Collaborative Commissioning in NHS Tayside 1 CONTEXT 1.1 National Context Delivering for Health was the Minister for Health and Community Care s response to A National Framework for Service Change in the NHS in Scotland: Building a Health Service NHS Fit For the Future. The work undertaken by Professor David Kerr and the SEHD to produce An NHS fit for the future was an excellent example of collaborative commissioning. The process provided opportunities for patients, the public, clinicians, public sector and private sector organisations with a role to play in improving health and health services to contribute collectively to a strategy for health in Scotland. It is a testament to the robustness of this collaborative commissioning that both Professor Kerr s report and the Minister for Health and Community Care s response attracted cross party support. 1.2 Local Context NHS Tayside put in place a Single Delivery Unit in 2006. From its inception it was intended that the delivery unit should be viewed less as a structure but more importantly as a collaborative. It brings clinicians and managers together in order to provide high quality services, which meet the needs of patients in Tayside. In its first year the Single Delivery Unit has made good progress in breaking down barriers between primary and secondary care. It has enhanced the establishment of CHPs and created a working environment, which is not based on line management but on matrix management. A matrix management approach brings clinicians patients and managers together to work on an agenda around improving services for patients. The organisation creates teams to work together to improve services. This can be for short-term work or sustainable service delivery. Staff members can therefore expect to play a role in a number of teams based on their ability to deliver better outcomes for patients. The challenge of matrix management is to support managers, clinicians and patients to work together on improvement. This means working in a structure with few reporting lines, lots of scope for innovation but an extremely strong governance structure that challenges and judges on the basis of improved outcomes, quality and value for money. NHS Tayside has also made progress in expanding its joint working with patients and the public. The Open Space (appreciative inquiry) events held in autumn 2006 and the involvement of patients via managed clinical networks and Patient Public Groups have all contributed to the strength of the patient voice.. The model for improvement provides NHS Tayside with a strong model to drive this agenda forwards to the next stage of its development. 2 Principles and Values In NHS Tayside our mission is to continually improve patient care and patient experience through an active and positive collaboration between patients, clinicians, and managers where we work together to solve problems and deliver innovative solutions. The collaborative commissioning model set out in this paper provides a framework to progress this mission i.e. It describes how patients, clinicians, managers and partners will work together on an ongoing basis to create and agree a common agenda around improving services for patients. This will influence NHS Tayside s Commissioning Plan. NHS Tayside s improvement collaborative work provides us with the tools to deliver our mission i.e. an inclusive methodology for how we will deliver small steps of change, which will deliver the promises, made in the Commissioning Plan. 1
All participants in the collaborative commissioning process will strive for continuous improvement and aspire to compete with the best in the world. They are driven by a strong evidence base and are willing and able to be held accountable for the continuous improvement of services. This model requires NHS Tayside to actively seek to strengthen the power of patients in the commissioning model and to continue to engage clinical staff and key partners in this collaborative process. It builds on examples of good practice, which already use the components of the methodology set out in the collaborative commissioning model e.g. The Palliative Care Strategy. The model provides a framework to extend this good practice across all of NHS Tayside s strategic and improvement agenda. 2 THE MODEL FOR COLLABORATIVE COMMISSIONING 2.1 Strategic Context for Collaborative Commissioning Collaborative Commissioning Governance Service delivery Commissioning Commissioning is the process by which NHS Tayside Board commissions the services that it wishes the Single Delivery Unit, or where appropriate, other service providers to deliver on behalf of the local population. NHS Tayside monitors the quality Commissioning Plan is the vehicle that links strategy agreed by the Board to the work plan of the Single Delivery Unit and where appropriate contracts and service level agreements with other service providers. The commissioning process needs to provide opportunities for patients, the public, clinicians, managers and key partners to influence NHS Tayside s Commissioning Plan. This Plan will be signed off by NHS Tayside Board and will be an appendix in the Board s Local Delivery Plan. Operational outcome agreements, as well as senior managers objectives will be drawn up to support the delivery of the Commissioning Plan. The linkages between the governance structure and the commissioning cycle are set out below: 2
