Prime Contractor Model King s Fund Nick Boyle Consultant Surgeon 27 March 2014
Current Referral Route options - Information 1. Horizon Health Choices Horizon Musculoskeletal Triage & Treatment Chronic Pain Treatment or Procedures, 1 New to 4 FU Treatment or Procedures, 1 New to 4 FU Injections BHT Physio Physio 1 New to 4 FU Injections 2. Direct Access Physiotherapy MSK Referral Secondary Care: ++ Direct Access Physiotherapy L&D Physio SEPT MSK Podiatry contacts Community Physiotherapy Physio 1 New to 4 FU 1 new to 4 FU Podiatric Surgery 1 New to 4 Follow Ups - OP Procedures 3. Direct Access to Consultant Out Patient Clinics No Triage Sec. Care OP 1st: T&O Rheum Plastics 576 Pain Non Attendances/Canc elled Referrals Secondary Care FU T&O Rheum Plastics 1,324 Pain Repeat referrals Daycases Electives
MSK Challenges There are over 200 musculoskeletal conditions affecting millions of people MSK conditions contribute to long-term disability The ageing population/technology increases demand MSK conditions = most common reason for repeat consultations with a GP (30%) Source: The Musculoskeletal Framework: A joint responsibility, doing it differently, DH (2006)
MSK Challenges Up to 60% of people on long-term incapacity benefit 8 10 million people in the UK have arthritis 40% of people over 70 have osteoarthritis of the knee Low back pain is reported by about 80% of people at sometime in their life By 2020, trauma caused by road traffic injury will become the third highest ranked cause of disabling conditions. Source: The Musculoskeletal Framework: A joint responsibility, doing it differently, DH (2006) - World Health Organization (WHO) and European Bone and Joint Health Strategies Project11
Problems Patient s/gp s perspective Un-coordinated Fragmented Inconsistent Variable quality Variable communication No central point of contact
Problems System view Variation in quality/clinical interventions Adherence to best practice inconsistent Hospital centric model Introduction of innovation such as self care/shared decision making slow High access times
Bedfordshire Hospital Waiting Times December 2013 18 weeks Referral to Treatment (RTT) pathways (Target 90%) Trauma & Orthopaedics 80.5% The non-admitted pathway (Target 95%) with the exception of 2 specialties: Trauma & Orthopaedics 94.1% The incomplete pathway (Target 92%) Trauma & Orthopaedics 87.8% From Bedfordshire CCG March 2014 Governing Body Integrated Quality, Safety & Performance Report
Bedford Hospital NHS Trust Performance Elective care: Failure to meet 18 week RTT consistently (for 18 months) with resulting subcontracting of private sector providers: 1 in 4 patients waits longer than 18 weeks for inpatient procedure Below average numbers of procedures being undertaken in some categories (e.g. hip and knee revisions) Low/no wound infection rates (in the 3 months audited) Average PROMs completion and outcomes data
NHS Annual MSK Spend is 6bn
What are the Problems? System of Care Micro-commissioning complex care pathways Perverse incentives PbR KPIs process drives neither population level improvement or patient experience No effective performance management of care Separation from clinical accountability from financial responsibility Lack of true clinical leadership
The current administrative micromanagement approach to cost containment Reduce activity Primary Care Assessment and Treatment Referral Management Prior Approval Increase activity Hospital Investigation and Treatment New / FU ratios LoS penalties Fragmented treatment for patients Only deals with referred patients Silo-driven hospital care Treatment Thresholds 11
It all starts with the Credo The beliefs that our partnership is founded on Our Purpose To build a great company dedicated to our patients. Our Parameters We focus our efforts exclusively on What we are passionate about What we can become best at What drives our economic sustainability Our Principles We are above all the agents of our patients. We empower our people to do their best. We are unrelenting in the pursuit of excellence.
