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East and North Hertfordshire & West Hertfordshire PCTs PCT

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					East and North Hertfordshire & West Hertfordshire PCTs PCT COMMISSIONING STRATEGY REFRESH UPDATE

Presenter at Board meeting:

Phil Crossley, Head of ICT/CIO

Purpose of Paper: To provide a progress report on the work being undertaken to refresh the PCT Strategy Assurance Framework Objective:
7(i) Become increasingly effective commissioners, including producing a three-year Commissioning Strategy

Linkage to the relevant SHA Improving Lives Saving Lives pledge All NHS Constitution: This paper relates to the section on Patient Rights and Responsibilities. Equality Impact Assessment: This is implicit within the strategy Action Required by Board:
The Board is asked to: 1) Note the update 2) Agree the Prioritisation Framework

Key areas for discussion or noting: Prioritisation Framework - Appendix 1 Relevant legal issues: None Public Engagement: Undertaken as part of Delivering Quality Healthcare in Hertfordshire & Investing in Your Mental Health Gareth Jones Director of Strategic Planning 17th November 2009 This document can be made available in larger font or in translation upon request.

PCT COMMISSIONING STRATEGY UPDATE 1.0 1.1 Purpose This paper provides the Board with an update on the work being undertaken to refresh the current PCT strategy. It examines the background as to why a refreshed strategy is required, highlights the outcomes of work undertaken in respect of realising the Delivering Quality Healthcare in Hertfordshire (DQHH) strategy and some of the early priorities for Quality, Innovation, Productivity and Prevention, then in the light of emerging findings proposes a prioritisation framework and identifies the main themes and next steps. Background In March 2009 the Board approved a joint PCT Strategic Plan for the period 2009 - 2014 that had at its heart three strategic priorities of keeping Hertfordshire healthy, enhancing the patient experience and commissioning high quality healthcare. The plan was comprised of nine work streams each of which contributed to achieving the overall vision and that in turn linked with the eight clinical work streams identified in the Next Steps Review and the NHS East of England strategy Towards the Best Together. Whilst it normally may be perceived too early to review the previously agreed strategic plan, there are a number of drivers that contribute to a requirement to take stock. The intention is not to rewrite the original document but to produce a revision which articulates the changes and that sits alongside the original. The key reason is the vastly changed economic position and the effects that this will have for future public sector expenditure and investment. There have been significant changes to the financial assumptions used as the basis for the strategy and whilst tolerances were included it is probable that the level of investment will not be available as previously anticipated. Following the publication of the NHS East of England planning assumptions for 2011 to 2014 the key message based on the PCTs current strategy is that there will be in the region of £26m less money each year for Hertfordshire PCTs with a cumulative shortfall of £71m by 2013/14. This is based on the “base case” assumption provided by the SHA of 0% uplift and tariff net uplift of -2%, the latter % reflecting efficiency savings of 4.5%. Given this scenario, it is necessary to review the strategic priorities to assess their affordability and to agree a clear and coherent approach to prioritisation and decision making. Agreeing the approach and being explicit about the outcomes and the affects for the workstreams will be the major outcome of the revision.

2.0 2.1

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An additional driver is that the World Class Commissioning Assurance framework requires Commissioners to update their Strategies and submit a refreshed document by 24th December 2009. Assessing progress across the various workstreams identifies a number of key areas where positive achievements have already been realised. Nevertheless, much of what has been achieved has been as a result of fairly significant investment, with less progress being achieved as a result of service redesign and re-evaluating ways of working. Key achievements include: √ Dedicated elective treatment centre (ISTC) at the Lister Hospital is under construction. √ Urgent Care Centres at Hemel Hempstead and pilots at Cheshunt & Hertford √ Consolidation of acute services at Watford. √ Ante natal pathways implemented (based on NICE guidance) which have increased early and direct booking with midwife, comprehensive health and social care assessments, advice on healthy eating, smoking, etc. resulting in tailored support being offered. √ Children and Young Persons Plan milestones achieved. √ Balanced Scorecard approach to quarterly monitoring of and reporting on general practitioner services embedded. √ Roll out of enhanced primary care mental health service completed. √ Halted the rise in childhood obesity. √ National Carers Strategy, including introducing carers’ breaks, implemented. √ Reduced waiting times for access to drugs and alcohol services. √ Plans implemented to reduce service gaps and variances across end of life care pathways. √ Significant reductions in waiting times for non consultant led clinics