Commissioning Board Commissioning Plan Governance NHS Tayside (to sign off Commissioning Plan) Board Local Delivery Plan (Commissioning Plan is an apprendix) Quality and Improvement Committee (to monitor progess) Operational outcome agreements Single Delivery Unit (to ensure delivery) Senior managers objectives Remuneration Committee (to sign off assessment of performance) Governance NHS Tayside Board and its standing committees have a governance role. It is therefore necessary for NHS Tayside Board to sign off the Commissioning Plan and for the standing committees to look at delivery against each of the service level agreements. It would be expected that the following standing committees would consider progress against the Commissioning Plan in a number of ways e.g. set out below: Improvement and Quality Committee Managed Clinical Network tables of commitment Commissioning promises relating to strategies agreed by the NHS Board Single Delivery Unit Committee All service level agreements between Directorates e.g. Modernisation and Development Team Human Resources Remuneration Committee Senior Managers performance objectives The standing committees should be monitoring the delivery of promises, improvement in services delivery and best value. To do this they may require input from professionals in the field of health economics and the services of the health intelligence function being developed within the single information service. The Medical Director of the Single Delivery Unit will be responsible for ensuring that relevant commitments are included in consultants job plans. The Chief Executive of NHS Tayside and the Chief Operating Officer will be responsible for ensuring senior managers personal objectives reflect commitments made in the Local Delivery Plan including those set out in the Commissioning Plan and NHS Tayside corporate objectives. GP contracts The GMS Contract is a framework for delivering evidence-based interventions in primary care. The contract is delivered in 4 elements: Essential services the care of people who are ill or perceive themselves to be ill 3
Additional services mainly preventable includes immunisation/child health/contraception etc Quality and outcomes framework performance related payments against nationally agreed clinical and organisational outcomes. This has been the focus of the chronic disease work and includes CHD, hypertension, stroke, diabetes, atrial fibrillation, thyroid disease, chronic kidney disease and mental health Enhanced services these are either nationally or locally agreed performance related contracts for services that local commissioners would wish to see in primary care e.g. drug dependency services. The GMS contract is monitored on a number of levels with performance managed through: annual contract review quality and outcomes visits supportive re improving quality enhanced service audits payment verification. 2.2 The Model for Improvement is Part of the Collaborative Commissioning The model for improvement asks the same 3 basic improvement questions of patients, managers and clinicians. What are we trying to accomplish? (AIM) How will we know that a change is an improvement? (MEASURES) What change can we make that will result in improvement? (CHANGES) Improvement is achieved by work together using the PDSA model to undertake small steps of change in order to achieve the desired improvement. Act Plan Study Do 2.3 Levers for Change There are a number of levers which will help NHS Tayside to manage a collaborative commissioning model. These include strong public involvement (citizen leadership), contractual arrangements with consultants and GPs (consultants and GMS contracts), senior managers performance arrangements, clinical leadership, strong relationships with key partners, shifting the balance of care (NHS Tayside Board paper April 2007) budgeting and the use of enhanced services. All of these levers for change operate within the strategy for health in Scotland Delivering for Health. There are also a number of quality frameworks, which underpin improvement. These include Quality Assessment Framework, 4
Quality Improvement Scotland work, and frameworks for specific services. The growth in self-care, where patients manage their own health, also provides an opportunity for patients to tell clinicians and managers how the service can better support them. 2.4 Setting Priorities Delivering for Health sets out a clear agenda for the development of the NHS in Scotland. NHS Tayside intends to put in place a more collaborative process for the setting of local priorities and implementation of the Delivering for Health agenda in Tayside. In doing this NHS Tayside will need to commission services in each of the following key policy areas across all population groups: Planned Care Palliative Care Mental Health Unscheduled Care Diagnostics Long Term Conditions Child Health Older People Shifting the Balance of care Adult Care and Rehabilitation Health Improvement 3 BUILDING A STRONG COLLABORATIVE COMMISSIONING MODEL 3.1 Strengthening Public Involvement The Organisational Development team will continue to work alongside relevant departments and partners to create legitimacy around patient and