Governing Body / Sub Committee Paper

Transcription

1 Governing Body / Sub Committee Paper Agenda Item:10 Title of Report Bedfordshire Delivering Plan for Patients Musculoskeletal System Redesign Executive Summary Musculoskeletal (MSK) care in Bedfordshire has been fragmented and inequitable. As one of the areas of greatest spend for BCCG using a programme budget approach, MSK was an early candidate for system redesign. Using innovative commissioning techniques a prime contractor approach BCCG is in the process of procuring an integrated system of MSK care that will deliver high value joined up care, using hospital facilities only when necessary, and improving the patient experience. The prime contract arrangement is underpinned by a capitation-based funding, incorporating a gainshare arrangement and financial incentives for delivering stretch quality outcomes. The process aims to share financial risk between commissioners and providers, such that commissioners can accurately predict annual spend on MSK and the prime contractor is incentivised to identify and eliminate waste from within the MSK supply chain and deliver seamless integrated care to the patient. GPs across all five localities of the BCCG in co-production with patient leaders have defined the system specification and outcomes of the MSK system in Bedfordshire. The project is currently within the invitation to tender stage of the procurement, with a tender submission deadline of 9th July The project has five shortlisted bidders who have been invited to tender. The planned go-live date of the new MSK system is the 2nd January Description of proposal Background To provide the BCCG board with the MSK case study update on delivering the plan for patients To invigorate change towards better value in healthcare locally, BCCG is adopting a fresh approach to commissioning which focuses on outcomes from both the patient and clinical perspective. Higher quality means better value and less waste, with patients getting the right care in the right place, first time. Taking a whole systems approach means moving beyond productive/technical efficiency (i.e. maximising the efficiency of any one institution) towards allocative efficiency (i.e. maximising the efficiency of a pathway served by more than one provider). To incentivise that collaboration and consideration of allocative efficiency, commissioners can align financial incentives for providers into delivery of a single set of outcome measures, shared by all providers within the system of care. Outcomes-based commissioning is not a new idea: outcomes-based contracts already exist in areas such as substance misuse care and sexual healthcare. However, undertaking an outcomes-based contract for a system as broad as MSK is novel, and BCCG are aware of how innovative this approach currently is. Underpinning our ambition is a firm belief that without considering the entire MSK system of care and using our financial resources to incentivise the delivery of improved patient outcomes, we will miss the opportunity to systematically encourage

2 providers to identify and remove waste, duplication and poor patient experience from MSK care. A successful MSK system will ensure that the available budget delivers as much benefit to patients as possible, i.e. delivers the highest possible value of care. Benefits / Intended Outcomes Outcomes and Intended Benefits Increase in the proportion of people with a long term musculoskeletal condition who feel they have had enough support in the last 6 months from local services to help manage their condition. Increase in the proportion of patient reported improvements in health related quality of life, using EQ-5D survey pre- and post-intervention Percentage of patients self-reporting that they have returned to (self-defined) normality e.g. self-reported return to work, absence of pain, or self-reported return to domicile Average and range of time from first symptomatic attendance at GP practice to patients reporting they have returned to (self-defined) normality e.g. self-reported return to work, absence of pain, or self-reported return to domicile Improvement in proportion of patients recovering to their previous levels of mobility/walking ability at 30 and 120 days Increase in the proportion of Patient reported improvements in health related quality of life categorised by: Ethnicity Age Gender CCG locality Increase in the proportion of people with rheumatoid arthritis who are diagnosed and treated within the clinically recommended period of three months from the onset of symptoms Improved patient experience of the overall MSK system Increase in the proportion of patients who feel they are making an informed decision about their onward management Increase in the proportion of patient reported improvements in outcomes using most appropriate score (e.g. Oxford Hip Score, Oxford Knee Score) Reduction in the percentage of total joint replacements (knee or hip) that required reoperation within two years Increase in the proportion of older people (65 years and older) who were still at home 91 days after discharge into rehabilitation services from a planned hospital in-patient

