HILLINGDON PRIMARY CARE TRUST

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					OPTION APPRAISAL FOR THE DEVELOPMENT OF                                               ITEM 8
PERFORMANCE MANAGEMENT SETTLEMENT AND
REVIEW FOR ACUTE PLANNED AND UNPLANNED
ACTIVITY TO STRENGTHEN COMMISSIONING
                      Decision       Discussion       Information



Report introduced by: Colin Peel, Interim Deputy Director of Finance


Report signed off by: Professor Yi Mien Koh, Chief Executive


Purpose of the report:
To set out for the Board options for the development of performance management settlement
and review for acute planned and unplanned activity to strengthen commissioning. To decide
the preferred means of developing the performance management function and authorise the
executive to proceed to contract.



RECOMMENDATIONS TO THE BOARD:
Board is requested to:

   1. Review the options for the development of performance management settlement
      and review for acute planned and unplanned activity to strengthen
      commissioning.
   2. Approve the selection of the option 5; to in-source selected functions and develop
      skills in house.
   3. Approve the letting of a contract under FESC and the setting up of an in house
      service to develop performance management.




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Date of meeting: 18 September 2007                                        Page No 1
OPTION APPRAISAL FOR THE DEVELOPMENT OF                                         ITEM 8
PERFORMANCE MANAGEMENT SETTLEMENT AND
REVIEW FOR ACUTE PLANNED AND UNPLANNED
ACTIVITY TO STRENGTHEN COMMISSIONING
                                                                  Contact Name: Yi Mien Koh
                                                                 Contact Tel No: 01895 452001
PURPOSE OF THE REPORT

To set out for the Board options for the development of performance management
settlement and review for acute planned and unplanned activity to strengthen
commissioning. To decide the preferred means of developing the performance management
function and authorise the executive to proceed to contract.

TERMS/ACRONYMS USED IN THE REPORT

FESC -        Framework for procuring External Support for Commissioners
SOC    -      Strategic Outline Case
SLA    -      Service Level Agreement
ROI    -      Return on Investment
ITT    -      Invitation to Tender
DH     -      Department of Health
CD     -      Commercial Directorate
LD     -      Learning disabilities

INFORMATION
SUMMARY AND KEY MESSAGES

The Board is asked to note that:

      The project Board has undertaken a comprehensive evaluation of the available
       options.
      The review of the options for provision of performance management settlement and
       review indicate that there are only two options available that meet the criteria.
      The risks of adopting the in house option are considered to be greater than the
       potential costs of letting a contract with a commercial provider.
The Board is asked to approve that:
      The Chief Executive concluded a contract with the preferred bidder for the provision
       of support to the performance management function and the development of in
       house skills within the Finance and Performance Directorate.


1. INTRODUCTION
1.1. The PCT has a significant level of recurrent overspend which it needs to address.
A significant part of this overspend is considered to be due to a high level of acute
provider activity. The Board agreed at the meeting on 17th January to consider the options
for the development of performance management settlement and review for acute planned
and unplanned activity to strengthen commissioning. To assist in the evaluation of the


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options the Board agreed a set of goals and supporting questions as set out in Table 1
below.
Table 1 Criteria for Assessing Options

        Goal        Key Supporting Questions

 Cost efficiency    •Will this support reduction in cost of managing the delivery of healthcare? (management costs lower)
 (internal)         •Does this demonstrate ‘value for money’ ?
                    •Can the outsource provider do this more efficiently than the PCT?

 Financial          •Does this permit greater financial control in healthcare?
 Re-engineering     •Does this free up investment funds and promote greater investment freedom?



 Innovation         • Does this facilitate the delivery of healthcare services at a lower cost per head of population?
                    • Will outsourcing this function encourage adoption of innovative approaches to the delivery of healthcare
                      and health that will:
                           –Reduce overall healthcare costs? (e.g. care pathway redesign, innovative purchasing practice)
                           –Improve patient outcomes?

 Productivity       •Can the outsourcer deliver more productivity than the PCT?
                    •Will this permit a broader scope of activities to be delivered with current resources?
                    •Will this free up time for employees to focus on core organisational competencies?

 Transfer of        •Will this reduce quantity or cap the risk to the PCT in delivering healthcare services in Hillingdon?
 Risk (share)       •Are you ensuring that significant new risks are being managed?