Re-design MSK Impact Reducing per capita cost whilst maintaining quality
Re-design MSK Impact Reducing per capita cost whilst maintaining quality
The Circle Vision for MSK Services across Bedfordshire Integrating Services by: Managing the whole pathway for MSK patients Ensuring joined up care Improving access by moving services to the community Encompassing all MSK services (ex-trauma) Ensuring Clinicians work in a truly integrated way Ensure consistent application of best practice clinical pathways Engaging patients in service development Empowering patients and facilitating self management
Bedford Prime Vendor model Circle as Prime Contractor: Integrate all MSK providers into a programme of care System wide accountability for financial control and high quality delivery by managing the MSK supply chain
Referral triage Primary care holistic assessment and care COMMUNITY MULTIDISCIPLINARY SPECIALIST SERVICE (Pathway Hub) Prime contractor Referral Highly specialised, intensive, episodic hospital care Hub functions: Referral triage Skilling up 1 care Specialist Assessment Specialist integrated care Share Decision Making Personal Health Planning Supported Self Care Patient & carer support Voluntary sector provision PATHWAY MANAGEMENT Subcontracting
Operational Model Key aspects of the model include: Bedfordshire MSK model developed with Pennine MSK, based on their best practice model implemented in Oldham Clinical triage of all MSK referrals to ensure patients are placed on the right pathway first time Iterative development of services through clinical engagement Developing patients as partners e.g. patient participation group, shared decision making Supporting the CCG in driving up the quality of MSK care in General Practice e.g. training events on MSK conditions Shifting care from secondary care into community or primary care. Working with the commissioner to reduce contracted activity within secondary care Development of the community workforce to support the integrated care model, including development of Consultant Orthopaedic direct listing clinics
Operational Model Key benefits: Application of best practice care pathways Reduction in secondary care referrals (c. 85% of cost base) Reduction in unnecessary diagnostics/interventions Improved patient experience and patient outcomes through optimum care pathways Overall system wide efficiency savings through consolidation of fragmented service e.g. reduction in repeat treatments/op Appts/investigations etc Improved secondary care efficiency = reduction in cost per treatment
Beds MSK Services: Benefits To Providers Reduction of high volume low income activity, allowing adoption of low volume high income activity. Increased OP capacity for repatriation of out of area work or alternative projects Increase in surgically ready patients worked up in primary care Improved margin performance through reduction of non value adding processes Increase in 18 week achievement rates for MSK Shared 18 week responsibility Reduction in Waiting List initiative cost risk Improved Financial rewards across the supply chain
Contract Structure Programme Budget BCCG 1 Prime Contractor Sub Contract Holders Circle Horizon Integrated Provider Hub Secondary Care Providers Sub Contract Providers Therapie s Podiatr y MSK Clinics Direct Listing Other Services Circle as Prime Contractor Integrate existing and other providers into a programme of care for the Bedfordshire MSK patient population To take on the accountability for both financial control and the delivery of a high quality system of care by managing the MSK supply chain Strategic Partnership Advised by long-term strategic partners Pennine MSK, National Rheumatoid Arthritis Society and Arthritis Care. Pennine MSK has developed an integrated MSK service in Oldham over the last 8 years Sub-Contracts Circle to hold sub-contracts with secondary Care Providers and Horizon, which is a consortium of GP s (representing c. 50% of clinics in the region) currently delivering a proportion of MSK services in the market Horizon will have responsibility for the provision of Community Care, and will hold sub-contracts with all other Community Care Providers 1. Bedfordshire Commissioning Group (BCCG)
New Service Model - Integration (Incremental End Point) Triage & Redirection Community Physio Diagnostics n < 20% MuSTT Bio Mechanical Assessment Procedures Direct Listing Day Case Direct Listing Electives MSK Referral (done by GP) SPoA (Horizon) Inflammatory Follow Ups Chronic Pain Injection Follow Ups SEPT MSK Podiatry Linked or Separate? Podiatric Surgery BHT Physio L&D Physio
