Outcome Based Commissioning in Richmond March 2015
Contents 1. What is Outcome Based Commissioning? 2. Case for Change for Community Services in Richmond 3. Findings from Outcomes that Matter and Detailed Design phase 4. High level schematic of the key outcomes for community-based care in Richmond 5. Recommendations for Community and Out of Hospital contract 6. Two stage process to move to an OBC contract for out of hospital health and social care 7. Progress with enhancing the 2015/16 contracts 8. Progress with development of 2016 approach 9. Timeline and process for 2016 OBC contract
What is Outcome Based Commissioning? Outcome based commissioning (OBC) is a relatively new approach to commissioning health and social care services in the UK. It rewards both value for money and delivery of better outcomes that are important to patients and other service users. Outcomes refer to the impacts or end results of services on a person s life. As such, outcome-focused services aim to achieve the aspirations, goals and priorities of service users. It enables commissioners to create the circumstances in which provider organisations can innovate to deliver improved outcomes for services users at a lower cost. This will enable the delivery of new models of care. Three benefits of OBC are: increased focus on whole-person care; enabling collaboration and integration; realising efficiencies in the system. Process for Commissioning Outcomes Moving to a system of commissioning for outcomes broadly requires a three phase seven step process, which is outlined below. After completing the Case for Change it was decided to proceed with Phase 2 of the OBC Programme in Richmond. Phase 1 Phase 2 Phase 3 BAU Governance Case for change Outcomes that matter Detailed design Contracting options Contracting Run, monitor, improve 3
Case for Change for Community Services in Richmond The case for change report was the output of the first phase of a programme agreed by the CCG governing body to assess the potential benefits of outcome based commissioning in re-commissioning community services for the population of Richmond. The report concluded that there was a clear case for changing the way in community services are commissioned in the London Borough of Richmond. The key problems are: 1. The public s experience of the system appears to be fragmented and does not focus on improving outcomes for them in a holistic way. This is a particular problem for elderly people with complex needs a population group forecast to increase significantly over the next decade; 2. Staff do not feel the way the service is commissioned and managed enables them to do their best for patients; rather it forces them to work in a siloed way when they would rather be working in integrated teams. New models of care are required; 3. Many GPs, as key customers of (and gatekeepers for) the service, experience it in a way which is almost random. There is no logical reason for the extent of variability of access to and engagement with the current service. The risks to patients of continuing to run a model with this level of variability should be of concern to all; 4. The current contract is poorly designed and not effectively managed. KPIs focus on inputs and processes, rather than improvements to patient health. Even if the contract were well-designed, it is not clear that the CCG has the capacity to manage it and hold the provider to account for delivering value for money. 4
Findings from Outcomes that Matter and Detailed Design work Key milestones and findings in Phase 2: Milestone Findings Design of key outcomes and indicators through public engagement, Outcomes Reference Group, and engagement with wider stakeholders. Outcomes framework designed through engagement with the public, capturing high level outcome categories, more detailed outcome goals, and suggested measures or indicators for these outcomes. This process also used significant engagement work that has been undertaken previously by Richmond CCG and LBRuT. Overseen by Outcomes Reference Group, who provide a statement in the public engagement report and outcomes that matter report. Also engagement with GPs, Practice Nurses, Public Health and Social Care Leads and senior representatives of the current provider of community services. A high level schematic of the key outcomes for community based care in Richmond is on the following slide. A recommendation of the Outcomes Reference Group, which was agreed at Programme Board was that if the contract was to include children and young people, mental health services, and those with learning disabilities it would require further engagement with users of those services. Analysis of as-is service provision, and budgets and contracts. Design principles for community services based on the key outcomes and as-is analysis for community services The as-is service map that has been developed and the range and scale of contracts for community provision and out of hospital care demonstrates a community services and out of hospital care market that is difficult to manage as a whole system, focusing on the needs of the population. In the scope of an outcomes based contract for community services and out of hospital care could be up to 100 contracts that are currently individually managed with value of 76m. Further work needs to be completed by the end of December to define the scope of the contract in more detail. Commissioning for outcomes involves a shift from dealing with episodes of care to continuous models of care - looking at the whole person and the situation in which they are living. 5