 Better Services/   Will outsourcing: fill in gaps in activities, not currently undertaken by the PCT?
 Improve Quality    To provide access to specialist skills and capabilities? Build stronger skills and capabilities internally?

 Better             Will outsourcing: Free up time for employees to focus on core organisational competencies? Provide access
 Management         to better skills management and the tools to support better overall management for staff internally?



1.2 At this stage the Board considered four options:

    Do Nothing
   Do not change any of the current practices and Procedures within the PCT.

    Build Internal Capability
   Develop the Internal processes and procedures by the recruitment of additional staff and
   investment in automation of procedures.

    Develop synergies with other organisations
   This approach typically looks for economies of scale to deliver savings by joining with
   other PCTs to share scarce resource and create conditions for the transfer of innovation
   and developments. This also provides for the sharing of the costs of any developments.

    In-sourcing
   The In-sourcing of the Commissioning activities to a specialist supplier looks to deliver
   desired outcomes quicker by buying in the skills and expertise. Out-sourcing also permits
   a longer term approach to investing in the PCT infrastructure (people and systems) to be
   adopted, overcoming the drawbacks of developing the capability internally within the
   NHS.




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1.3 At the Board meeting on 15th May 2007 the Board considered the Review of the
PCTs Commissioning Function.

     1.3.1 Summary of work undertaken

     Hillingdon PCT assessed the effectiveness of its current commissioning function using
     three different approaches as follows:

      Analysis of the results from the PCT Fitness for Purpose exercise
      Process mapping of current commissioning processes
      Identifying the key areas of commissioning critical to financial recovery

     A project structure was established with support from the Department of Health’s
     Commercial Directorate. The chief executive as Senior Responsible Officer chaired
     the project board which membership included the PBC chair, chair of Community
     Voice (the main community group in Hillingdon), PCT senior managers and
     representatives from the Commercial Directorate.

     1.3.2 PCT Fitness for Purpose

     The 2006 national PCT Fitness for Purpose (F4P) exercise assessed PCT
     performance against best practice criteria. For the purpose of this review, the F4P
     framework was mapped against the commissioning functions to identify key strengths
     and weaknesses. All areas except Patient and Public Involvement were rated as red -
     i.e. weak. As F4P only covered strategic planning, care pathways management and
     contract monitoring, the other areas of commissioning were analysed using process
     mapping.

     1.3.3. Process Mapping

     Detailed process mapping was undertaken. Process mapping is a business technique
     used to capture and analyse the way an organisation works and how things are done.
     Before an organisation can contemplate outsourcing, it needs to be clear about its
     processes in order to identify where efficiencies and improvements could be achieved.
     Without this, a contract will be unable to specify the service requirements and
     therefore the measures to be used to assess results.

     A total of 34 process maps were undertaken by trained PCT staff, supported by the
     Commercial Directorate. The process maps covered all three commissioning functions
     of Assessment and Planning, Contracting and Procurement and Performance
     Management, for all eight service areas of acute planned and unplanned, community,
     primary care, mental health and learning disabilities (LD), social care, specialist
     services, and ambulance services. So far, with the exception of mental health and LD,
     social care and ambulance services, all process maps have been completed.

     Overall not all processes were in place for Contracting and Procurement and
     Performance Management. Furthermore, a number of the processes were not
     transparent or were individual-dependent instead of being embedded in organisational
     systems and processes. The exercise provided sufficient evidence that these areas
     could be improved with external support.




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     1.3.4. Commissioning Areas Critical to Financial Recovery

     Financial recovery is the top priority for the PCT in 2007/08. The 57 work streams in
     the recovery plan were mapped against key areas of commissioning. As a significant
     proportion of the £22 million planned savings is dependent on contract performance
     management, this is a critical area for the PCT to strengthen. Table 2 below shows
     the distribution of savings targets mapped against the three commissioning areas.

        Table 2        Commissioning to Deliver Recovery
                                                                            £000’s
         Assessment and Planning                                            4,180
         Contracting and Procurement                                        0
         Performance Management                                             12,555
         Corporate Efficiencies                                             6,020
         Total                                                              22,755

1.4 Summary of PCT commissioning issues.

   The analysis found insufficient processes in a number of areas within Assessment and
   Planning. Although there appeared to be sufficient information to provide detailed
   specifications in Contracting and Procurement, and Performance Management, they
   were neither transparent nor embedded within the organisation. Early quick wins could
   be gained by strengthening performance management.