3 or day case MSK-related admission Reduction in the number of patients admitted for hospital based inpatient care Reduction in the number of hospital based outpatient appointments Increased use of patient decision aids and the choices patients make as a result of using them Evidence of budgetary control and overall reduction in programme budget expenditure Increase in the proportion of patients being treated within a community setting Quality Incentives Quality of care and improving outcomes for patients is at the heart of the stages of MSK care. This part of the requirement will therefore be arranged around a quality incentivised model. It is the intention of the BCCG to reward the delivery of quality through outstanding performance against a specific set of quality outcomes that ultimately will be a reward for excellence in the treatment of patients and the overall patient experience of the new MSK system in Bedfordshire. Quality Incentive 1 Technology Quality Incentive 2 Integration Quality Incentive 3 Patient Outcomes Quality Incentive 4 Patient Experience Quality Incentive 5 MSK System Annual Report Actions For Information Only Requested: Impact Assessments: I can confirm the impact assessments set out at Appendix 1 have been undertaken and any potential non-compliance highlighted as appropriate. Name of key contact/author Tim O Donovan Job Title System Redesign Manager Month and Year May timothy.o donovan@bedfordshire.nhs.uk Telephone No (Note for info: Appendix 1 items are; NHS Constitution, Equality & Diversity, Sustainability, Risk, Legal / Statutory, Communications, Resources

4 Introduction The Musculoskeletal (MSK) System Redesign is the redesign of services that diagnose and treat bone, muscle, and tissue conditions and disorders, and associated pain within planned care pathway. (ICD-10 Chapter XIII, M00-99). The MSK system Includes elective orthopaedics, rheumatology, physiotherapy, podiatry and chronic pain and excludes trauma and non-elective activity. Bedfordshire Clinical Commissioning Group and its localities currently commissions over 20 different MSK providers, offering different services across the whole of MSK system. These commissioned services make up an area of associated spend, described as the MSK programme budget. The programme budget spend within 2012/13 was circa 25 million pounds serving approximately a MSK population of 45,000 patients. The challenge One of the main problems with the current MSK system defined by patient feedback is no direct referral from one part to the system to another, with patients left feeling like being ping ponged back to the GP with a continual onward referral to different elements of care until a diagnosis is received. Other areas of patient feedback are: Long waits within outpatients clinics Lack of integration between specialities and social care at assessment Lack of easy access to post op contact Lack of coordination of information and administration across the system Delays The patient journey now Patients are currently referred by their GP to a number of different musculoskeletal services which tend to work in isolation from each other. The majority of MSK patients that are referred to specialist consultants within secondary care do not require surgical intervention (70%). Sometimes this means patients are not seen by the right service or could be receiving care from different professionals over the same period of time without a clear understanding of what treatment is offering the most benefit. If treatment offers little benefit, then patients are often required to go back to their GP for further referral. This can create unnecessary delays for patients in receiving the right care. Given the regular nature of this patient feedback there is agreement within the NHS, that the NHS fails many of its patients because it fails to provide joined up or integrated care. This is not simply a failure in the care that most patients experience; it is a considerable waste of resources.

5 Problems within the wider system With the current financial pressures within the economy, the NHS requires sustainable models of care that demonstrate living within its means, delivering the maximum value and outcomes to patients within the available resources. However the traditional commissioning landscape and techniques have proved to be barriers in achieving integrated care, such as: Historical inability to manage demand using current levers e.g. referral thresholds, prior approvals Poor alignment of incentives (focus on activity rather than outcomes) Micro-contracting of an incredibly complex business process/ care pathway/ supply chain little integration The current configuration of health services is not sustainable. Increasing demand with an unprecedented reduction in financial resources means all healthcare organisations need to do much better with much less The current MSK system is an outdated, hospital-oriented system of care. This system was set up long before advances in physiotherapy, exercise and drug interventions resulted in opportunities for community-based services to achieve better outcomes and enable more efficient use of resources. Other issues within the current MSK system are: Lack of integration: Primary, community & secondary care Physical and mental health Health and social Variable service quality and customer experience Insufficient, support for self-care or shared decision making Unnecessary referrals into secondary care Duplication in services Multiple entry & exit points into system Multiple stand-alone contracts across the MSK system Capacity issues within secondary care 30% surgical conversion rate from orthopaedic outpatient appointments A number of Bedfordshire GPs have highlighted a future model that enables a referral to a system rather than isolated service (where patients are continually seen by GPs for the same condition and referred to different parts of the system, and back again) BCCG Strategic Vision The coalition government white paper: Equity and Excellence: Liberating the NHS sets out the government s long-term vision for the future of the NHS. With the liberation comes opportunity and the emergence of a new commissioning environment to: Encourage integration and co-ordination of services by contracting for a system of care, using a prime contract Commission for improved clinical and patient outcomes, better value and less waste, with patients getting the right care in the right place, first time Empower clinical and patient leadership to challenge and champion, and to develop new ways of providing care outside hospitals where appropriate