High level schematic of the key outcomes for community-based care in Richmond 6
Recommendations for community and out of hospital contract: Given these findings a contract for Community and Out of Hospital health and social care services which has the following features was recommended: Explanation and reasoning Outcome based Capitated and population health management Contract length Payment will be based on meeting a set of patient centric outcomes. This will cause a shift in thinking away from activity towards how better outcomes can be sought for patients. We will be moving away from a block contract towards a capitated budget for the population. This, combined with the outcome based contract, will incentivise providers to invest proactively in maintaining the health of the population. The contract will be designed to incentivise the providers of health and social care services to promote wellbeing and healthy independent living. To allow the most capable provider to demonstrate improvement in patient outcomes we would suggest the contract duration will be 5-10 years. Single accountable alliance of providers The integration of health, social, community and primary care will be delivered from a single accountable provider responsible for providing all the care for our population over the contract length. The accountable provider could be a single organisation or multiple organisations that have come together as the contractual counterparty. GPs, community health services, hospital specialists and social care would combine to create integrated out-of-hospital care as a Multispecialty Community Provider. 7
Two stage process to move to an OBC contract for out of hospital health and social care The November Governing Body accepted the recommendation for a two stage process to achieve an outcomes based contract for Community Services and Out of Hospital Care. Stage one: To enhance the 2015/16 contracts and move providers towards an OBC approach. Stage two: To let a more complete OBC contract for Community Services and Out of Hospital Care to commence in April 2016. The two stage process was agreed due to the scale and complexity of the vision for change. 8
Progress with enhancing the 2015/16 contracts - moving providers towards an OBC approach Areas of focus for change: Better integrated District Nursing Improvements to discharge planning with an immediate focus on Rapid Response and Rehabilitation Service (RRRT) Overall better integrated care planning across the services; and Support reductions in non-elective admissions (supported by points 1-3) Changes under negotiation / discussion: Potential new contract features for community and associated providers e.g. incorporation of some select outcomes and financial measures within the FY15/16 contract to facilitate change, prior to full Outcomes Based Contract in 2016/17. Changes to the service specifications / service delivery models within the 15/16 contract in relation RRRT, wider discharge process, community nursing, IV service, and use of TMH beds to deliver more coordinated and effective care models. Informed by discussions with GP New or refined requirements on providers to collect appropriate data to show performance against the outcomes and highlight areas of concern / disagreement more effectively Capacity / staffing 9
Progress with development of 2016 approach Design work to develop a vision and ideal operating model of service delivery for the outcomes specified. Development of initial scope of contract from the ideal operating model (paper to Programme Board in February for an initial decision on the scope of the contract). Selection of coordinating providers Development of detailed plan and process to reach 1 st April 2016 see slide overleaf for high level view. Initial engagement with providers and Vanguard bid for MSCP. 10
Timeline and process for 2016/17 OBC contract Route A: Coordinating provider development Jan 15 END FEB Finalise selection of Healthcare Most Capable Providers and notify existing providers of decision and process MARCH Publish MOI to providers setting out overall terms and process from March 2015 to April 2016, including requirement for providers to submit Governance Qualification MOU Mar 15 Jun 15 Oct 15 Jan 16 Providers develop Memorandum of Understanding (MOU) MAY Confirm collaboration between Social Care and OBC Governance Qualification Most Capable Providers submit MOU demonstrate collective agreement JUNE MCP OBC dialogue documents released Contract negotiation MCP Response SEPTEMBER Interim Checkpoint Review and Feedback DECEMBER Formal Evaluation Contract negotiation 6 weeks MARCH Mobilisation Checkpoint Review of initial mobilisation and transition plan April 16 Phased transition Fail On-going dialogue and performance assessment Fail Route B: Open Market Procurement MCP Most Capable Provider 11