   The process mapping exercise raises a number of issues regarding the quality of
   commissioning in the PCT. These are summarised below:

   1.4.1 Assessment and planning
    Public health function is good but lacks connectivity to commissioning
    There is a weak connection between planning and contracting
    Planning appears to be reactive rather than proactive
    Service planning and contracting were based on quantity rather than outcomes
    Decisions lack rigorous prioritisation
    Recent history of unstable leadership at the PCT
    Potential loss of corporate memory

   1.4.2 Contracting and Procurement
    Untested data quality with high error rates
    Weak rules of engagement with providers
    Central guidance open to interpretation
    Inconsistent, irregular and inaccurate data partly due to lack of automation
    Staff lack robust negotiation skills
    Poor quality contract documentation
    Contract management arrangements poorly defined/understood
    Contracts based on budgets/deficits or previous referrals, and not needs

   1.4.3 Performance Management
    Absence of robust tools and resources to manage contracts
    No systematic contract monitoring arrangements across all service areas
    Contract over-performance at year end due to inaccurate planning and inadequate
       in-year monitoring



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      Lack of robust data – either not collected at the right level or inappropriately analysed
       for reporting purposes
      Financial and activity data need to be linked in performance monitoring
      Limited evidence of performance management linked to Assessment and Planning.

1.5 High level benchmark data has highlighted that HPCT has a significantly higher
expenditure in a number of areas than the London PCT average, in total 11% greater
expenditure, see table 3 below. The implications of this are that the PCT is providing higher
cost treatment to its population. There are currently no means of identifying the reason for
this additional expenditure.

             Table 3 - Standardised Ratio in relation to London


             Age_Grouped_Results       HRG_Chapter       HRG Chapter Name                     Ratio
             All Age Bands             A                 The Nervous System                   161
             All Age Bands             B                 Eyes and Periorbita                  97
             All Age Bands             C                 Mouth, Head, Neck and Ears           101
             All Age Bands             D                 Respiratory System                   103
                                                         Cardiac Surgery and Primary
             All Age Bands             E                 Cardiac Conditions                   104
             All Age Bands             F                 Digestive System                     117
                                                         Hepto-biliary and pancreatic
             All Age Bands             G                 system                               94
             All Age Bands             H                 Musculoskeletal System               137
             All Age Bands             J                 Skin, Breast and Burns               111
                                                         Endocrine and Metabolic
             All Age Bands             K                 System                               115
                                                         Urinary Tract and Male
             All Age Bands             L                 Reproductive System                  88
             All Age Bands             M                 Female Reproductive System           89
             All Age Bands             N                 Obstetrics and Neonatal Care         117
             All Age Bands             P                 Diseases of Childhood                112
             All Age Bands             Q                 Vascular Surgery                     111
                                                         Spinal Surgery and Primary
             All Age Bands             R                 Spinal Conditions                    144
                                                         Haematology, Infectious
                                                         Diseases, Poisoning and Non-
             All Age Bands             S                 specific Groupings                   105
             All Age Bands             T                 Mental Health                        102

                                                         All chapters                         111


1.6 Based on this review the Board agreed that the area which could provide the most
significant returns in the shortest time scale was Performance Management and Review of
Acute Planned and Unplanned activity. It was therefore decided to concentrate on the
development of performance management and review of acute planned and unplanned
activity as the first project.




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1.7 This performance management and review would concentrate on the identifications of
areas where the costs of service provision were higher than the average to identify potential
reasons. The first step of this would be to ensure that all activity is recorded and charged for
correctly. This will enable the performance management to concentrate on the review of the
efficiency and effectiveness of the clinical pathways that are being recorded. This will be
undertaken by a clinically led review of provision against local and national comparators to
enable the PCT to contract for appropriate service levels and care pathways.

1.8 Following this review the Board agreed to consider a fifth option.

1.8.1 In-sourcing Selected Performance Management Functions and Developing In-
     house Skills

        This involves sourcing externally support for part of the performance management and
        review function. The support would include bringing in expertise to develop systems
        and skills in-house with a view to improving internal capacity and capability in future
        years.

1.9 The Board required that each of the options be evaluated and that a Full Business case
be developed to support the decision on the preferred option.

