1 Galvanising Clinicians – On the right things

10. 10 Easy answers in Secondary Care? Diagnostic Atlas %age stroke patients undergoing brain imaging within 1 hour of arrival at hospital, by hospital 80 th %ile -55% Fairfield -43% NMGH -32% MRI - 7% Royal Oldham - 4%

11. 11 Secondary Care Diagnostic Atlas %age stroke patients undergoing brain imaging within 24 hours of arrival at hospital, by hospital 80 th %ile -98% Fairfield -96% NMGH -91% MRI -81% Royal Oldham -94%

12. NHS Bradford City CCG Heart disease pathway = 95% confidence intervals Initial contact to end of treatment

13. 13 Bradford’s focus on optimal system and value - CVD Population Prevention Individual Risk Factor Management and Prevention Chest Pain Atrial Fibrillation Heart Failure L-term RoIS- and m- term RoI S-term RoI M-term RoI Embed and use the tools of delivery – business process, service specifications and protocols, contract management, monitoring, support and managing pathways

14. AID - Adopt, Improve or Defend: Clinical protocols viability assessment and prioritisation 1.Research and collate clinical referrals protocols – start with Vale of York CCG’s - www.valeofyorkccg.nhs.uk/rsswww.valeofyorkccg.nhs.uk/rss 2.Gather impact assessment group (IAG), comprising reform lead, clinical lead and finance lead. 3.IAG - follow initial impact assessment process (next slide) 4.Assess appropriate protocols against locally determined criteria – e.g. use reform decision tree 5.Adopt, or Improve and adopt, dependent on prioritisation – N.B. base the financial prioritisation on collated impact

15. Initial Impact Assessment process Is the protocol deemed clinically appropriate for local use? Are new pathway steps required to be implemented locally? Can amendments be made to make it so/ optimise it for local use? Will it reduce demand and/ or more complex/ costly treatment? Make amendments Describe new pathways steps Pass to reform team to work up initial viability assessment Collate impact and process through decision tree Yes No Yes No

16. Do not proceed No Are there any health benefits? Ideas & Cases Is it a must do? Can it be delivered? Does it save money? Can it be made deliverable? Prioritise Yes Yes* Yes No Do not proceed No Does it increase value*? *See additional slides at end Yes Rate of Return <12 months Rate of Return >12 months High Priority RoI* >£250k Medium Priority RoI* >£100k Low Priority RoI* <£100k Medium Priority RoI* >£250k Low Priority RoI* <£250k Set Timetable for completion of case outline* Decision Tree for prioritising reform proposals No High Priority RoI* >£500k

17. 17 6 steps to an optimal urgent care front end system 1. Operate robust Ambulatory Care protocols 2. Care home education and training Manage in home, reduce admissions 3. Advanced Paramedic Practitioner 1 WTE = >£1m impact on frequent callers per CCG Supports Parity of Esteem 4. Commissioner/ Primary Care-led A&E triage Only way in to A&E is via triage, unless ‘major’ Triage to MDTs and UCC/ H@H Divert unnecessary urgent care 5. Multi-Disciplinary Teams for key care areas (Respiratory, CVD, Diabetes, Dementia, etc) Detect, divert and begin case management 6. Urgent Care Centre/ Hospital @ Home Provide less complex alternative for ‘minors’

18. 18 Bury priority: Mental Health

19. 19 Bury priority: Mental Health

20. ‹#› Phase 3 – How to Change Behaviour, culture and leadership development Attitude to implementation Delivery levers, contract and market management -Service specifications, CQuINS, PDAs and contract clauses; -Referrals management (reactive Vs proactive, pathway aides) Market management - 4 steps to buying optimal (in order of ease) -Agreement, negotiation and persuasion (current provider improves willingly); -Contract management (make them do it); -Using current market options (encourage price and quality competition), and; -Creating new market options (AQP, Tender, etc)

21. 21 Leadership - Not for the fainthearted BPE for improvement is designed to: Make you look for problem areas (and face entrenched views) Make you fix them (no matter how hard) Highlight and deal with blocks in progress (including when important people/ stakeholders) Doesn’t allow you to shy away

22. 22 Change behaviours - Change is inevitable

23. 23 Patient Decision Aids – Implementation Process 1.Identify best 6 PDAs for local impact Use DD, CfV, AoV, PLCV, local enthusiasm, etc 2.Localise with local GP lead and add referrals criteria and protocols C. 50% of unwarranted activity dealt with by PDAs, 50% by protocols 3.Implement in key practices and prove impact 4.Spread across practices 5.Implement next 30 PDAs (in phases or collectively) 6.Implement International best practice Optional (innovative): 7. Design own, use and spread

24. 24 Leadership behaviour - Not for the fainthearted NHS RightCare is designed to: Make you look for problem areas (and face entrenched views) Make you fix them (no matter how hard) Highlight and deal with blocks in progress (including when important people/ stakeholders) Doesn’t allow you to shy away

25. 25 Everyone gets to be Homer… Which Homer are you? Homer 1 (The Iliad) - “Give me a place to stand and I will move the earth.” Homer 2 (The Simpsons) - “Trying is the first step to failure”

26. 26 World’s 1 st change management guru – “To avoid criticism say nothing, do nothing, be nothing” Aristotle, c.350BC

27. 27 Typical CCG embedding process Get buy-in and mandate from Key leaders (AO, GP Chair, CFO) Wider group (Gov Body, Clinical leads, SMT, GP forums) Demonstrate to wider stakeholders (Provider managers and clinicians, local PH, HWBs) Work with senior leads – BPE, Templates, Decision criteria, DT, governance structure and local guidance to support Whilst also progressing Where to Look (can include “quick win pre-What to Change phase” for the financially challenged) Support deep dive service review, evidence-building, case for change development, decision-making Whilst also developing delivery skills in preparation Build improvement capability – BI, programme office, project management, leadership resilience, contract management knowledge- base, delivery lever identification and use