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2.9

There are also a number of workstreams where the progress and anticipated benefits have not been realised. Initiatives that have not delivered the anticipated targets include: x x x x x x x x x x achievement of smoking quitters targets 2 WCC outcomes; proportion of people controlling their own diabetes and COPD prevalence implementation of elements of dementia strategy introduction of personalised care planning for patients with diabetes and COPD provision of 1:1 midwife care for women in labour achievement of a range of heart and stroke metrics expansion of breast screening services to women 65-70 targeting additional parenting support at first time mothers and fathers involvement of children and young people in service planning reductions in the proportion of people dying in hospitals compared to their own homes
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3.0 3.1

Our approach to Quality, Innovation, Productivity and Prevention A significant amount of work has been undertaken developing the PCT Recovery Plan, reported elsewhere, that will ensure the PCT achieves a year end balance. Key actions have included: • • • • • • Validation and challenge of activity Benchmarking performance Reviewing referral trends Investigation of frequent attendees at A&E’s, Walk-in Centres etc. Review of clinical pathways Prior approval process

3.2

Whilst the initial focus has been on achieving financial balance, all these activities will have future application and will make an underlying contribution to delivering QIPP. The major part of the QIPP plan for 2010/11 going forward will be focussed on delivering DQHH and “Care closer to home”; there are other aspects that will address the wider health needs implicit in improving health and well being, together with those that are relevant to the broader mental health agenda. The commissioning approach will be one that encourages the delivery of high quality care, with innovation key to delivering services in the most financially efficient way. Examination of current data confirms that outpatient activity rose during 2008/09 and 2009/10 driving an increase in elective activity beyond that originally envisaged in the DQHH strategy. It is apparent that as yet the move of care closer to home and the resulting reduction in acute hospital activity envisaged in the DQHH business case is not being achieved and therefore it has become essential to address referrals as these clearly drive hospital activity. NHS Institute for Innovation and Improvement (NHSII) benchmarking date, suggests that when comparisons are made between the PCTs current performance and the upper decile (10% best performing ) PCTs, there are a number of opportunities to transfer or reduce activity in the acute sector, moving care closer to home, saving significant resources and aligning activity with that projected in DQHH. Mindful of Hertfordshire’s funding, demographics and relative prosperity, the PCTs therefore decided to use the NHS Institute II benchmarking as the key tool for measuring performance. The PCT aspiration, working with the Practice Based Commissioning (PBC) Groups and Provider Trust is to move into the top 10% of PCTs within 3 years.

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PCT purchasing intentions will reflect the determination to reach the upper decile performance by 2012/13 for all the important acute referrals and first outpatient appointments, and as a minimum, the upper quartile for follow up outpatient ratios, day case and inpatient activity, emergency procedures that could be performed in primary care/community and excess bed days that could be reduced in an acute setting. The known potential reductions in acute activity that could be realised if these targets are achieved within three years are summarised in the following table: Reducing referrals for First Outpatient Attendances to NHSII upper decile level Reducing the ratio between First/Follow up Outpatient Attendance to NHSII upper decile level 130,000 attendances 28,000 follow ups

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3.10

There is a single strategy for the PCT, based on DQHH. This has been consulted on at great length and it’s importance needs to by the entire health economy and public. Work has been undertaken to validate DQHH activity modelling against current activity currencies since there have been a number of changes in issues like Payment By Results and Health Resource Group code groupers. This has enabled the mapping of DQHH activity against top performing PCTs across the country, using the NHSIII database. This demonstrates that other PCTs are already achieving activity levels similar to those set out in DQHH and that these levels of performance are equivalent to national upper decile performance in: • new: follow up ratios • referrals / first outpatient appointments per head of population • acute interventions (day case plus inpatient) In order to prevent the need to continually map 07/08 currencies against those of 09/10 and beyond, the upper decile PCT performance will be used as a proxy target, since this is broadly equivalent to DQHH.
Herts PCT's First Outpatient Activity Projections
450,000

3.11

3.12

400,000

350,000

Outpatient Attenadces

300,000

250,000

200,000

150,000

100,000

50,000

0 2007/08 2008/09 2009/10 DQHH Original Projection 2010/11 Revised Projection 2011/12 2012/13