1.10 In order to achieve this, the Board agreed to seek tenders from external suppliers for
the provision of performance management settlement and review for acute planned and
unplanned activity to strengthen commissioning in order to evaluate the costs of the out
sourcing option. This tendering process was to take place under FESC with the support of
the Commercial Directorate of the DH .

1.11 This tendering process has now been completed and the PCT is therefore able to
consider the cost effectiveness of all the options.

2. EVALUATION OF OPTIONS

2.1 Summary of Options Evaluation

   The options to be reviewed against the assessment criteria are

   1.    Do Nothing
   2.    Build Internal Capacity
   3.    Develop Synergies with other organisations
   4.    Out Sourcing
   5.    In-sourcing Selected Performance Management Functions and Developing In-
         house Skills

        Table 3 Summary Evaluation against Criteria
         Goal              Option 1    Option 2 Option 3        Option 4     Option 5

         Cost              ×           √           √            ×            √
         Efficiency

         Financial Re-     ×           √           ×            √            √



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       Goal              Option 1    Option 2 Option 3        Option 4     Option 5
       engineering

       Innovation        ×           √           ×            √            √

       Productivity      ×           √           √            √            √

       Transfer of       ×           ×           ×            ×            √
       Risk

       Better            ×           √           √            √            √
       Services/
       Improved
       Quality

       Better            ×           √           ×            √            √
       Management

2.2 Do Nothing
    The initial option of doing nothing met none of the proposed goals and is not an
    acceptable action given the current financial situation of the PCT. This option was
    therefore rejected.

2.3 Build Internal Capability
    This option has the potential to deliver some of the desired goals and has been started
    within the PCT in the interim with the deployment of staff on temporary contracts.
    However it is recognised that the development of the full performance management and
    review function would require a comprehensive development programme across the
    PCT and that this would require a period of time. Typical development tasks will need to
    address all areas of capability (people, technology and policy and process) across the
    PCT.

   It is considered that building these capabilities internally through this style of programme
   would present a high risk option due to the failure to achieve similar outcomes in
   previous years within the financial and funding constraints placed on the PCT by the
   NHS. This option was retained as a public sector comparison, whilst accepting its
   limitations.

2.4 Develop synergies with other organisations

   2.4.1 Initially this option appears attractive in the light of the Commissioning Support
   Service currently proposed for London. However the nature of the option presents
   Hillingdon with a number of problems which makes the option less attractive to
   Hillingdon:

              Reliance on other organisations for the pace of change
              Reliance on other organisations to support and drive economies of scale and
               outcomes


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             Tendency to result in a “one size fits all” outcome
             Economies of scale are unlikely to realise size of savings required

    2.4.2 Although supportive in delivering Hillingdon’s turn around and Fitness for Purpose
    objectives, these options are unlikely to address the fundamental over-spend in
    healthcare currently seen today and have therefore been discounted as viable options in
    their own right. But they do provide a useful lever that may allow additional savings to
    be realised through the in-sourcing option, as they provide benchmark costs for
    elements of the services to be in-sourced enabling harder negotiations to be
    undertaken.

    2.4.3 The option of developing a service in conjunction with neighbouring PCTs was
    considered as similar to the In House option with the advantage of some shared costs
    but the disadvantage of requiring to move at the speed of development of the slowest
    member of the consortium. The PCT’s financial position requires that it moves with all
    due speed to develop this function.

    2.4.4 The continuing delay in the implementation of a full performance management
    and review function across London has meant that this option is not viable in the short
    term. However this option is not ruled out for the future as the service across London
    develops.

    2.4.5 This option was therefore rejected from further consideration at this stage.

2.5 In-sourcing

    2.5.1 The In-sourcing of the Commissioning activities to a specialist supplier looks to
    deliver desired outcomes quicker by buying in the skills and expertise for an
    organisation already equipped to provide these services. In-sourcing also permits a
    longer term approach to investing in the PCT infrastructure (people and systems) to be
    adopted, overcoming the drawbacks of developing the capability internally within the
    NHS.

    2.5.2 The PCT could not find any organisation that had provided these services to a
    PCT in the form that was required. Whilst some organisations had provided some
    elements of the service there were no comparators to determine the scale or cost of in-
    sourcing. It was therefore agreed that the PCT would utilise the FESC process under
    development by the CD at the DH to test the market for the provision of these services.

