World class commissioning:
the road ahead
Claire Whittington
Acting Director of Commissioning
Department of Health
“The aim of world class
commissioning, and therefore
the ultimate test of its success,
will be an improvement
in health outcomes and a reduction
in health inequalities”
Adding life to years and years to life22
WCC is making an impact
The WCC assurance process is leading to an improvement in PCTs’* %
4
Prioritisation
12
of key health outcomes 1
51
Plans to improve key
health outcomes
56
12
Strategic planning
Financial planning
Board role in shaping
and driving the
commissioning agenda
Strongly agree
Agree
2
3
6
10
46
18
8
Neutral
33
34
43
54
49
Disagree
24
43
Strongly disagree
Adding life to years and years to life33
Competency results
n=
152
Frequency
1
1. Locally lead the NHS
2
135
8
3
4
9
0
20
0
0
0
4
0
2
0
0
0
0
0
1
0
0
0
1
0
124
2. Work with community partners
8
3. Engage with public and patients
51
4. Collaborate with clinicians
32
5. Manage knowledge & assess
needs
41
6. Prioritise investment
86
101
116
7. Stimulate market
66
135
17
8. Promote improvement and
innovation
9. Secure procurement skills
109
56
103
10. Manage the local health system
49
95
49
102
Source: 152 panel scores as of 31 January 2009 (post national calibration)
Adding life to years and years to life44
Panels scored PCTs below their self-assessment,
with the largest gaps on competencies 5 and 6
Self-assessment
Panel assessment
U.K. overall
2.1
2.0
1 Locally lead the NHS
2.1
2 Work with community partners
1.7
3 Engage with public and patients
1.9
1.7
4 Collaborate with clinicians
2.0
1.7/
5 Manage knowledge and assess needs
1.4
6 Prioritise investment
7 Stimulate the market
1.2
8 Promote improvement and innovation
2.0
1.7
1.4
1.7
9 Secure procurement skills
2.0
1.4
1.6
1.7
10 Manage the local health system
1
2.4
1.9
2
3
Source: 152 panel scores as of 31 January 2009 (post national calibration)
Adding life to years and years to life55
Panel governance ratings
n = 152
90
45
Strategy
17
78
61
Finance
13
78
71
Amber
Green
Board
3
Red
Source: 152 panel scores as of 31 January 2009 (post national calibration)
Adding life to years and years to life66
Comparison of SHAs by competency score
SHA
Competencies
Governance (% by rating)
SHA Average
% of subacross all
competencies
competencies
scored as 3
Av = 1.64
Strategy
Yorkshire and The
Humber
1.76
9
7
South West
1.73
5
14
North West
1.71
4
8 38
East Midlands
1.68
5
West Midlands
1.65
9
South East Coast
1.62
0
0
South Central
1.59
4
11
North East
1.56
3
17 25
London
1.56
3
6
East of England
1.55
4
Finance
64
0
21
33
59
63
6
38
67
7 29
11
24
0
19
71
67
88
78
0
10
21
0
0
0
0
11
33
74
64
88
0 44
35
67
57
13
0
22
59
86
0 43
88
22
58
14
0
64
13
22
74
Board
86
13
0
54
67
29
7 7
29
64
18
National average across
all competencies*
56
76
50
24
50
67
0 42
22
58
16
3
81
16
14
7
71
21
Source: 152 panel scores as of 31 January 2009 (post national calibration)
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But the financial context has tightened
"Tax increases and spending cuts are
inevitable immediately after the election,
assuming that there are signs of economic
recovery by then - and any managers of a
public service who are not planning now on
the basis that they will have substantially less
money to spend in two years time are living in
cloud-cuckoo-land."
Steve Bundred, Chief Executive, Audit Commission
The Times, February 27 2009
Adding life to years and years to life88
The economic climate

5.5% growth in both 2009/10 and 2010/11
 Invest to save opportunities

Assuming little or no growth from 2011 onwards

Release efficiency savings between £15-20bn across the
service between 2011 - 2014