3.13

Looking back at the DQHH strategy, there will be other elements that need ongoing review and validation as a matter of good practice and
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implementation monitoring. As the Board is aware, one of these is the use of urgent care centres, now that some of these have been operational for about a year and the other is intermediate care. 3.14 The PCT now faces a very different financial picture than that anticipated in the initial commissioning strategy. As a result, all elements of the strategy need to demonstrate Value for Money and effective use of resources. Hence the importance of delivering the activity shifts, if the PCT is to commission best care for its population and continue to respond to evidence-based improvements in clinical practice. The process going forward over the next month is to develop Project Initiation Documents for the projects that will deliver these shifts and demand management. In the meantime a number of assumptions will have to be made, based on the original DQHH assumption for reprovision, with regard to the activity being taken out of the acute sector through demand management and more effective community provision. The PCTs approach here mirrors national drivers such as the Next Steps strategic review which emphasises transformational change of services, care closer to home, quality and productivity. The Darzi next stage review has only reinforced the need for the DQHH strategy. There will clearly be a need for all sectors of Hertfordshire NHS - acute, community providers, mental health, out of area care - to drive down cost and improve all aspects of quality: patient experience, effectiveness and outcomes. DQHH was a strategy for the whole health economy, incorporating all NHS organisations, which supported and signed up to deliver. It is necessary to foster this collaboration and reinforce the ultimate benefit to all of Hertfordshire. In support of this approach, the PCT will: • • • • 4.0 4.1 engage providers and PBC commissioners continue to collaborate through the DQHH programme board consider a more active role in service and pathway redesign for expert providers encourage GPs to self audit referrals and care patterns

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Financial Projections Work is currently being undertaken to refresh the financial model in the light of updated assumptions about allocations and tariff uplift, forecast expenditure assumptions and the QIPP plan. The overarching financial assumption is that the Recovery Plan will deliver year end financial balance in 2009/10.
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In addition, the following assumptions have been included in the financial projections. • • • • • • • Allocation assumption is nil growth from 2011/12 Tariff uplift is -2% from 2011/12 PCT prescribing 5% increase in expenditure from 2011/12 GMS 1% increase in expenditure from 2011/12 Dentistry 0.2% increase in expenditure from 2011/12 Updated forecast of expenditure in 2009/10 Updated estimate of cost pressures in 2010/11 onwards

4.4

The activity model, incorporating the QIPP changes, will then be run and incorporated within the financial model, including the cost of reprovision based on DQHH assumptions. This will show the extent to which investments can be made to further our strategic extent. Prioritisation As the financial position tightens it is clear that the Board will require a greater degree of rigour as to how investment/disinvestment decisions are made. It is therefore important that a proper framework exists to make those decisions. Based on work undertaken elsewhere in the NHS and adapted locally a proposed framework that enables an assessment against an agreed weighted scoring system, with ten key factors is attached as Appendix 1 to this paper.. Subject to Board approval a panel will be established that will included Non Executive, Executive, Clinical and invited lay representation and using the prioritisation framework will develop a view on our key priorities to feed into the strategy refresh. A further paper will be developed based on the experiences of this initial panel that will formalise the governance arrangements and which will be presented to the Board in order that the process can be mainstreamed into our commissioning process.

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Financial Assessment The following cost pressures have been identified arising from current commitments:
Current identified Cost Pressures West £ 000's 850 1000 250 500 1300 2000 5900 East £ 000's 800 1000 250 500 1400 2000 5950

Ambulance Growth Great Ormond Street arbitration London Strategy NICE Guidance Continuing Care Specialist Commissioning Total

6.2

The current strategic plan identifies a number of priority areas for investment, the level of funding against these has been reviewed and the latest estimate is summarised in the table below.
Areas of Significant Investment 2010/11
Additional spend per annum at end of 2013/14

West £ 000's Staying Healthy Tackling inequalities Roll out of Chlamydia screening Breast Screening (increased age range) Bowel Screening Acute Care Urgent Care Centres Planned Care Dental Achievement of 100% target for 18 weeks work Provision of satellite radiotherapy units Mental Health Investment including IAPT Maternity Maternity matters Children' Health Children End of Life Increase numbers Workforce redesign and comms Patient Experience Various initiatives 500 59 125 125 797

East Commentary £ 000's 500 59 125 127 1652

2800 500 500

2200 500 Non recurrent 500 Recurrent (2012/13)