6 Prime Contracting Developing a genuinely coordinated care supply chain of healthcare for MSK from the complex and varied interactions that are necessary to make that chain work as well is a highly complex task. The very different organisations that provide the very distinct aspects of this care are used to working separately, all having very different perspectives and paradigms of care. Whilst it is easy to create imperfect but much better relationships between these different organisations, creating a complete interlinked and coordinated supply chain of health and social care is a logistical problem with at least the same complexity in creating the supply chain that exists in the retail trade or the automobile industry. The prime contractor or accountable lead provider model provides strong power for the integrator, since they have both the clinical and financial accountability (and budget) for the whole programme of care and can create the new integrated incentives that will make integrated care possible. In this model, BCCG will let a contract for the complete MSK system to a single organisation that will then both provide care and integrate existing and other providers into a programme of care for the Bedfordshire MSK patient population. It is the prime contractor/lead provider s task to ensure that every part of the overall MSK programme is delivered in a way that joins up with the other parts of the pathway. This provides the prime contractor/lead provider (with its subcontractors) the ability to construct an overall pathway of care and incentives that provide BCCG, as the commissioner, with the outcomes that they want whilst remaining within the available budget. The prime contractor will, through this contract, take on the accountability for both financial control and the delivery of a high quality MSK system of care. Providers in the supply chain must be managed to ensure each one understands and delivers its part in the delivery overall of an integrated, seamless service and that it does so whilst ensuring maximal quality of care and productive efficiency. Therefore, the prime contractor/lead provider must be able to (and demonstrate that it can) manage the MSK supply chain: this is as crucial to the overall success of the system as the care delivery itself. The successful prime contractor/lead provider will demonstrate his ability to marshal reporting, analysis, financial and contract management through the supply chain whilst harmonising the overall contract management with the quality of patient care delivery Commissioning for outcomes and quality not activity based Taking a whole systems approach means moving beyond productive/technical efficiency (i.e. maximising the efficiency of any one institution) towards allocative efficiency (i.e. maximising the efficiency of a pathway served by more than one provider). To incentivise that collaboration and consideration of allocative efficiency, commissioners can align financial incentives for providers into delivery of a single set of outcome measures, shared by all providers within the system of care. Outcomes-based commissioning is not a new idea: outcomes-based contracts already exist in areas such as substance misuse care and sexual healthcare. However, undertaking an outcomes-based contract for a system as broad as MSK is novel, and BCCG are aware of how innovative this approach currently is. Underpinning our ambition is a firm belief that, without considering the entire MSK system of care and using our financial resources to incentivise the delivery of improved patient outcomes, we will miss the opportunity to systematically encourage providers to identify and remove waste, duplication and poor patient experience from MSK care. A successful MSK system will ensure that the available budget delivers as much benefit to patients as possible, i.e. delivers the highest possible value of care.

7 Clinical and patient leaders Historically commissioning decisions have been made by leaders and management within primary care trusts. The emergence of clinical commissioning groups gives local clinicians and local patients the real opportunity of leading change within the local health care system. This opportunity has been taken by local clinicians and patients within Bedfordshire. Clinicians and patients have been working together on every aspect of the commissioning cycle, from care pathway design, service specification development, and procurement evaluation and decision making. This leadership co-production provides a blue print in the culture of working for the future. Accountable to patients and CCG members With the emergence of clinical and patient leaders comes the responsibility placed on CCGs to engage with the local population, the local health and social care system and its CCG members. Engagement has been built on historic proactive and positive engagement with the local community with a further emphasis to ensure the duty of engagement places patients, clinicians, CCG members and partnerships (both existing and emerging) at the heart of commissioning decisions for delivering high value care right now, in the future, when it is not so simple. Proposed MSK Integrated System of Care The prime contractor will be responsible for developing and implementing an integrated and coordinated programme of MSK care within Bedfordshire. The key stages of the MSK system are: Stage 1 Prevention, support for self-care and advice to patients, carers and professionals Stage 2 Primary Care assessment, investigation, management, and onward referral Stage 3 Community-based specialist MSK triage, assessment, investigation & management Stage 3a Discharge (i.e. transfer) back to support by primary care or supported self-care Stage 3b - Shared decision making, patient choice, surgical listing and fitness for surgery assessment Stage 4 Hospital-based specialist MSK intervention and immediate rehabilitation Stage 4a Discharge (i.e. transfer) back to support by community-based specialist MSK team, primary care or supported self-care Next Steps The MSK redesign is currently within a procurement process. Five organisations have been invited to tender, with a tender submission deadline of 9th July GP and patient leaders across the BCCG localities will be evaluating all tender submissions during July 2013, with a planned contract award date of 29th July The new integrated MSK system is planned to Go-Live on the 2nd January 2014.