Value-Adding Approach to Lot 9 Service Delivery

Securing the highest quality of care and outcomes in a sustainable way is central to the success of health and care systems. SCW supports numerous systems across the UK to identify and realise efficiencies. We manage over £6bn of NHS contracts across acute, community, mental health and independent sector providers, making optimal use of the flexibilities in the NHS standard contract to drive best value for health and care commissioners. We have co-developed new contract models that align objectives and incentives with system-wide priorities and we are supporting a number of systems to drive efficiency and harness the collective potential of all partners in the system by transitioning to outcomes-based contracts.

  • Our finance, analytics, contracting and procurement teams, who are experienced in supporting the development of capacity planning models and internal control agreements, work with system leaders to prepare and secure sign-off for system control totals and underpinning agreements.
  • We are an accredited NHS RightCare delivery support organisation and we build this approach into system efficiency and optimisation programmes we support. 
  • Our expertise extends to other techniques and approaches in use across health and care, such as “Getting It Right First Time” (GIRFT) and the Best Possible Value (BPV) programme, which we apply to local quality and cost improvement programmes. 
  • We capture improvement opportunities that emerge from the care systems we support (e.g. relating to prevention at scale, integrated care, acute care configuration, and crosscutting enabling programmes in digital strategy, estates, infrastructure, and workforce) in the NHS Efficiency Map and share them across other systems we support, to encourage spread and adoption. 

We provide access to partners such as The Dartmouth Institute, Catalyze, Unipart, Lightfoot and Milliman who bring additional expertise in areas such as process reengineering, actuarial analysis, and driving sustainable change through shared decision-making and behavioural change ‘at the frontline’. This expertise will ensure SCW continues to develop sophisticated methods for measuring and improving cost and quality outcomes to underpin the development of value-based contracts. 

The case study that follows this response describes how SCW has worked in collaboration with other CSUs to lead a national programme to support effective decision-making, improve outcomes and deliver financial savings. It also demonstrates how, after concepts have been developed, tested and proven, they can be adopted at scale to deliver tangible system wide benefits to patients, primary and secondary care. While we have the ability to produce credible and thought-provoking reports and plans, we invest most energy in actually delivering and embedding change in the fabric of a local system. We are passionate about creating beneficial change at the front line. We take accountability for delivering transformation outcomes, and we optimise sustainability by ensuring that local care teams are fully engaged in the process. We have an appetite for sharing the pain and pressure of change, which helps build commitment, motivation and resilience in the individuals delivering it. This is our definition of partnership working. 

Extended Case Study: Supporting Systems to Manage Quality, Cost and Clinical Outcomes

Next Steps on the NHS Five Year Forward View clearly articulates the challenges systems face in delivering services that people want and need now, while also securing a sustainable future for health and care. To support these aims, NHS England and local health systems have commissioned SCW to lead national and regional improvement programmes that focus on optimising care quality, cost and outcomes. This includes the national QIPP Delivery Programme, developing the national toolkit for Procedures of Limited Clinical Effectiveness (PoLCE), and implementing enhanced policies and practices across local health and care systems.

 

NHSE commissioned SCW in 2017 to support 70 CCGs at high risk of not delivering their QIPP plans. We provided analytics and benchmarking support including RightCare variation analysis to identify opportunities. We then supported business case development and mobilisation. For the four CCGs in our own geography, we identified £1.1m in-year savings and £6m potential savings in 2018-19. Additionally, we provided at- scale support for all CCGs, by providing resources, templates and toolkits for Medicines Optimisation, Continuing Healthcare, and PoLCE (as we describe below). As an example, a switch process to biosimilars that we presented will deliver an estimated national saving of £200million.