2,000 500

2,000 250

800 50 62 40 30 500 9388

800 50 63 Non recurrent 40 Recurrent 30 Non recurrent (2010/11 - 2011/12) 500 9396

Carers Strategy Total

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6.3

The financial situation requires that these initiatives will need to be prioritised in accordance with an agreed approach Next Steps Subject to Board approval to adopt the proposed Prioritisation framework, a panel will be set up to review the key initiatives and agree a prioritised list for investment. The outcomes of the first panel will be incorporated into the revised strategy document that will be prepared and presented for approval to the December Board briefing. Subject to any amendments that may be identified, following consideration by the Board, the revised document will then be submitted in accordance with the prescribed WCC Assurance deadlines. Recommendation The Board is asked to note this update and approve the Prioritisation Framework detailed in Appendix 1.

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Gareth Jones Director of Strategic Planning 17th November 2009

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APPENDIX 1

HERTFORDSHIRE PCTs DRAFT FRAMEWORK FOR PRIORITISATION OF SERVICES

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GENERAL PRINCIPLES 1. A framework that enables the two Hertfordshire PCTs to prioritise its investments in healthcare helps to define the basis on which it approaches the commissioning of various treatments/ interventions/ procedures. 2. The PCTs uphold the values enshrined in the NHS core principles on which the NHS operates. These principles underpin the working practice of the PCTS. These principles are laid out in paragraphs 4-13 below. 3. The NHS will provide a universal service for all based on clinical need, not ability to pay Healthcare is a basic human right. Unlike private systems the NHS will not exclude people because of their health status or ability to pay. Access to the NHS will continue to depend upon clinical need, not ability to pay. 4. The NHS will provide a comprehensive range of services The NHS will provide access to a comprehensive range of services throughout primary and community healthcare, intermediate care and hospital based care. The NHS will also provide information services and support to individuals in relation to health promotion, disease prevention, self-care, rehabilitation and after care. The NHS will continue to provide clinically appropriate cost-effective services. 5. The NHS will shape its services around the needs and preferences of individual patients, their families and their carers The NHS of the 21st century must be responsive to the needs of different Panels and individuals within society, and challenge discrimination on the grounds of age, gender, ethnicity, religion, disability and sexuality. The NHS will treat patients as individuals, with respect for their dignity. Patients and citizens will have a greater say in the NHS, and the provision of services will be centred on patients' needs. 6. The NHS will respond to different needs of different populations Health services will continue to be funded nationally, and available to all citizens of the UK. Within this framework, the NHS must also be responsive to the different needs of different populations in the devolved nations and throughout the regions and localities. Efforts will continually be made to reduce unjustified variations and raise standards to achieve a truly National Health Service.

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7. The NHS will work continuously to improve quality services and to minimise errors The NHS will ensure that services are driven by a cycle of continuous quality improvement. Quality will not just be restricted to the clinical aspects of care, but include quality of life and the entire patient experience. Healthcare organisations and professions will establish ways to identify procedures that should be modified or abandoned and new practices that will lead to improved patient care. All those providing care will work to make it ever safer, and support a culture where we can learn from and effectively reduce mistakes. The NHS will continuously improve its efficiency, productivity and performance. 8. The NHS will support and value its staff The strength of the NHS lies in its staff, whose skills, expertise and dedication underpin all that it does. They have the right to be treated with respect and dignity. The NHS will continue to support, recognise, reward and invest in individuals and organisations, providing opportunities for individual staff to progress in their careers and encouraging education, training and personal development. Professionals and organisations will have opportunities and responsibilities to exercise their judgment within the context of nationally agreed policies and standards. 9. Public funds for healthcare will be devoted solely to NHS patients The NHS is funded out of public expenditure, primarily by taxation. This is a fair and efficient means for raising funds for healthcare services. Individuals will remain free to spend their own money as they see fit, but public funds will be devoted solely to NHS patients, and not be used to subsidise individuals' privately funded healthcare. 10. The NHS will work together with others to ensure a seamless service for patients The health and social care system must be shaped around the needs of the patient, not the other way round. The NHS will develop partnerships and co-operation at all levels of care - between patients, their carers and families and NHS staff; between the health and social care sector; between different Government departments; between the public sector, voluntary organisations and private providers in the provision of NHS services - to ensure a patient-centred service.