public involvement. This will include continued development of the following: Patient and Public Involvement Groups The population of Tayside is already reaping the benefits of the establishment and development of the patient and public involvement groups. These need to be sustained and further developed. Open Space Events (Appreciative Inquiry) The Open Space (appreciative inquiry) events held in Autumn 2006 have provided clinicians and managers with valuable feedback about what patients and the public think about the services we provide. Annual GP Surveys All GP practices are obliged as part of the QOF (Quality Outcomes Framework) to undertake an annual review of patient experience. This should be reviewed by the relevant section of the single delivery unit. Increasingly they are reviewed with practices patient participation groups. Patient Satisfaction Surveys NHS Tayside undertakes a wide range of patient satisfaction services 5
3.2 Creating a Climate for Strong Clinical Leadership NHS Tayside is fortunate in that clinical staff are keen to participate in collaborative commissioning. There are a number of existing opportunities for clinicians to discuss models of care and emerging priorities. The commissioning cycle should see to utilise existing mechanisms such as the Managed Clinical Networks, Area Clinical Forum, discussions with clinical leaders, clinicians involvement in open space events, the Efficiency Review sub group on priorities to increase the level of discussion with clinicians. The list below provides examples of where clinicians are able to debate clinical issues. Managed Clinical Networks The Managed Clinical Networks (MCN s) provide an opportunity for patients and clinicians jointly to become involved in the redesign of services. NHS Tayside wishes to see this level of involvement increase both in numbers of patients involved and number of services working with patients in this way. A number of established Managed Clinical Networks are already well placed to support NHS Tayside s vision for collaborative working. MCNs are underpinned by an infrastructure where clinical and managerial partnerships have been forged and patients are integral to planning processes determining priority developments for the future. It is widely recognised however that one approach does not fit all and alternative approaches and methods require to be made to reach out to varying age groups, cultures, urban and rural communities. This will enable the organisation to embrace opportunities for working in partnership with patients, carers and members of the public. MCNs have a crucial role supporting the organisation in this work. Clinicians Conferences NHS Tayside has run a number of successful clinical conferences. This provides an opportunity for clinicians to discuss clinical priorities and to reflect on the feedback from patients about how they want to see services develop. These events are part of an important ongoing dialogue where clinicians are able to reflect on the feedback from patients about how they want to see services develop. It is important that the number and breadth of interest of clinicians engaging in this process needs to increase. As the result of their role representing a multi professional, interagency infrastructure, Managed Clinical Network lead clinicians are pivotally placed to inform and be informed through these clinical conferences and to ensure that the contributions of patients and the wider clinical community are reflected in service development. Professional Advisory Structure NHS Tayside undertook a review of the professional advisory structure in the summer of 2006. One of the outcomes of this review was a commitment by NHS Tayside to strength role of the professional advice. The work of the professional advisory structure needs to feed into the collaborative commissioning cycle. In particular there is a need to ensure both primary and secondary care consultants have an appropriate level of involvement in emerging strategic proposals. It is therefore necessary to review the current spend on locum costs and explore opportunities to realign this to support input into the collaborative commissioning cycle. The Area Clinical Forum should also be asked to take an active role in getting clinical involvement in open space events, clinician s conferences and where appropriate Board development events. 6
Role of Clinical Leaders NHS Tayside has created clinical leader roles in Community Health Partnerships and across the clinical directorates. The clinical leaders have a role to play in improving the level of clinical engagement to the wider clinical workforce. Clinical leaders already promote discussion with their clinical colleagues on emerging clinical and strategic issues and share these discussions within the policy making structure. This interaction needs to be built on to include interaction with more clinical staff and across a wider range of issues. 