Need transformational approach to come through this
Adding life to years and years to life99
Commissioners need to lead the way
Quality
Productivity
Innovation
Prevention
• Focus on improving
health outcomes
• Prioritise most
effective treatments
and services
• Manage demand
and performance
• People make healthier
choices
• The healthier choice is
easier
• Advice and support for
people most at risk
• Prioritising reduction in
harmful behaviours
• Technical efficiency
• Allocative
efficiency
Adding life to years and years to life10
10
Levers
• Clinical commissioning
• Transforming community services
• Information
•
•
•
•
To eliminate unwarranted variation
To stimulate debate & change behaviours
Publication of survival rates etc
To produce evidenced based commissioning decisions
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11
Community services: 12-fold variation in productivity, starting from a
low base
Average number of daily visits by nurse in specified period (%)
24
23
Examples of key
levers to increase
efficiency
20
• Streamline travel
routes
• Replace night
agency staff with
permanent staff
• Adjust staffing
levels to demand
• Standardize
process/
interventions
12
8
4
4
2
1
1–2
2–3
3–4
4– 5
5–6
6–7
7–8
Source: 3-month sample of district nurses in provider arm of a PCT
1
9–10 10–11 11–12
1b PCTs’ prescribing costs: more than twofold variation in prescribing
cost per weighted population*
Prescribing cost per weighted population* by PCT. £/ capita, 2006/07
Typical sources of
inefficiencies
192
Median: £151/pop
• Unexploited
switches to cheaper
alternatives with
identical outcomes
• Avoidable specialist
and restricted drug
spend
• Waste reduction
• Lack of formulary
85
* Age and need weighted population
Source: PCTs spend, Mckinsey analysis
• Supply chain
inefficiencies
The specific opportunities for improvement fall into four areas with a
range of mechanisms to capture
Mechanism
 applicable to
capture the value
Areas of opportunity
Mechanisms to
capture value
1
2
3
4
Drive through cost
efficiencies in all
provider services
Optimize spend
and ensure
compliance with
commissioners’
standards
Shift care into
more cost
effective
settings
Prevent people
from becoming ill
through increased
prevention