11. The NHS will help keep people healthy and work to reduce health inequalities The NHS will focus efforts on preventing, as well as treating ill-health. Recognising that good health also depends upon social, environmental and economic factors such as deprivation, housing, education and nutrition, the NHS will work with
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other public services to intervene not just after but before ill health occurs. It will work with others to reduce health inequalities. 12. The NHS will respect the confidentiality of individual patients and provide open access to information about services, treatment and performance Patient confidentiality will be respected throughout the process of care. The NHS will be open with information about health and healthcare services. It will continue to use information to improve the quality of services for all and to generate new knowledge about future medical benefits. Developments in science such as the new genetics offer important possibilities for disease prevention and treatment in the future. As a national service, the NHS is well-placed to take advantage of the opportunities offered by scientific developments, and will ensure that new technologies are harnessed and developed in the interests of society as a whole and available to all on the basis of need. 13. Ethical Commissioning Principles: The PCTS will commission patient care taking into account the ethical and commissioning principles listed below. These principles will also guide the decision-making process when considering individual requests for treatment of individual patients: a. Evidence of the safety of the proposed treatment/ intervention/ procedure for the patient. This will be based on information from the MHRA and/or the EMEA. b. The clinical effectiveness of the proposed treatment/ intervention/ procedure, incorporating evidence-based information from a variety of sources such as NICE Guidance, Cochrane Reviews, SIGN Guidelines, and a variety of other information sources and databases. The key success factors in evaluating clinical effectiveness are the need to search effectively and systematically for relevant evidence, and then to extract, analyse, and present this in a consistent way to support the work of prioritisation and commissioning. Choice of appropriate clinically and patient-defined outcome needs to be given careful consideration, and where possible quality of life measures and cost utility analysis should be considered. We will promote treatments for which there is good evidence of clinical effectiveness in improving the health status of patients and will not normally recommend treatment that is shown to be ineffective. Issues such as safety and drug licensing will also be carefully considered. When assessing evidence of clinical effectiveness the outcome measures that will be given greatest importance are those considered important to patients’ health status. Patient satisfaction will not necessarily be taken as evidence of clinical effectiveness. Trials of longer duration and clinically relevant outcomes data may be considered more
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reliable than those of shorter duration with surrogate outcomes. Reliable evidence will often be available from good quality, rigorously appraised studies. Evidence may be available from other sources and this will also be considered. Patients’ evidence of significant clinical benefit is relevant. c. Cost effectiveness of the proposed treatment/ intervention/ procedure. The PCTS will take into account costeffectiveness analyses of healthcare interventions (where available) to assess which yield the greatest benefits relative to the cost of providing them. It will compare the cost of a new treatment to the existing care provided and will also compare the cost of the treatment to its overall benefit, both to the individual and the community. It will consider technical cost-benefit calculations (e.g. quality adjusted life years), but these will not by themselves be decisive. d. Equity and fairness in the distribution of resources, in keeping with the PCT’s overall responsibility to address the health needs of the wider community it serves. The PCTS considers each individual within its population to be of equal value. It will commission and provide health care services based solely on clinical need, within the resources available to us. It will not discriminate between individuals or groups on the basis of age, gender, gender identity, sexual orientation, race, religion, lifestyle, occupation, social position, financial status, family status (including responsibility for dependants), intelligence, disability, physical or cognitive functioning. However, where treatments have a differential impact as a result of age, sex or other characteristics of the patient, it is legitimate to take such factors into account. The PCTS has a responsibility to address health inequalities across our population. It acknowledges the proven links between social inequalities and inequalities in health, access to health care and health needs. Higher priority may be allocated to interventions addressing health needs in sub-groups of our population who currently have poorer than average health experience (e.g. higher morbidity or poorer rates of access to healthcare). e. Access - The PCTS will ensure that the care we commission is delivered as close to where patients live as possible. Many specialised services cannot be provided in local settings and we may need to commission some services from distant providers in order to ensure quality, safety and value for money. f. Patient Choice - The PCTS respects the right of individuals to determine the course of their own lives, including the right to be fully involved in decisions concerning their health care. It will consider patients’ autonomy and rights, and the need to provide treatment that is of benefit and does not harm taking note of the views of the patient /
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carers. However, this has to be balanced against the PCTSs’ responsibility to ensure equitable and consistent access to appropriate quality healthcare for all the population. In commissioning healthcare, the PCTS will: i) ensure that in assessing the effectiveness of health care, we take account of outcomes that are important to patients and the patient’s experience of the care. ii) ensure, wherever possible, that within the care commissioned or provided there are a range of alternative options available, and that patients are given the necessary support to make an informed choice. iii) recognise that evidence of effectiveness usually relates to groups rather than individuals. We have set up an “individual case” mechanism to allow individuals to be considered as an exception to commissioning policy where evidence is available to suggest that an intervention not routinely funded may be of particular benefit to them in relation to other patients who might not be funded. iv) As a general rule, decline to provide individual funding for care that is not routinely commissioned or provided solely on the basis that an individual, or a clinician involved in their care, desires it. This is in line with our responsibility to ensure consistent and equitable access to care for all our population. It reflects our concern not to fund for one individual care which could not be openly offered to everyone in our population with equal clinical need. v) decline to provide a treatment of little benefit simply because it is the only treatment available. vi) consider treatments which effectively treat ‘life time’ or long term chronic conditions equally to urgent and life-prolonging treatments.

