Peter Taylor

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World Class Commissioning for Sexual Health HIV

• Peter Taylor
• Acute Services
• Development Manager
• E peter.taylor3_at_nhs.net

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Agenda

• Supporting Service Modernisation/ Local
  Reconfiguration
• Progress Priorities
• Holistic Models of Service Delivery
• Assessment of Local Needs
• Local Authority Partnerships
• Tariffs

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Commissioning for improved sexual health through

• adopting a holistic commissioning model which
  looks at sexual health in an integrated way and
  commissions along the care pathway
• commissioning at an appropriate level to ensure
  fair, effective and best-value provision
• linking service networks to the commissioning
  process and business agenda, and using them to
  inform and improve commissioning quality
• skilling up sexual health commissioners to meet
  world class commissioning requirements
• strengthening the public voice in commissioning
  disseminating evidence where investment in sexual
  health interventions provide good value for money
  and are cost-effective
• producing an easily accessible sexual health and
  wellbeing framework, and self-assessment tool to
  support commissioners
• accelerating the development of tariffs which
  allow for different service models and reflect
  the real cost of services

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National Drivers - Darzi

• Working with their local partners, every PCT will
  commission comprehensive wellbeing and prevention
  services, with the services offered customised to
  meet the specific needs of their local
  populations efforts must be focused on six key
  goals.

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Current Policy Agenda
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World Class Commissioning
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• Display visionary leadership
• Perceived as investors
• Commission for improved outcomes
• Stimulate innovation and efficiency
• Prepared to experiment
• Adhere to standards of conduct
• selflessness integrity objectivity
  accountability openness honesty and leadership

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Do It Once Do It Right

• Is used to
• Maximise value
• Eliminate waste
• Provide safe and appropriate care
• Provide leadership through coaching

Its about being able to do more with the
resources available
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• The 5 steps of Lean

Define Value
Specify Valuestream
Pull
Flow
Pursue Perfection
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Do It Once Do It Right World Class
Commissioning Sexual Health Services County
Durham and Darlington Lean Projects 1 2
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Links To The Strategic Plan

• The Public Health directorate is committed to
  working in partnership with all of the sexual
  health services in order to improve the health of
  the population, support people with long term
  conditions and to improve access to services.
  This aims to address
• Inequalities in opportunity to provide sexual
  health education to individuals and service
  providers through PSHE programmes, workforce
  development and a robust communication strategy
• Inequalities in lifestyle choices sexual
  activity and the links with drugs and alcohol
• Inequalities in access to services for those
  with infection and with enhanced risk factors for
  disease through achieving 48 hour access to GUM
  and developing community based level 2
  contraception and sexual health services

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• Project 1
• To define and review the current state of
  services with local stakeholders, and develop an
  owned future state with recommendations
• 70 Day Project

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Sexual Health Service Review

• Why?
• HNA
• Political drivers
• Strategic plan
• Commissioning priorities

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The process
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Current State
Sexual Health Outreach
CASH
GUM
CSP
HIV Prevention
Primary Care
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Stakeholder comments

• How could sexual health services be delivered
  better?
• Include rapid HIV testing
• Ensure that primary care offer Chlamydia
  screening as core business
• Ensure robust referral pathways
• Model to integrate prison services
• Provide central phone line with good social
  marketing
• How could the patient experience be improved?
• By providing a holistic, one stop shop service
• Shared tertiary care for complex cases
• Provide psychosexual service
• Target vulnerable groups e.g. BME, travellers etc
• Ensure boys and young mens support
• Ensure choice of male and female practitioners

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• How do we take out waste within the current
  systems
• Do we know where waste is?
• Avoid unnecessary patient flows between services,
  and ensure clients access correct
  service/practitioner first time
• Avoid duplication between services with
  better/standardised I.T. systems, see minimum
  number of staff
• Effective marketing and sign-posting
• Ensure availability of appointments
• Ensure lab reporting of results electronically
  and timely
• Ensure clinical pathway avoids waiting and
  movement between staff
• Ensure effective system to obtain results e.g.
  electronic/texting
• Reduce unnecessary work e.g. letters to test
  initiators (CSP), giving results, follow up

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Future State
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• Lean Project 2
• World Class Commissioning for Integrated Sexual
  Health Services in County Durham and Darlington
  Primary Care Trusts
• 90 days Oct 2008 - Jan 2009

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Metrics

• 5 year sexual health strategy with a 3 year
  action plan
• Strategy development steering group

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• PCPI involvement in commissioning and monitoring
  of services
• PCPI steering group

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• A Workforce development plan from a
  commissioning perspective
• Workforce development steering group
• Continuity planning
• Commissioning accredited training
• Innovation through extended roles

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• New Contracts Service Specifications
• Commissioning steering group
• Future state steering group
• Notice served, Contracts extended
• Clinical / 3rd sector involvement
• Innovation encouraged through PBC, prison health
  etc

