Specialised Commissioning AUHUK & NHS England Improving Value Workshop Slides and Notes from Group Work Improving Value 7 th October 2015 www.england.nhs.uk
Contents 1. Presentation 1: Shared Agenda, Shared Challenge 3 Peter Huskinson, NHS England 2. Presentation 2: Setting Context - Provider Perspective 20 Mike Sexton, UHB 3. Presentation 3: Improving Quality, Reducing Variation 31 Wayne Bartlett-Syree, NHS England 4. Presentation 4: Service Variation – What do we know? 38 Madi Parmar, UHB 5. Presentation 5: Shared Agenda – High cost Drugs & Devices 43 Michael Whitworth, NHS England 6. Group Discussion facilitator notes summary 52 www.england.nhs.uk
Shared agenda Shared Challenge Peter Huskinson NHS England www.england.nhs.uk
AGENDA • WELCOME AND INTRODUCTIONS • SETTING THE CONTEXT – A SHARED AGENDA & CHALLENGE • SHARED AGENDA ON EXCLUDED DRUGS & DEVICES • COST OF SUBOPTIMAL QUALITY IN SPECIALISED CARE • LUNCH • CONSTRUCTIVELY ADDRESSING VARIATION • NEXT STEPS www.england.nhs.uk 4
Context Setting some context • Key challenge for today – expend energy on the shared agenda • The future looks challenging for both providers and commissioners • Efficiency, CIP and QIPP – do we have shared understanding? • Tariff Context but not focus • Range of Treatments • Looking ahead to 29 th – service rationalisation and review www.england.nhs.uk 5
Context Challenge for today Addressing Not ignored, but real not today’s focus incurred costs The achievable ‘efficiency ask‘ Pricing, Top ups, Risk Share Contract Terms Causes / extent of 13/14 deficit (unless linked to solutions) www.england.nhs.uk 6
Context Increasing proportion of spend on Specialised care 2014/15 share of 2015/16 share of 2013/14 share of allocation allocation allocation % % % CCGs 69.3% 69.3% 68.8% Primary Care 12.7% 12.8% 12.7% Public Health 1.8% 1.7% 1.7% Specialised 13.8% 14.0% 14.5% Other Direct 0.5% 0.5% 0.5% Commissioning NHS England Internal 1.9% 1.8% 1.5% Budgets Transformation 0.0% 0.0% 0.2% Total 100% 100% 100% Source: NHS England corporate finance, board paper www.england.nhs.uk 7
Context FYFV Productivity Challenge for Specialised Services Five Year forward view productivity challenge Spend on specialised services £bn • It has previously been calculated that the Nominal costs on specialised services by the NHS is predicted to increase by 7.2% per NHS faces a gap between expected demand annum between 2013/14 and 2019/20. and funding of ~£30bn by 2020/21. Nominal 1 • To address this gap we will need to take £bn 20.2 action on three fronts: demand, efficiency 22 0.7 and funding. Less impact on any one of Excluded 7.2% 20 these will require compensating action on the Devices other two. 18 Excluded 4.5 4.5 Drugs 16 • Delivery of the more active demand and 13.3 prevention activities outlined in the Forward 0.5 14 View would deliver in the short (e.g. 4.8 2.9 Other 4.7 12 2.4 prevention of alcohol harm) and medium term (e.g. action on diabetes). 10 3.8 3.6 8 • The long-run efficiency performance of the NHS has been ~0.8% annually. We have 6 achieved nearer 2% more recently, although 10.2 Staff 4 this has been based on some actions that 10.2 7.4 6.9 are not indefinitely repeatable, e.g. pay 2 restraint. 0 2013/14 2019/20 www.england.nhs.uk 8 1) NHS England Strategic Finance team.