g. Affordability and availability of resources within the context of competing needs. The PCTS may not be able to afford all interventions supported by evidence of clinical and cost-effectiveness within their available budgets. Where this is the case further prioritisation will be undertaken based on criteria including national and local policies and strategies, local assessment of the health needs of the population, to ensure that we do not exceed our available resources. The PCTS is duty-bound not to exceed its budget, and the cost of treatment must be
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considered. The cost of treatment is significant because investing in one area of health care inevitably diverts resources from other uses. This is known as opportunity costs and is defined as benefit foregone, or value of opportunities lost, that would accrue by investing the same resources in the best alternative way. The concept derives from the notion of scarcity of resources. A single episode of treatment may be very expensive, or the cost of treating a whole community may be high. h. Needs of the Community balance against the needs of the individual and Exceptional need. Public health is an important concern of the PCTS, and the PCTS will seek to make decisions which promote the health of the entire community. Some of these decisions are promoted by the Department of Health (such as the guidance from NICE and National Service Frameworks). Others are produced locally. The PCTS also supports effective policies to promote preventive medicine which help stop people becoming ill in the first place. Sometimes the needs of the community may conflict with the needs of individuals. Decisions are difficult when expensive treatment produces very little clinical benefit. For example, it may do little to improve the patient’s condition, or to stop, or slow the progression of disease. Where it has been decided that a treatment has a low priority and cannot generally be supported, a patient’s doctor may still seek to persuade the PCTS that there are exceptional circumstances which mean that the patient should receive the treatment. There will be no blanket bans on treatment since there may be cases in which a patient has special circumstances which present an exceptional need for treatment. Each case of this sort will be considered on its own merits in light of the clinical evidence. The PCTS has procedures in place to consider such exceptional cases on their merits and this will be done through applying its Individual Funding Request Policy. 14. The PCTs aim to commission its services based on the health needs of the population and to be to ensure that it commissions high quality effective healthcare. It is governed by the principles of accountability to its constituent PCTs in the use of public funds, ensuring that it meets financial break even, year on year, whilst securing effective and efficient health care locally. 15. Commissioning plans will be based on the commissioning prioritisation process, taking into consideration the detail contained within each individual business case template and the prioritisation process detailed below.

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16. Prioritisation will inform the annual commissioning plan of the PCTs. The annual commissioning plan will then translate into the annual operating plan (work plan) of the PCT. This plan, will, in turn, be translated into annual contracts that the PCTs will sign off with the providers. 17. Where the business plan is for investment into corporate/support services, a decision will be based on the effectiveness of the subject matter of the proposal, and the proposal will, where appropriate, be assessed against the Ethical and Commissioning Principles. 18. Health Outcomes and Quality of Care The aim of commissioning is to achieve the greatest possible improvement in health outcome for our population, within the resources available. In deciding which interventions to commission, the PCTS will prioritise those which produce the greatest benefits for patients in terms of both clinical improvement and improvement in quality of life. The PCT will aim to commission high quality services as evidenced against national and international best practice. The quality of services will be measured where possible not only in terms of quality of outcomes and clinical effectiveness but also in terms of process and organisational efficiency; reducing dependency on health care; the quality of patient care; and the quality of the patient experience. 19. Where the business plan is for investment into corporate/support services, a decision will be based on the effectiveness of the subject matter of the proposal, and the proposal will, where appropriate, be assessed against the Ethical and Commissioning Principles. 20. Policy Drivers The Department of Health issues guidance and directions to NHS organisations which may give priority to some categories of patient, or require treatment to be made available within a given period. These may affect the way in which health service resources are allocated by individual PCTs. The PCT operates with these factors in mind and recognise that their discretion may be affected by National Service Frameworks, NICE technology appraisal guidance, Secretary of State Directions to the NHS and performance and planning guidance. 21. Disinvestment As well as commissioning new services on the basis of the criteria above, the PCT will keep existing services under review to ensure that they continue to deliver clinical- and cost-effective services at affordable cost. Where possible we will seek to divert resources from less effective services to more effective ones.
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PRIORITISATION PROCESS To be articulated and incorporated after ratification by the Board.