    2.5.3 This option was therefore retained for full evaluation.

2.6 In-sourcing Selected Performance Management Functions and Developing In-
house Skills

  2.6.1 This involves sourcing external support for part of the performance management
  and review function. The support would include bringing in expertise to develop systems
  and skills in-house with a view to improving internal capacity and capability in future
  years. It offers the option of piloting procuring external support on a small scale.

  2.6.2 As this is a hybrid of the two remaining options it was retained for full evaluation.




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3. DETAILED EVAUATION OF REMAINING OPTIONS

3.1 The PCT set up a formal project Board to consider the remaining options. The Project
Board considered that the unknown option was the out sourcing of the performance
management function and therefore decided to concentrate the initial evaluation on this
option.

3.2 OPTION 3 - In-Sourcing

3.2.1 The PCT, in conjunction with the CD at the DH , developed a specification for the
provision of a performance management, settlement and review function for acute planned
and unplanned activity. This was a number of elements of the framework for procuring
support for commissioners (FESC) that was under development. It was therefore agreed
that the PCT should use the FESC as the procurement model.

3.2.2 The specification was sent to seven potential suppliers on 1st June 2007 and
responses received form six bidders on the 18th June 2007. These bids were evaluated
against a set of evaluation criteria that had been agreed by the Project Board on 24th May
2007. These evaluations were undertaken by a panel of senior officers of the PCT between
19th and 22nd June 2007. The results of this evaluation were reported to the Board in private
session, due to the commercial in confidence nature of the bids submitted, on 29th June
2007.

3.3.3 At this meeting it was agreed that

       none of the tenders received matched the evaluation criteria on financial grounds.

       four of the tenders received indicated sufficient substantial benefit to the PCT on
        service requirements to warrant further work to address the financial considerations
        of the bidders and the PCT.

3.3.4 As a consequence the four remaining bidders were requested to submit revised bids
against a revised specification of a three year contract with particular emphasis on the
clinical aspects of the performance management and review.

3.3.5 The revised tenders were received on 13th July 2007 and were evaluated by the same
team of senior officers against the evaluation plan on 16th July 2007. The results of this
evaluation were reported to the Board, again in private session due to the commercial in
confidence nature of the bids submitted, on 25th July 2007.

3.3.6 At this meeting it was agreed that:

       Three of the revised tenders failed to meet the evaluation on service criteria

       The remaining tender failed to meet the evaluation on financial criteria and therefore
        affordability.

3.3.7 It was therefore decided that the full in-sourcing of the performance management
settlement and review functions was not a viable option.

3.4 Option 2 - Build Internal Capability



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3.4.1 The process of evaluating the tenders has developed the PCTs understanding of the
nature of the performance management and review function. The components of an in
house team, in addition to the existing staff at the start of the review, to provide the services
required have been considered.

3.4.2 The in house would require the recruitment of eight staff plus the development of a
clinical support network. The details of an in house service are set out in Appendix A and
are estimated to cost £0.850 million per year, £2.55 million over three years.

3.4.3 The development of this option will take time over the next three to six months with the
recruitment of staff and development of the process for the clinical evaluation of the activity
data. This will take up scarce management time which will have to be diverted from other
projects. There is also no certainty that the staff with the skills required for this assignment
are available currently. It may require the training and development of staff to provide the
services required.

3.4.4 The risk of delivery of the service will be wholly on the PCT and the management of
the function would be line management which has inherent difficulties where there is
performance failure.

3.4.5 The development of a clinical network to successfully review the efficiency and
effectiveness of the acute sector activity would be a new development. Whilst this is
considered to be theoretically possible the development would take time and would also
require considerable work to bring together to provide the services that are required.

3.4.6 The project for the performance management and clinical review of acute planned and
unplanned activity is based on the premise that the PCT is currently not obtaining best value
from the services. This is based on the review of historical data and benchmark
comparisons at a high level with other PCTs and initial work undertaken over the last three
months. There are therefore considerable grounds to consider that these are true.
However, if the original premise is incorrect, it would take some time for an in house team to
identify this and the break up of the team would present challenges, and potentially
redundancy costs.

