Howard Perry

1
Squaring the Circle WCC/WCP NHS Networks
21st August 2008
Howard Perry Interim Managing Director Tower
Hamlets Community Health Services
2
WORLD CLASS COMMISSIONING/WORLD CLASS PROVIDING
SQUARING THE CIRCLE

• Context for Tower Hamlets PCT
• Autonomous Provider Organisation in London
• Tower Hamlets APO Programme
• Service Line Reviews
• Performance Dashboards
• Strengthening Commissioning in London
  (Commissioning/Providing Split)
• Next Steps for Tower Hamlets PCT

3
What has changed for Tower Hamlets PCT Community
Services

• Opportunity for Tower Hamlets Community Health
  Services
• Learn from Provider APO Pilots
• Headroom to get ready and become fit for purpose
  as a provider arm of PCT.
• Capture the enthusiasm of our staff
• Develop Alliance with Inner NE London PCTs
• Develop closer links with LBTH, Primary Care and
  Barts London Hospital Trust

• Greater focus on Networks of Care
• Increased Commissioning of Patient Pathways
• Integrated Commissioning with Local Authorities
• Foundation Trusts Payment by Results
• Practice Based Commissioning
• Needs Based Commissioning
• Improving Health and wellbeing

• Health Care for London
• Darzi Report
• Independent and Third Sector Provider Entrants
• Increased Public awareness and expectations
• Contestability of Service Providers
• NHS London Provider Pilots (APO)

• Significant Investment for Local People
• Innovative Awards success
• Balanced budget
• Vision for Excellent patient care
• Board commitment to developing Commissioning
  Providing within Tower Hamlets

4
POTENTIAL GOVERNANCE MODELS FOR PROVIDER SERVICES
Governance
Definition
Finance

• An organisation that operates separately within
  the host PCT, with separate management, financial
  and governance structures

• Governance is delivered through a subcommittee of
  the PCT board with specific responsibility for
  provider services and policies are in place to
  manage conflict of interest

• Provider services has a separate income and
  expenditure accounts and the PCT is able to
  allocate overheads appropriately between itself
  and provider services

• Governance is delivered through a subcommittee of
  the PCT board with specific responsibilities for
  provider services, policies in place to manage
  conflict of interest and a clear and detailed
  scheme of delegation which outline roles and
  responsibilities

• The PCT and provider services run separate sets
  of financial accounts (including separate balance
  sheets), but the accounts of provider services
  are not audited

• An organisation that is capable of, but not
  currently, operating independently from its host
  PCT (autonomous organisations continue to share
  an accountable officer with the host PCT)

• An organisation or set of service lines
  completely independent from its former host PCT
• May or may not reflect the existing
  organisational structures

• Organisational form has been decided and agreed,
  and all legal arrangements are in place
• Governance is completely separate, with separate
  accountable officers and Boards of Directors

• Financial accounts are completely separate and
  independently audited

5
7 PCT PROVIDER ARMS ALREADY PILOT APOS
Pilot members
Camden
Barnet
City and Hackney Teaching
Westminster
Havering
Kensington and Chelsea
Tower Hamlets PCT
Wandsworth Teaching
6
PROVIDER FITNESS FOR PURPOSEAS APO
ü
1.1 Vision for the future
ü
1.2 Review of service lines
ü
1.3 Relationships with commissioners
1.4 Commissioning intentions
ü
1. Strategy
1.5 Competitive analysis
ü
1.6 Competitive environment of APO
1.7 Impact of wider healthcare changes
ü
1.8 Partner relationship management
ü
2.1 Data control
ü
2.2 Activity reporting
ü
2. Services
2.3 Information management
ü
2.4 Productivity improvements
2.5 Performance management
ü
2.6 Estate management
ü
3.1 Workforce management
ü
3.2 Staff engagement
3. Staff
3.3 Talent management
3.4-3.7 Staff resource
ü
ü
Required for APO status
3.8 Training students
ü
4.1 Understanding of income
ü
4.2 Percentage of business, non-host PCT
ü
4.3 Contracting
4.4 Costed service lines
4. Money
4.5 Overhead allocation
ü
4.6 Cost efficiencies
ü
4.7 SLAs for back office services
ü
4.8 Balance sheets
ü
4.9 Audited accounts
5.1 Board
ü
5. Governance
5.2 Organisational options
5.3 Top team skills assessment
ü
6.1 Clinical governance
ü
6. Quality
6.2 Quality metrics
6.3 Patient satisfaction
ü
7
THE TOWER HAMLETS PCT APO PROGRAMME