ASSESSMENT CRITERIA The PCTS will use a weighted scoring system to prioritise service plan objectives. The weighted criteria approach is as follows: • • List of criteria to be used Each criterion given a weighting depending on the perceived level of importance of each criterion. There are degrees of scoring within each sub-level: HIGH – 3 MEDIUM – 2 LOW – 1 NONE - 0 These scores will then be multiplied by the pre-agreed weighting to achieve a weighted score for each objective, allowing them to be ranked. Each objective will have an overall score, objectives can then be ranked.

•

•

The full criteria for assessing service, commissioning and support services plans for financial investment into the Commissioning Plan is detailed in Appendix A. The weighting for each criterion is highlighted in bold within brackets

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THRESHOLDS AND CONDITIONS Once all business cases have been scored, the individual mean scores will be compared with the agreed threshold level. A threshold level has been set, which will need to be achieved in order for the business case to go forward for final approval. Any business case, which scores below the predefined threshold, will be removed from the process, and will not proceed onto any further stages. Each member of the Panel will score individually and the mean score of the Panel for each business case will be calculated. A number of conditions will also be set for certain areas of the criteria. For example, although some plans may not achieve as high a score as others, if they get a full score for PSA targets plus a full score for Achievability then they will automatically proceed through. In business cases involving services other than clinical services (e.g. corporate services like IT); additional appropriate criteria will be set The additional conditions/criteria to be set will be decided upon previous to the prioritisation process taking place.

PERFORMANCE MANAGEMENT It is essential that the schemes/objectives that have received final approval are performance managed throughout the year, once implemented. This will be done through the corporate performance report and the mid-year and end-of-year business plan reviews. In addition, each funded scheme should be performance managed at a more local level by the service/PCT lead themselves. This will demonstrate whether the funded objectives/schemes are delivering the anticipated outcomes, keeping within budget and are on target in terms of timescale.

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Appendix A

Criteria for assessing service, commissioning and support services plans for financial investment into the Commissioning Plan

Criteria & Weighting

The proposal scores The proposal HIGH (3) scores MEDIUM (2)

The proposal scores LOW (1)

The proposal scores NONE (0)

STRATEGIC FIT (9) Key notes: a. PCT Vision b. PSA Targets c. LAA Targets d. Other local or national performance indicators e. NICE Guidance f. SFBH The plan demonstrates that as a minimum there is a major contribution to the PCT vision and one or more key PSA targets. The plan demonstrates a contribution to the PCT vision and also contributes to one or more of the areas within the strategic fit. The plan demonstrates a contribution to one or more of the areas within the strategic fit. There is no evidence showing that the plan contributes to any of the areas of strategic fit.

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Criteria & Weighting

The proposal scores The proposal HIGH (3) scores MEDIUM (2)

The proposal scores LOW (1)

The proposal scores NONE (0)

GOVERNANCE (LEGAL & CLINICAL) (8) Key notes: There is a legal requirement for the PCT to undertake this or this is covered by NICE Technology Appraisal Guidelines. This case is covered by guidance or recommendations from an external source (E.g. Healthcare Commission, Audit Commission, NICE) This is considered to be recommended 'best' practice (E.g. ALE level 4, World Class Commissioning, etc) There is no requirement or recommendation that the PCT undertake this.

ASSESSED NEEDS (6) Key notes: Need has been assessed locally through a Health Needs Assessment. Need has been extrapolated from HNAs based on other populations. Need has been demonstrated through health profiling locally, regionally or nationally There is no evidence of need.