As part of the national QIPP Delivery Programme, we delivered two products to support best practice in clinical policy commissioning aimed at reducing inappropriate referrals and activity related to PoLCE. The first was an end-to-end best practice Clinical Policy Commissioning Toolkit covering all aspects, from setting governance and operational policies to procuring databases and tools and embedding clinical and public engagement. The Toolkit has been rolled out in every NHSE region and will soon be launched on the national Financial Resilience SharePoint site. The second was a Benchmarking Tool to compare CCGs with RightCare peers and all other CCGs, to identify opportunities for policy review, development and decommissioning. We are now reviewing every CCG’s PoLCE policies to build and maintain a full repository, allowing us to update the Benchmarking Tool and offer updated intelligence and support for realising the opportunities identified. We have also started work with the NHS RightCare programme to co-develop a wider solution that will accelerate the spread of best practice nationally. We developed web-based databases with interactive tools to track, monitor and manage referrals, activity, outcomes and expenditure. These tools help embed the best practice processes we defined, while allowing local adaptations where necessary. Standardised policies and working consistently at scale helps reduce variation and improve operating standards across the NHS.

To inform the policies we developed, our Clinical Effectiveness Team (which includes clinical coders) undertook extensive clinical engagement and evidence and best practice reviews. This reassured commissioners and patients that patient outcomes as well as financial savings determined policy thresholds. The benchmarking analysis we conducted supports effective prioritisation decisions by clinical commissioners, helping protect them from challenge and the potential for reputational damage. Our collaborative approach with clinicians facilitated the development of peer group networks, which will help sustain progress over the longer term.

As a further measure to drive quality, our IFR service implemented a web-based IFR and prior approval database across multiple health systems, which has streamlined case management and improved consistency of policy application. The underlying database allows us to produce tailored interactive reports for each organisation to monitor IFR performance. It improves efficiency by enabling providers to create, submit and review the outcomes of their own IFRs online. Clear summary reports enable organisations to visualise and monitor the impact of revised PoLCE policies in terms of finance and activity benefits, giving them a valuable peer performance benchmark right down to procedure level. This supports health and care planning and can identify areas requiring support, for example to improve clinical engagement or review pathways.

Our Clinical Effectiveness Team updates clinical policies and commissioning thresholds in line with best practice and evidence to ensure procedures of low clinical and cost effectiveness are not normally funded. The financial impact of applying agreed policy statements is achieved through either recommending the use of equally clinically effective but more cost effective interventions as the first line treatment, or by introducing evidence-based access criteria to ensure that care is targeted to those patients who will benefit most. The IFR service supports this work by applying policy and processes which mean commissioners can ensure the right patient gets the right care at the right time, and that financial savings are realised. Clinicians considering referrals for PoLCE are supported by an online flow chart that is visually intuitive and simple to use.

SCW has delivered a fivefold return on investment for Bedford and Hampshire CCGs through our IFR/PoLCE service. The Thames Valley IFR service we operate reported savings (decisions where funding was denied) increasing from £3,288,826 in 2016/17 to £6,419,329 in 2017/18. Bedfordshire CCG’s rose by more than 15% to £2,196,000 in in 2017/18. 

We’re really pleased about what the information [the Benchmarking Tool] is telling us and how it has been set out. We have identified a few areas where the CCG are outliers, and which have now been placed in the 2018/19 QIPP programme’s speciality reviews.

Andrew Tanner, QIPP Programme Manager, Herefordshire CCG

RightCare data benchmarks CCGs to their similar 10 demographic peers but does not always benchmark all procedure types within a programme area. The CCG was able to use the Commissioning Policies tool to benchmark at procedure level to the similar 10 for some MSK procedures (e.g. Bunions) not shown in the RC MSK pack.

Carl Marsh, NHSE RightCare Delivery Partner

How We Work with Partners in Lot 9

Specifically within this lot, our support offer includes expertise from established partners such as The Dartmouth Institute, Catalyze, Unipart, Lightfoot and Milliman who bring additional expertise in areas such as process reengineering, actuarial analysis, and driving sustainable change through shared decision-making and behavioural change ‘at the frontline’. This expertise will ensure SCW continues to develop sophisticated methods for measuring and improving cost and quality outcomes to underpin the development of value-based contracts.

 

Case Studies

SCW is currently working with STPs/ICSs to provide population segmentation and analysis of key patient groups including costed care, and has experience of developing costed Year of Care profiles through the Somerset Symphony project. Our Symphony data enables us to demonstrate utilisation of services and cost profiling alongside clinical and patient reported outcomes to evaluate the effectiveness of personalised care and redesigned care pathways. We support care systems to measure and monitor progress by providing timely data and information through dashboards and standard reports that have the functionality for self-service interrogation of the data. Our Intelligence Point reporting tool is widely accessible across different levels of the care system, with reporting views that we can tailor for different stakeholders including clinicians, managerial teams, practice staff, clusters, CCGs or whole systems. By making the right information easily accessible at the right time, we give users the insights they need for effective decision-making across different levels and parts of the system.