3.3 Working with Key Partners NHS Tayside recognises the value in working collaboratively with its partners in order to provide the best outcome for patients. Partners include Local Authorities, Universities, the voluntary sector and where appropriate the private sector. Examples include Marie Curie on palliative care services, The Corner Project which supports work with young people, Dundee University on the clinical research centre and Abertay University to support training of nurses in child protection. It is recognised that for the Community Health Partnerships in particular, but by no means exclusively, Local Authorities are very much joint partners in delivering improved services. Examples include tackling delayed discharges, mental health, older people s and children s services and learning disabilities. Community Health Partnerships have a specific role in ensuring that the collaborative commissioning model set out in this paper incorporates, where relevant, additional steps which encompass the joint working being undertaken within Community Planning Partnerships. It is also important to recognise a wide range of interagency work undertaken to progress the inequalities agenda. The Directorate of Public Health has a specific role to advise the Board on commissioning to reduce inequalities. 3.4 Benchmarking and Best Value Historically, individuals with specialist expertise rather than systems of care have driven NHS development For the latter approach to be viable it requires: strong clinical leadership understanding of best value robust financial framework effective models for delivery transitional approaches It is likely that within a significant number of budgets there will be a shift of activity and resource from secondary/tertiary settings into community based settings. Historically, it has been difficult for commissioners to manage some of the financial risk associated with the balance of care as there are no outcome based arrangements with primary care. The enhanced model of the GMS contract, which is outcome based and will be replicated within the Community Pharmacy Contract, provides commissioners with an unprecedented opportunity to manage change. Best value is, however, a whole systems approach and consideration needs to be give to the whole patient journey and how best to redesign this to maximise its value to the patient. There would be value in exploring models such as NHS Highland s cost cube work and also to consider the benefits that the involvement of an economist would bring to a best value approach. 7
4 THE COLLABORATIVE COMMISSIONING CYCLE Collaborative commissioning is not about moving commissioning power from to one group to another. It is the responsibility of Tayside NHS Board to lead and manage a process that brings together views from all the stakeholders above in an ongoing debate about what and how services should be provided. It requires strong citizen leadership, strong clinical ownership and leadership and robust management and commissioning expertise. Appendix 1 shows the timing of how this work will fit into the Board s annual planning cycle. There are a number of specific recommendations in this paper about increasing clinician involvement as part of this cycle. 4.1 Commissioning Cycle 9.1 Issues, which are not progressing sufficiently, referred to TayStat 9. Performance reporting and monitoring mechanisms established 1. Consider clinical evidence, health policy and best practice, economic appraisal, forecasting and capacity 2. Start a dialogue with the public, clinicians and other key stakeholders 3.1 If not refer to SDU ET or Board Executive Group 8. Tests of change Proposed collaborative commissioning cycle 3. Agree issues which are appropriate for the Commissioning Plan 7. Establish an improvement collaborative to take forward action and agree measures for improvement 6. Clinical Strategy approved 5. Create and agree key promises 4. Review current service provision: variation, waste, duplication in patient flows. 6.1 Financial decisions and business plans to Strategic Policy and Resources Committee for approval 8
4.2 Example Child Health Set out below is a description of the process undertaken for the Child Protection Review 2006. It describes each of the commissioning stages set out in the commissioning model as described in section 4.1 above. 1. NHS Tayside s Child Protection Review undertaken in 2004 required to be updated. Significant work undertaken in 3 Child Protection Committees and the work of NHS Tayside s Child Protection Action Group have all generated new actions for NHS Tayside, introduction of a significant number of protocols and procedures which now require to be assurance for compliance, ongoing significant ministerial interest and action on child protection, new legislation currently making its way through the Scottish Parliament on vulnerable people, Angus HIME review of child protection underway. 