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Criteria & Weighting

The proposal scores The proposal HIGH (3) scores MEDIUM (2)

The proposal scores LOW (1)

The proposal scores NONE (0)

EVIDENCED BASED (4) Key notes: The plan is clearly The plan is supported by The plan is supported supported by robust some trial evidence, by professional evidence of including cohort studies opinion. effectiveness based on or non-randomised, nonrandomised, blinded, blinded trials. controlled trials, or by the opinion of NICE. EFFECT ON INEQUALITIES (4) Key notes: If the plan includes a This plan is proven to This plan is likely to Health Equity Audit a reduce health result in a reduction of higher score should be inequalities. health inequalities given. The plan is not likely to affect health inequalities. There is a possibility that this plan may increase health inequalities There is no evidence available to suggest that the plan is effective, but also no evidence that it is harmful.

ACCESS (3) Key notes: If the plan includes a There is a clear There is a clear The scheme provides The scheme does not
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Criteria & Weighting

The proposal scores The proposal HIGH (3) scores MEDIUM (2)

The proposal scores LOW (1) health care in a setting more convenient to patients but the required capacity has not been robustly calculated or matched to demand

The proposal scores NONE (0) make services more accessible to patients, but does not make it any less accessible.

Health Equity Audit to indication that this assess access a higher proposal will make score should be given. services accessible for hard to reach groups where there is a clear unmet need, and the planned capacity has been clearly evaluated

indication that this proposal will make services more accessible for patients and the required capacity has been clearly evaluated and matched to demand

COST EFFECTIVENESS (7) Key notes: Costs of the service have been benchmarked to similar or alternative services and are lower for a higher output Costs of the service have been benchmarked to similar or alternative services and are lower for a comparable output Costs of the service have been benchmarked to similar or existing services and are comparable, for a similar output, or costs are higher for a higher output There is no evidence of the cost of the service being benchmarked to similar or alternative services, or costs have been benchmarked to existing or alternative
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The planned

Criteria & Weighting

The proposal scores The proposal HIGH (3) scores MEDIUM (2) intervention is proven to be more costeffective that any currently commissioned intervention for the same indication and is within the limits set by NICE (i.e. max £30k / QALY) The planned intervention is proven to be cost-effective within the limits of NICE guidance (i.e. max £30k /QALY) and is not replacing any currently commissioned service for the same indication.

The proposal scores LOW (1)

The proposal scores NONE (0) services and are higher for a similar output

The planned intervention is no more cost-effective than any currently commissioned intervention for the same indication.

The planned intervention has no cost-effectiveness evidence, is outside the limits set by NICE or is less costeffective than any currently commissioned intervention for the same indication.

FINANCIAL IMPACT (4) Key notes: No cost or net financial saving The net cost of the case is nil to 100k The net cost of the case is 101k - £499k The net cost of the case is in excess of £500k (Board
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Criteria & Weighting

The proposal scores The proposal HIGH (3) scores MEDIUM (2) (Officer approval)

The proposal scores LOW (1) (PEC approval)

The proposal scores NONE (0) approval)

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ACHIEVABILITY (6) Key notes: There is a clear plan for achieving the scheme with realistic assumptions and timescales. There is a low risk of failure. Evaluation is built in. There is a clear plan for how the scheme might be achieved but with ambitious targets and timescales. There is no obvious plan or mechanism for delivering of the scheme that has evidence of being thought through. The plan is likely to create antagonism which will block its implementation.

ACCEPTABILITY (4) Key notes: It clearly supports agreed strategy and fits with the wider service context. There is evidence of involving patients and stakeholders in the service design. Some links can be made with agreed strategy. Stakeholder involvement still required to move initiative forward. The plan is unlikely to elicit any degree of antagonism or support. The plan is likely to be unacceptable to some and will necessitate work to demonstrate need.

A significant degree of change involving loss to many stakeholders.

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Appendix B

1. Objective (1) Objective/Action Objective

Project Lead

Other involved (BPCT and other stakeholders)

Timescale

2. Performance Management Project Milestones

Key Performance Indicators

Outcome Measures

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3. Risk Risks to delivery of objective Risk Score

Risks if objective is not achieved

Risk

Score

4. Resource Impact Please list below any supporting business cases that are associated with this objective

5. Strategic Fit Standards for better health Please mark and select from the drop down list for each area, where this objective relates to a specific area of standards for better health.

ALE Please mark and select from the drop down list below if this objective relates to a specific area of ALE.

PSA Targets Please list below any PSA targets that this objective delivers

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Description: East and North Hertfordshire & West Hertfordshire PCTs PCT