1. LINCOLNSHIRE Good Idea Good Data Budget right in first place Configuration / Clinicians working together (unscheduled care example)- framework Succession planning Risk – size of budget – what bit of the budget Control of Contracts Workload / Time Understanding what we commission Legislation- passion / will Locally Sensitive Governance Framework Lean & Agile System Real Budgets in the East Midlands event 8Jun10

2. LINCOLNSHIRE (cont) Glass is half full in NHSL !!! Team engagement CBSM Dashboard -Up for it -Started bits of it already ( 2 devolved Budgets) -We feel we are ahead of the game -Radical -Break from tradition sky is the limit THINK BIG! Solve how the budget works  GMS / PMS  Succession Planning Will / Desire Buy in from all GP’s Framework / levers Budgets right Scale up Real Budgets in the East Midlands event 8Jun10

3. NOTTINGHAMSHIRE COUNTY What do we need? Legal entity & form, set up costs Managing internally – rules of engagement & sanctions for underperformance Rules for performance management Data & intelligence – is this good enough to sign the cheque? Clarity over direction of travel  ? No longer clear commissioning / provision split Incentives for providers ? Tariffs for whole pathways of care Less income = less capacity to do anything but the “day job” so incentives to engage essential Infrastructure Real Budgets in the East Midlands event 8Jun10

4. NOTTINGHAMSHIRE CONTY (cont) ? Liability for overspend ? 1 year “break even” no longer 3 years Shared incentives with providers including secondary care shared targets Threshold for tendering Need to move from small scale risk-averse to large scale impact = higher risk, permissive culture Huge reduction in management capacity What % of the total PCT budget – including (PCT) management? How big to influence provider behaviour vs how small to keep everyone engaged & local perspective? Real Budgets in the East Midlands event 8Jun10

5. NOTTINGHAM CITY & BASSELAW INFORMATIONORGANISATION How to make data fit for purpose? What will budget be: Historical What are the sanctions? What’s wrong with current PBC toolkit? How do we deal with outliers? Who will negotiate prices? Dependent on willingness to become engaged (size) Like minded or Geographical Economies of scale – size does matter Consortia SLA to negotiate Who regulates consortia? Governance CLINICAL ENGAGEMENTTRANSACTIONS What do GPs want to do? How will internal practice opinions be managed? How will we manage secondary care? Leadership vs followship Ownership vs commitment EU Procurement Managing conflict Organisation more commercially savvy Private industry “Boots” Join commissioning with social care Real Budgets in the East Midlands event 8Jun10

6. DERBYSHIRE COUNTY Answer from task 1: Tiered approach levels of risk sharing choice for clinical consortia Increasing autonomy & Increasing responsibility 2 dimensions size “federation” size “super-federal” responsibility & autonomy Decision devolved to lowest possible level & nearest to problem & delegate upwards issues that need to be shared subsidiarity Networks of shared interest i.e. all consortia coming together to negotiate with acute provider Consortia contract for commissioning expertise on an ‘agency basis’, ‘chambers’, ‘virgin’ or ‘BUPA’ Would need a governance framework to act as a safety net in case of market failure of commissioner or providers Would also want to retain some of benefits of larger organisations & joint working Real Budgets in the East Midlands event 8Jun10

7. DERBYSHIRE COUNTY (cont) Key Issues - ‘Hard’ budget #1 a.What happens when you overspend? b.Need to completely disentangle & fully understand budget (how possible?) how do we disentangle block contracts? c.Link GMS/PMS prescribing & commissioning as whole – risk assess, due diligence & go d.Issues of time, capacity & skill to do this e.How do we manage conflict of interest in whole budget’? f.Revolution may be unrealistic & undoable – Evolution may be option – currently GPs manage services & risk g.How do we make the difficult decision to close the local hospital? h.What are the transaction & management costs of operating this system? Real Budgets in the East Midlands event 8Jun10

8. DERBYSHIRE COUNTY (cont) Key Issues - ‘Hard’ budget #2 i.Solution – give clusters the budget & they will disentangle j.Benefits in joint working & a federated approach – spread best practice k.Increased management costs offset by reduced duplications l.Not a vehicle for equity but a vehicle for innovation – will this be politically acceptable? & to the public? Real Budgets in the East Midlands event 8Jun10