The CCG specified a requirement for an at-scale automated CMS that provided in-year and annual planning / baseline / provider-offer capability. Their objectives were to manage a £500m contract portfolio efficiently, drive efficiency gains, and drive down overspends against tight resources. We undertook extensive stakeholder engagement and requirements mapping with the CCG, NHS England and stakeholders. We implemented a scalable CMS solution to transform their transactional reporting. This entailed work to load, conform, configure and map more than 25 providers’ data and develop standardised historical reporting outputs and, to address gaps, new reports from scratch. CMS is now a standardised and automated end-to-end process that includes in-year monitoring and forecast positions for Acute Trusts with Community, Mental Health, Ambulance and 111. 

As a result of the integrated insight that our CMS reports provide, collaborative team working and integrated MDT discussions have improved considerably in the system. By standardising and automating reports, there is more time for investigation and contextualisation. In-year monitoring now feeds the recurring contract baseline and CCG contract offers to providers in a standardised way, which generates further efficiencies across the planning cycle. The CMS reconciles to the financial ledger-close report on working day 7, so that provider financial positions are reported in line with reports to Boards and the public. The CMS also incorporates STP reporting against STP financial control totals. 

Since its launch in Bedfordshire, SCW has now deployed the solution to other health and care systems.

 

As a regional DSCRO service, SCW has the advantage of accessing most national data flows in advance of the publication date. This enables our DSCRO to query NHS Digital directly on perceived delays if the data is not immediately accessible. We send communications to our Business Intelligence (BI) Area Leads and Principal Analysts who are primary touch points with our customers, and/or directly to customer contacts where agreed. 

Our validation process is underpinned by a reporting system covering over two hundred data quality reports all centralised within our BI portal (‘Intelligence Point’) that is accessible by internal staff and customers. Data quality reports highlight where data deviates from the expected norm. Data transfer reports include narrative to give commissioners insight into data issues to support rapid resolution. We achieve this level of detail by combining automated reports with a reporting interface that allows SCW staff close to the data to link descriptive narrative to a particular set of reports – without the need for developer intervention. This means that data quality insights are based on strong local knowledge and we are able to focus developer time on activities that increase the value of our service to our customers.

Our leadership of the successful National QIPP Delivery Programme evidences our ability to work across systems to identify and deliver efficiencies. The programme has supported 52-70 CCGs over time, which NHS England Regional Teams identified were at risk of under-delivering QIPP savings. We are supporting these CCGs to achieve their financial control totals and to provide assurance that their QIPP delivery plans are robust. In addition to mobilising and managing the central PMO function, SCW is delivering intensive local support to nominated CCGs. For example, with four CCGs in our own geography, we identified £1.1m in-year savings and £6m potential savings in 2018-19. “SCW colleagues have played a vital role in the delivery of Phases 1 and 2 of the QIPP programme in London which has supported CCGs to de-risk their current plans and identify additional schemes this year.”  David Slegg, Director of Finance, NHS England (London Region).

Somerset CCG wished to confirm the clinical benefits they would achieve by centralising stroke services at Taunton Hospital and closing the service at Yeovil Hospital. SCW’s team undertook a systematic analysis of how the proposed changes would impact the whole population of the large, rural county. 

Our team presented stakeholders with complex data on travel times and other key criteria in a visible way. We completed a comprehensive travel time analysis covering emergency vehicles and private and public transport options to identify the implications of the proposed change. The study confirmed that the clinical benefits of closing Yeovil’s stroke service would be more significant than had previously been anticipated and the increased travel times would have a critical impact on the speed of treatment for many stroke patients.

Our team’s evidence‐based analysis informed the planning process, indicating the best clinical outcomes achievable within the available resources. The evidence we produced altered the original direction of the review and led to Somerset CCG deciding to retain both stroke services.  This support enabled Somerset CCG to demonstrate that their decision was made in the best interests of delivering safe, effective care, and not by the need to deliver financial savings.

 

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