2. The Chairman of NHS Tayside instructed the Commissioner for Child Health to undertake a review of Child Protection services provided by NHS Tayside to take account of all the issues identified in 1 above and make recommendations to the NHS Board. Commissioner for Child Health wrote to key stakeholders inviting them to contribute to the review 3. The Board Chairman decided that due to the sensitivity and complexity of the issues within child protection to appoint a non executive member of the Board to provide the Board with an assurance around the governance and robustness of the review 4. Current service review undertaken in a 3 stage process: Completion of a detailed questionnaire by all relevant departments on compliance with standards and protocols and invited comments on staff awareness of child protection plus any areas where services could be improved Meeting with key individuals and departments. The interview schedule was determined as the result of feedback from the questionnaires; comments received from stakeholders and issues on which the Commissioner for Child Health wished to receive specific assurances. Development event held where there was an opportunity to discuss emerging recommendations and to start the process of agreeing measures for improvement 5. Recommendations / key promises finalised for inclusion in paper to be presented to NHS Tayside Board for approval 6. NHST Board approve the recommendations/promises in the Child Protection Review. These promises are now part of NHS Tayside Commissioning Plan. NHS Tayside also agree funding for a range of initiatives 6.1 The financial arrangements made at NHS Tayside Board are included in the financial plan 2007/08. 7. Child Protection Action Group (CPAG) developed action plan, which includes measures for improvement. CPAG agreed as the collaborative to progress this work. nb: NHS Tayside improves in services in line with the Child Protection Committees in Perth & Kinross, Dundee and Angus. It therefore also provides regular updates on progress to these Committees. 8. Relevant departments implement agreed promises using small steps of change. 9. Performance monitoring template agreed. This will be monitored by CPAG on a regular basis and by NHS Tayside Board or one of it s standing committees annually. 9.1 Waiting times for Child and Adolescent Mental Health have increased significantly. TayStat Chairs Scrutiny Panel considered the data and asked for an action plan to effect an improvement in waiting times. Board s Executive Team consider a paper from the Deputy Child Health Commissioner 9
and agree additional funding to address waiting times. This is reported to and agreed by the March 2007 TayStat Chair s Scrutiny Panel. This issue will require regular review and therefore an annual update plus a major review of the service in 2008 will be required. 4.3 Collaborative Commissioning Working Example The methodology for collaborative commissioning set out in this paper has evolved from the inroads NHS Tayside has made over the past few years in engaging collaboratively with patients, the public and clinicians. The work undertaken this year in the Open Space events provides a working example of this methodology in practice. NHS Tayside held a Clinicians Conference in Spring 2006. The event focused on how clinicians and managers would address the challenges set out in Delivering for Health. The output of this conference formed the basis of the agenda for the public appreciative enquiry events held in each of the 3 CHP areas at the end of 2006. As a result of the feedback from the public and discussion at the Single Delivery Unit development day a series of commissioning promises have emerged. These were communicated to the public, clinicians and managers through a newsletter, which was produced in March 2007. The public identified 5 key clinical areas where they felt improvements would make a huge difference to the care they receive. These were: Outpatients revamping outpatient services to reduce waiting times and ensure patients see the most appropriate health professional for their condition at the right time Emergency care how emergency care is delivered and how enhanced services could be provided in local minor illness and injuries units and community hospitals Patient information systems transferring from a paper based to an electronic system will allow quicker exchange of information Diagnostic services how can we make more diagnostic services and routine investigations available locally Management of long-term conditions plans to work more closely with Local Authority services to support people better at home. Patients and carers also identified specific issues in relation to access to GP appointments; palliative care services, diagnostic tests and public involvement. 5 RECOMMENDATIONS It is recommended that: 1. NHS Tayside Board endorse the commissioning model set out in this paper. 2. NHS Tayside realign its strategic work with the commissioning cycle as described in this paper. 3. The Commissioning Plan for 2007/08 be produced in line with the indicative timetable set out in appendix 1 of this paper. 4 A number of exemplar pieces of work/strategies be agreed to allow the evaluation, testing and refinement of the cycle. The 3 exemplars below would be part of a formal evaluation of the commissioning cycle and lessons learned from this work will be shared widely throughout the organisation. 10