Future Financial Pressures Differential impacts across services 15 specialised services to illustrate variation in spend ,growth and pattern of provision 1 Projected service spend CAGR 14/15 to 19/20 15 Infectious Diseases Adult TAVI Internal medicine Cancer & Blood Mental Health Neurology Tier 4 Chemotherapy 10 CAMHS Trauma & Rehabilitation Renal Women & Children Renal Dialysis Transplant Cardiac Paeds CC Secure surgery £250m total mental service spend health 5 Complex in 2013/14 Paediatric Morbid Neonatal CC thoracic surgery Obesity surgery Surgery Likely funding growth CAGR? HIV 0 0 50 100 150 Number of providers 1. Top 5 services by spend and top 10 services by growth (excl. those with <£30m spend) Source: Future Financial Pressures in Specialised Services ( financial model) www.england.nhs.uk 9
Future Financial Pressures Six services account for ~50% cost growth to 2019/20 (Pre HEP C) – is the addressable spend in these areas? Total spend on specialised services (nominal) £m 22 £bn Total: £3.6bn 2.5 20.2 20 52% of total growth 0.1 18 0.2 0.2 0.2 0.3 0.3 0.3 0.5 16 0.6 1.7 14 13.3 0 2013/14 Chemo- Secure MH Renal Neurology Neonatal Neurosurgery Rare Cardiac - Paediatric Infectious Other 2019/20 spend therapy Dialysis Intensive Cancers Cardiac Intensive Diseases services spend Care surgery Care Adult Internal Medicine Cancer & Blood Mental Health Trauma & Rehabilitation Women & Children Note: Chemotherapy growth includes growth in CDF spend, which is assumed to grow inline with growth in non-CDF chemotherapy spend www.england.nhs.uk 10 Source: FFP analysis. See model for sources of assumptions
Future Financial Pressures 6 contributory interventions were recommended from provider/commissioner workshop input Publish data to Publish national activity, cost and outcome data by service and provider to provide 1 reduce variation oversight of variation between providers Reduce incentives to increase volume, for example by using contracting tools to Reduce incentives 2 incentivise providers to help reduce activity related costs, and by moving towards for volume population-based budgets where appropriate Control Work with NICE to introduce a national deployment model that assesses all new deployment of 3 interventions prior to widespread adoption across the system, and identifies what legacy interventions (and associated costs) the new intervention will replace new interventions Enhance the role of CRGs to enable them to improve the value of their respective Increase focus on 4 services, for example by adjusting referral protocols and clinical thresholds to reduce healthcare value unnecessary care or identifying low-value interventions to de-commission Suspend low volume / low quality services, removing associated spend from these Reshape supply 5 providers. Enable new models of supply to emerge that increase value in services (e.g. lead provider models and consolidation of planned care in higher volume centres) Reduce avoidable Incentivise early interventions and prevention, especially in services where this can 6 reduce avoidable secondary or tertiary care (e.g. early detection of cancer) specialised care www.england.nhs.uk 11
Context Tariff Context • Two equal and opposite errors: 1. Payment system changes are irrelevant 2. Payment system changes will solve our problems (provider / commissioner) • Providers and Commissioners engaged in an advisory group chaired by health economist Anita Charlesworth of the health foundation • HRG4+/Top ups are being impact assessed • Marginal tariff /risk-share options are being considered • Recommendations are likely to be produced by the end of this month • We understand a programme of engagement such as webinars and links to existing regional events will take place during November, with NHS providers • Purely for the purpose of today expect that: • Prices will better reflect complex care than they do today but imperfectly • The principle of funding the extra costs for additional patients, some version of shared gain/pain on excluded items • Some recognition of the impact on efficiency from changed arrangements • Overall ‘efficiency ask’ is unlikely to be anything other than stretching for the foreseeable future. • Expect allocations for commissioners to be equally challenging www.england.nhs.uk 12
Context Efficiency, CIP and QIPP Affect Provider Reduce the unit-cost per COST costs care-episode delivered IMPROVEMENT May not affect PLANS commissioner (technical efficiency ) expenditure Affect Reduce the number of Commissioner episodes per patient treated expenditure (productive efficiency) Usually affect QIPP PLANS provider cost Reduce the number of people May be + or – needing to be treated on provider (allocative efficiency) profitability www.england.nhs.uk 13
Context Complimentary Agendas QIPP LOS within Trim CIP Excess Bed days Input costs for Lower cost & Nationally priced Spells with price per episode Episodes complications (locally priced) Pathway steps / Staff productivity Gain/risk share follow ups Readmissions Cannot purchase Price/usage of Cannot deliver services patients excl. D&D service within need without it income without it Common Ground? 1. Neither COST SHIFTING nor INCOME GENERATION are efficiency 2. MOST Initiatives are a combination of QIPP and CIP - interdependent www.england.nhs.uk 14
Context How would we know change is an improvement? Serving NHS purpose Population Health Status & Improvements in health Health Service Outcomes & Service Quality Indicators Equity Efficiency Service Responsiveness, Access & Patient Experience Financial Protection for individuals facing health problems Public values Health outcomes > Responsiveness 2:1 Public values Equity > Average Improvemen t 1.5:1 Consensus of WHO, OECD, EU agencies e.g. Smith, Papanicolas, Mossialos, Leatherman (2009) www.england.nhs.uk 15
Recommend
More recommend