CURRENT KNEE PATHWAY BEDFORD PRIMARY CARE COMMUNITY / SECONDARY TREATMENT & DIAGNOSTIC PHASE DISCHARGE / AFTERCARE Bedford Hospital Triage Unit/ Diagnostics referral initiated Discharge no post operative care GP referral Direct to Consultants Direct to Hospital Orthopaedic Dept Patients enter Diagnostics and Knee Surgery wait list Patients referred for Physio go Bedford Physio Hospital triage enter wait list to see a community provider Patient attends GP for post operative care Discharge with full discharge package Direct to Community Services for Physio
INTEGRATED PROVIDER HUB PRIMARY CARE IPH TREATMENT PHASE COMMUNITY/DISCHARG E Triage GP referral Multidisciplinary Team Shared Decision Making and Assessment Knee Surgery with Hospital Provider GP referral with Diagnostics Informed Choice is offered to the Patient Physio with Community Provider Post Operative Care plan with Community Physio Pre Operative assessments and Diagnostics if required Self Management See and Treat Appointments & Minor Surgical Procedures
Examples of Projected Financial Savings 1. Diagnostics - 180 (average cost per patient ) Patients have the right diagnostics first time due to shared decision making and the multidisciplinary team approach. Up to 25% of patients have inappropriate diagnostics! 2. Pre Operative Tests - 121 ( Cost per patient ) The IPH employs nurse prescribers to complete these tests 15,000 patient contacts 3. Post Operative Physio - 119 First and 3 x 70 Follow ups Community Physio Providers provide this at 103 for 1 and 4 sessions 15,000 patients 4. 90% Conversion rate target vs the current average conversion of 30 % Consultant appointment charges dramatically reduced due to only seeing The most clinically appropriate patients that have been worked up. This Also improves hospital efficiency.
Examples of Projected Financial Savings Activity growth managed in line with demographic growth of 1.9% Receive 100% of CQUINs 2.5% of contract value, all of which is passed through to providers Moderate level of pathway redesign achieved, including: a) Price Sub-tariff prices with Secondary Care providers due to efficiency gains b) Cost Phased movement of Secondary Care outpatient appointments into Community at reduced local tariff. All activity moved into Community setting by Year 4 c) Cost Movement of Bedford Hospital Trust Direct Access Physiotherapy into Community setting at reduced local tariff from Year 1 d) Volume Stepped reduction in Orthopaedic First to Follow-up ratios, to 1.25 in Year 3 (from 1.93)
Overview of proposed programme budget Total programme budget of 169 across 5 years 39 38 Annual MSK expenditure ( 'm) 37 36 35 34 1.9m 2.6m 3.4m 4.1m 4.9m 33 32 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019 Projected CCG Baseline Expenditure Budget Proposal Annual programme budget in year 1 of 34.2m. The annual programme budget will be reduced over the course of the contract in line with savings. Total savings of 17m to be delivered across 5 years. The programme budget includes 24m savings in surgical costs across 5 years. A quarter of these savings will be offset by an increase in non-surgical costs as patients are treated in a different setting through pathway redesign. Average underlying assumptions Demographic growth: 1.43%¹ Underlying growth: 1.90%² Tariff deflator: (1.90%)³ ¹ See Appendix for details 27
Implementation Plan Oct 13 Nov 13 Dec 13 Jan 14 Feb14 Mar14 Apr 14 May 14 Jun 14 July 14 Aug 14 Sep 14 Contract Approvals Due Diligence PLC Approval Contract Finalisation Prime Contract Finalisation Sub contract Mobilisation Triage Trials Service Commencement Commence Trial Pathways Commence Triage Hub Mobilisation Stakeholder engagement Roll Out Contract Management Rollout Ramp-up
Lessons Learnt/Key Success Criteria Early agreement of programme budget (PB) Assessment of PB requires clinical and assessment expertise Marginal analysis not universally available Availability and quality of data Cultural transformation and innovation take time Ability to engage with local organisation and especially with clinicians at early stage Contracting process is complex and requires time Commissioners require commitment. Good working relationship with Prime Contractor is key Best practice pathway application is central to success Key enablers are independent clinical engagement, contracting and integrating IT platform
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