Older Peoples Strategy One aspect of the Older People s Strategy will be part of an exemplar cycle. This would start at stage 1 in the commissioning cycle. This will allow testing of the whole cycle. Long Term Conditions This work is currently at step 5 in the commissioning cycle. The work undertaken to reach this stage fulfils the criteria set out in stages 1 4 of the cycle. This exemplar will allow us to test stage 5 to 9 of the cycle in a relatively short time period. Diabetes Strategy This work is currently at step 5 in the commissioning cycle. The work undertaken to reach this stage fulfils the criteria set out in stages 1 4 of the cycle. This exemplar will allow us to test stage 5 to 9 of the cycle in a relatively short time period. 4. Three population-based commissioners (Child Health, Older People and Mental Health) will lead commissioning work in their respective areas and working with the Organisational Development Team to develop the Commissioning Plan in these areas. 5. NHS Tayside should put in place a performance monitoring mechanism which tracks service improvement progress against promises made in the Commissioning Plan. This includes the introduction of service level agreement to support the Commissioning Plan. Where there has been insufficient progress on any promise this will be referred to the TayStat scrutiny process. 6. NHS Tayside s Organisational Development Plan should identify specific interventions for clinical leadership, citizen leadership and expanding the influence of service users on all service improvement work. This will include putting in place an annual cycle of clinician s conferences and public appreciative enquiry events, which will influence NHS Tayside s annual Commissioning Plan. 5 NHS Tayside will re-align the current spend on locum costs for clinicians to ensure that the collaborative commissioning cycle is supported. 7. On 2 days each year the current clinical effectiveness days organised for acute sector clinicians and the Protected Learning Time events for primary care staff should be run jointly. This will provide an opportunity to involve clinicians in specific discussions around issues and strategies that will form part of the collaborative commissioning cycle. 8. The current Board development events will be scheduled throughout the year to all Board members the opportunity to discuss, review and influence the production of the respective commissioning plans. 9. NHS Tayside should strengthen its public involvement work through continued support of the PPGs, development of the appreciative enquiry events as well as other networks. 10. NHS Tayside should develop an interactive public website designed to encourage patients and the public to provide feedback on their experience of service provision, and views about how services could be improved. It will include dynamic media such as notice board, posted comments etc. This website should be supplemented with regular information leaflets for wide distribution throughout Tayside encouraging participation from those who prefer this means of communication. 11. On behalf of NHS Tayside the Head of MCNs will lead commissioning work for the development of MCNS and work with the Organisational Development Team to develop related commissioning activity. 11
12. Further work be done to explore the opportunities around benchmarking, Best Value and the NHS Highland s cost cube to see if this can be used to enhance the collaborative commissioning model. Caroline Selkirk Director of Change & Innovation Dr Andrew Russell Director of Primary Care 17 th April 2007 12
Appendix 1 Illustrative Timelines For Annual Collaborative Commissioning Cycle Started Dec Information from Open Space events widely distributed March Clinicians Conference 1 clinical priorities for the following year April/May Open Space event 1 - in each local area patient and public views on priorities for the following year Focus on older people June Board Development event 1 (NHS Tayside Board and Single Delivery Unit standing committee joint event) July Feedback newsletter to public September Clinicians Conference 2 October Open Space event 2 November November December Board Development event 2 (NHST Board and Single Delivery Unit standing committee joint event) Commissioning Plan 1 st draft produced Feed into Financial Planning Seminar December Commissioning Plan draft 2 produced January Draft service level agreements and objectives drawn up to support the Commissioning Plan subject to Board approval of plan February Board agrees Commission Plan for coming year March This will be an annex to the Local Delivery Plan Public newsletter 2 promises for the following year and issues for next round of collaborative commissioning 13
Appendix 2 Commissioning Plan Illustrative Example What you told us: Public, Patients, Clinicians Clinical Evidence and Best Practice Why do I have to wait so long for the results of my tests like scans and X- rays? There seems there are unnecessary delays and I never know when to expect results and who to contact hospital or GP. The Commissioning Plan Reduce time waited between scan and X- rays and results being received by patients. Measures for Improvement Measures for Judgement Lead Executive Reduction in time from scan to agreed interpretation of results by an appropriate clinician Reduction in time from interpretation of results to production of results letter/form Reduction in time for delivery of results to GP or other relevant clinician Reduction in time for patient appointment with clinician to receive results % of results delivered electronically to GP practices % of X-ray clinics with a consultant radiologists present Reduction in results referred for judgement to more senior clinician than at the present time Increase in availability of senior radiologists at clinic Reduction in the number of steps required in the pathway for scans and X-rays Chief Operating Officer 15