3.4.7 The development of the in house capacity is therefore considered to be a viable but
risky option.

3.5 Option 5 - In-sourcing Selected Performance Management and Review Functions
and Developing In-house Skills

3.5.1 In the course of this review, since January 2007, the PCT has been developing the
performance management and review of acute sector SLAs through existing staff and staff
on temporary contracts. This has identified that a significant element of the technical review
of the activity data can be provided by the current in-house staff. The area of critical
shortage in existing capacity is the clinical review of activity data, both on coding of activity
and the clinical efficiency and effectiveness.

3.5.2 The review of the tenders that failed on the evaluation of the service criteria showed
that the weakness in all these tenders was the clinical review. The only tender to pass the
service criteria could demonstrate previous experience of the clinical review, in a different
but related environment, in a manner which was transferable to the NHS. It also showed
that the financial criteria were not being met due to the requirements for the production of


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routine data report on the levels of activity. This also led to the lack of risk share by the
tenders.

3.5.3 A revised specification was prepared which still retained the essence of the original
specification but left the production of the routine data down loads with the PCT. This is
attached as appendix B. In addition allowed for the PCT to undertake a review of the activity
data prior to submission to the tenderer. These discussions lead to a revised commercial
bid from the remaining tenderer which provided for more risk sharing on the outcome of the
review. This provides for an expected cost of £3.2 million with savings to the PCT of £4.9
million (gross savings £8.1 million). The minimum cost to the PCT with the contract break
clause would be the first year fixed fee of £0.4 million. The fixed fee over the full three years
of the contract would be £1.1 million. The maximum cost to the PCT would be £3.8 million
with net savings to the PCT of in excess of £6.2 million.

3.5.4 In the sharing of the performance management and review of acute activity, the PCT
would:

       prepare the data down loads from each acute sector provider
       undertake initial review of data for errors such as incorrect responsible
        commissioner
       provide the tenderer with the data set along with a schedule of the potential errors
        identified.

3.5.5 The tenderer would:

       undertake review of the data for anomalies in data coding, particularly relating to the
        clinical coding of activity
       review the data for indications of clinical inefficiencies or ineffectiveness
       provide the PCT with a detailed schedule of data queries along with the basis of
        challenge.

3.5.6 The PCT and Tenderer would meet with the acute provider to

       agree adjustments to the data set for errors in the coding of data
       discuss areas of clinical inefficiency or ineffectiveness with the aim of identifying
        agreement to the development of agreed clinical pathways to eliminate these
        inefficiencies or ineffectiveness.

3.5.7 This sharing of work load would lead to the development of the process and
procedures for the evaluation of the performance and review of acute activity. It would
enable the PCT to bring the commercial sector experience of clinical review into the process
and share knowledge. This will provide for the future development of the service provision
from within the PCT.

3.5.8 The involvement of the commercial sector will enable the teams to be mobilised to
undertake this work quickly and pass the management of the unknown element of the
process to a third party. The performance related element of the contract provides the
incentive to the tenderer to identify the clinical challenges. However the contract provides
for the disengagement of both parties should it be identified that there are not the degree of
coding errors or clinical inefficiencies or ineffectiveness that is suspected.




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3.5.9 Full details of the commercial bid from the remaining tenderer are set out in a separate
commercial in confidence paper. This is compared to the estimated costs for an in house
service.

4. CONCLUSION

4.1 There are only two options which meet the majority of the assessment criteria. The
detailed evaluation of these show the greatest potential benefit to the PCT would be through
the in house option. However this comes at the cost of the delay in the setting up of the
service which would result in the results of the performance review not being available to
inform the SLA negotiations for 2008-09. In addition should the project not identify the
savings that are envisaged from the work the potential costs would be higher than the hybrid
option.

4.2 The shared work load model provides for the immediate mobilisation of a team for the
clinical evaluation with the majority of payments being dependent on the identification of
deliverable savings. It also provides for the disengagement at minimal cost should the work
identify that these savings are not identified.

4.3 It is therefore concluded that the least risk is with the development of a shared service
between the PCT and the remaining tenderer.

5. RECOMMENDATIONS TO THE BOARD:
Board is requested to:

   1. Review the options for the development of performance management settlement
       and review for acute planned and unplanned activity to strengthen
       commissioning.
   2.   Approve the selection of the option 5; to insource selected functions and develop
        skills in house.
   3. Approve the letting of a contract under FESC and the setting up of an in house
       service to develop performance management.

APPENDICES

Appendix A     In House Service

Appendix B     Revised Specification for Support to Performance Management and Review




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