Market
structure/
management

Pricing/
reimbursement



Contracting and
setting/ enforcing
standards



Technical
efficiency
Allocative
efficiency
The 10 most frequently selected account for 60% of all outcomes chosen
by PCTs in the WCC assurance system
Percent
100% =
54 outcome
choices
940 national
outcomes
selected
20
64
Top 20
choices
Top 10
choices
18
20
60
18
Nationally
defined
outcomes
Outcomes from
national set chosen
by PCTs
Top 10 measures nationally
#PCTs
1
Smoking quitters
100
2
Rate of hospital admissions per 100,000
for alcohol related harm
75
3
CVD mortality
72
4
Percentage of all deaths that occur at
home
69
5=
Under 18 conception rate
53
5=
Childhood Obesity
(locally-defined)*
53
7
Cancer mortality rate
51
8
Diabetes controlled blood sugar
43
9
Infants breastfed
41
10
Percentage of stroke admissions given
a brain
scan within 24 hours
33
* Childhood obesity was the only locally-defined outcome among the top 20, and so is not included in graph on the left hand side of the page.
Source: 152 PCT submissions; DoH; team analysis
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CUMULATIVE
Over 80,000 life years and about 60,000 QALYs can be gained over 5 years
if PCTs improve their performance by a quartile
Years to life….
Life years gained*
82,170
13,000
9,500
~40,000
3,600
16,000
Smoking**
Alcohol
70
CVD mortality
Cancer mortality
Diabetes**
Stroke
Total
Life to years….
QALYs gained*
59,150
8,700
8,800
26,600
5,000
10,000
Smoking**
Alcohol
50
CVD mortality
Cancer mortality
Diabetes**
Stroke
Total
* By a one quartile improvement relative to historical baseline for PCTs selecting the outcome. PCTs in top quartile improve based on vital signs.
** 10 year time delay between intervention and full benefit capture
Source: Team analysis – details in appendix.
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ESTIMATES
A one quartile improvement in PCT performance for these outcomes would
result in a 10-15% reduction in health inequalities* by year 5
Health inequality gap – rate of smoking quitters
Percent gap*
73
63
45
-10
Health inequality gap - rate of admissions for
alcohol related harm
Percent gap*
80
69
Baseline
Up a quartile**
-10
Percent gap*
44
Percent gap*
51
35
Health inequality gap - Diabetes controlled blood sugar
-11
Health inequality gap - CVD mortality rate
61
Health inequality gap - Cancer mortality rate per 100,000
Percent gap*
27
-17
Health inequality gap - Stroke admissions given a brain scan
Percent gap*
74
-10
Baseline
58
-16
Up a quartile**
* Between top and bottom PCTs.
** PCTs in the bottom three quartiles move up a quartile whilst top quartile PCTs improve at the rate of their Vital Signs ambitions.
Source: 152 PCT submissions; DoH; team analysis
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Assurance Year 2 – fine tuning the system
Scope of
the
changes
Main
changes
 WCC will not change substantially in the future
 The principles, framework and high-level process will be
maintained
 Feedback indicates four main implications for the future
iterations
 Focused yet rigorous process
 Allocate more time for the process
 More resource/support
 National consistency
 Outcomes: review national list, provide greater guidance for
choosing outcomes and introduce more ‘stretch’
 Competencies: clarify criteria where needed, introduce
competency 11
 Governance: strengthen and clarify criteria, streamline
financial template
 Process: extend PCT prep and analytical phases, streamline
document submissions and provide greater guidance to
panelists on where to focus during the panel days
 Better Website
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Given the current economic climate, Competencies 6 & 11 are being revised
Competency 11 is being introduced . . .
. . . and Competency 6 is being enhanced
Competency 11 – ensuring technical and
allocative efficiency and effectiveness of spend
Competency 6 – prioritise investment in line
with funding expectations and according to
local needs, service requirements and the
values of the NHS
a
Measuring and
understanding
effectiveness of spend
b
Subcompetency
b
Based on impact on health
outcomes:
 Rigorous prioritisation of
investment
 Named disinvestment
c
 Strategic commissioning
plans for different
financial scenarios to
include downside funding
Identifying opportunities
to maximise effectiveness
of spend
c
Delivering effectiveness of
spend sustainably
*whilst fulfilling health outcome requirements of the population
Additional focus
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19
Freedoms and Incentives in 2010/11
Rewards would apply to top performers from 2010/11, following the
conclusion of the second round of WCC assurance
Financial
 Manage financial risk over a greater period
 Access to innovation and development funds
 Consider pay flexibilities
Support
 A lighter touch performance management approach
proportionate to overall performance of a PCT;
Non-financial
 The kudos of being within the high performing group
 Creation of a franchising model to facilitate high performing
PCTs to take over commissioning functions of
underperforming PCTs
 Direct input into national policy formulation
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Intervening in under-performing PCTs in 2010/11
 Those PCTs defined as poor performers after the second
round of WCC assurance will be subject to intervention by
the SHA, in line with Developing the NHS Performance
Regime and The Transaction Manual
 New Commissioner Performance Framework to apply from
2010
- with clear thresholds for early intervention
- a clear rules based process for escalation, and
- based on clear set of performance metrics
 Will be working with NHS over coming months to develop
the Framework
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Next steps – prepare for year two
June 2009 - Fine tune year two co-production
 Competencies – tighten language & focus (3,4 & 10)
 Competency 11
 Strengthen governance
 Strategy – focus on allocative efficiency
September 2009
 Data pack
 Web site
 Communications & materials
Timetable
 Sept – Dec 2009
 Jan – Mar 2010
 Apr – May 2010
 July 2010
PCTs collate evidence
Analytical phase
Panels
Publish Scorecards
Freedoms commence
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The road ahead
Clinical commissioning
Integrated care
Partnerships
Managing the health system
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