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Specify the What, not the How

• It is this developing beyond a specification
  that ultimately symbolises the great strength and
  possibilities of commissioning within the NHS.
  In describing clearly what we want we are neither
  telling a provider how they must deliver this nor
  are we saying that they must not deliver beyond
  it.
• Innovation is key to modern commissioning and
  whilst it can be seen within the service
  specifications we develop, and the strategic
  plans that we have, it is what comes from outside
  of that process that will bring about the biggest
  elements of change to the health of our
  communities.
• Sexual Health Strategy 2009-2014, NHS County
  Durham NHS Darlington

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• A report of the learning around the process of
  commissioning a complex integrated service

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Outputs Measuring Our Success

• Interaction with local NHS organisations
  assuring, developing, and promoting their
  functions
• Effective stakeholder management
• Transformational not just Transactional
• Clinical Care outcomes
• Health outcomes
• Community outcomes

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Tariffs Rules of Engagement
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How do YOU use the contestability process?
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Framework for Managing Choice, Cooperation and
Competition

• choice on the part of patients between providers
  of clinical services, settings and models of
  care
• competition between providers for, and in, the
  healthcare market
• governance arrangements in place in contracting
  organisations
• contracts between NHS contracting organisations
  and providers
• strategic partnerships and
• information for patients and referrers to enable
  them to make informed choices, for commissioners
  so that they can secure the best services for the
  people they serve, and for providers and
  clinicians to benchmark themselves against.

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Court review of procurement procedures

• Legal action may be taken challenging a contract
  award by a service provider who believes that
• (a) there has been a breach of the procurement
  rules, and
• (b) it has suffered or will suffer loss as a
  result.
• If the challenge is successful, the court may
  grant an injunction suspending the award of the
  contract if the contract has not yet been entered
  into with the successful bidder.
• If an injunction cannot be granted, the
  challenger may claim damages for the loss that it
  has suffered.
• These may be based on wasted bid costs or
  possibly on a proportion of the profits of the
  contract, where the challenger can show a
  sufficient degree of probability that it would
  have won the contract had the rules been applied
  correctly.

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• When the new Remedies Directive is implemented
  the courts will have power, in certain
  circumstances, to grant injunctions and overturn
  contracts even after they have been entered into.
  
• In addition, an aggrieved tenderer may also bring
  a claim based on breach of an implied contractual
  term, where a contracting authority has failed to
  abide by the tender processes it has published to
  tenderers or where it has not acted in good
  faith.
• The Directive details the requirement for a
  standstill period before concluding a public
  contract to give the tenderers concerned
  sufficient time to examine the contract award
  decision and to assess whether it is appropriate
  to initiate a review procedure.
• The main implications are that contracting
  authorities should ensure that the procurement
  decisions are documented in a way that can be
  audited and justified.

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The Complexity of Plurality

• The guardian of NHS funds is the commissioner.
• Plurality of providers means that some NHS money
  will be spent on non-NHS providers for the public
  good.
• However, if there is a financial incentive to
  reach targets, e.g for reducing prescribing costs
  or the numbers of follow-up outpatients, and the
  provider achieves that, then the financial reward
  will use NHS money but will not necessarily be
  channelled back into providing services.

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• A plurality of providers means there is also the
  potential for fragmentation of the pathways or
  services, because of a lack of trust between the
  different providers of the service.
• Some NHS services such as the provision of
  informal training and mentoring and research are
  often not documented or costed, and there is a
  risk that the NHS will stop providing these if
  the provider management does not draw attention
  to them, and to their value.

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And What of The Rules?

• PbR Facilitates plurality of provider and
  contestability providers compete on an equal
  basis whether NHS or independent sector

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National Tariff The Rules

• NHS Data Model and Dictionary, Version 3, June
  2009
• Consultant Led Service
• A Consultant Led Service is a SERVICE where a
  CONSULTANT retains overall clinical
  responsibility for the SERVICE, CARE PROFESSIONAL
  TEAM or treatment.
• The CONSULTANT will not necessarily be
  physically present for each Consultant Led
  Activity but the CONSULTANT takes clinical
  responsibility for each PATIENT's care.

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• Consultant Led Activity
• A Consultant Led Activity is an ACTIVITY where a
  CONSULTANT retains overall clinical
  responsibility. The CONSULTANT is not necessarily
  physically present for each PATIENT's
  APPOINTMENT, but he/she takes overall clinical
  responsibility for PATIENT care.
• The MAIN SPECIALTY of the CONSULTANT retaining
  overall clinical responsibility is recorded using
  the appropriate MAIN SPECIALTY CODE along with
  their CONSULTANT CODE. A TREATMENT FUNCTION CODE
  will be recorded where the ACTIVITY is delivered
  in a TREATMENT FUNCTION.
• The MAIN SPECIALTY CODE is used by the Secondary
  Uses Service to identify Consultant Led Activity