• Top level analysis of existing Services Assess
  our Fitness For Purpose
• Deep Dive into five Service Lines
• District Nursing
• Psychology
• Services for Older People (Inpatient and
  Community)
• Occupational Therapy
• Women Young Peoples Services

• Strategic Future
• Analyse our Income
• Describe present and future Commissioning
  relationships
• Describe competitive landscape for our Provider
  Services
• Define future sore services and opportunities
• Recommend strategy for provider future

• District Nursing Tariff and Remaining Provider
  Diagnostic
• Conclude District Nursing Costing Pricing
• Complete 12 x Service Line Deep Dives
• Service Line Financial Reporting
• APO Submission

8
SERVICES DISPERSED ACROSS TOWER HAMLETS POPULATION
Budget, , Estimate
Care settings
1.0 m
Acute and mental care
Primary care
Community care
0.5 m
MEH out-pa-tients
MEH in-pa-tients
Serv-ices at BLT
0.1 m
Host sites
Preven-tion
GPs
Home
Clinics
BLT
Other
Service line
14
Children
16
4
12
12
1. Older People
3
16
4
12
15
3
16
10
16
11
4
4
2. District Nursing 6. Health Visiting 7. School
Nursing
14
4
13
10
5
8
8
8
3
12
16
12
12
3
6
6
3
6
7
15
3
7
3. Physiotherapy 10. OT 12. Speech and
language 16. Audiology
11
11
15
11
11
13
Young people
15
15
15
8
4
9
5
11
11
11
4
15
11
13
4. Dental
8
5
Adults
Women
3
4
3
5. Direct GP 8. Urgent Care
11
4
4
15
16
16
17
15
15
17
9. Learning Disabilities 11. WYPS 13.
Psychology 14. Childrens Services 15.
Podiatry 17. Diabetic Services
15
15
15
11
17
17
11
16
4
8
10
3
16
17
17
8
13
15
13
11
4
4
8
9
9
9
9
10
13
4
9
9
13
4
3
3
3
10
2
2
1
10
3
1
1
4
1
1
5
1
3
16
17
17
16
17
16
16
4
17
4
4
8
3
15
16
4
10
15
1
15
4
10
Older people
4
4
15
15
2
1
1
15
3
1
5
17
2
3
1
3
3
1
10
17
13
15
8
16
1
13
10
16
8
E.g., Mobile clinics, schools, non-traditional
out-reach centres E.g., Clinics at GPs,
Clinics at Healthcare centres Including
services provided at BLT budget but staff
employed by OT S.L. Note Excluding other
services (Advocacy and Interpolating, CAS,
Out-of-Hours GPs, Specialist Nursing) Source Tea
m discussions with Heads of Service
9
BUDGETS OF PROVIDER ARM SERVICES ALLOCATED ACROSS
PATIENT CARE SETTINGS, WITH VAST MAJORITY IN
CLINICS AND INPATIENT
1
17
SFOPR
Occupational Therapy
16
2
District Nursing
Diabetes
3
15
Physiotherapy
Audiology
4
Community Dental
14
Podiatry
Patient
13
5
Directly managed GPs
Services for Children
12
6
Health Visiting
Psychology
7
11
School Nursing
SLT
8
Urgent Care
10
9
Learning Disabilities
WYPS

• The inner circle represents home and preventive
  care (14m)
• The middle circle is clinic-based care (23m)
• The outer circle is in-patient care (22m)

10
DEEP DIVE OVERVIEW WOMAN AND YOUNG PERSONS
SERVICES
Strengths/Learnings
Opportunities
Strategic implications
In an autonomous organisation
Highlights of the CG campaign
1
Costs of providing patients multiple access
points (i.e. many clinics) will need to be
balanced against staff/operational costs Services
will need to actively seek new patients
groups/areas to provide services for A large
proportion of decision making will need to be
devolved to HoS (streamlining decision
making) Activity collection and performance
management will have to be robust to understand
economics of service
1

• Quick and flexible decision- making
• Decision making was devolved to HoS
• Innovative ideas were adapted quickly (inc.
  marketing)

2
3
4

• Increase patient access (3 visits vs. 4)
• Increase patients seen (510)
• Save staff time (36hrs per week)

Next steps

• Clinic may be inefficiently utilised
• Workplan developed to further assess utilisation
  and possible centralisation

• Service line lead to be assigned Performance
  dashboard workplan developed in conjunction

11
TH PROVIDER ARM HAS MANY DIVERSE SERVICES
5.5
Service line mapping
1
High
Low
ü
Form of Commission-ing
Currently facing competition
Confirmed with service lead
Reference Costs ()
Ratio of funding from TH PCT
Integrated with social services
Service line
m
ü
-10

• Some out of area

• Older people and rehab.

10.1
Block
ü
-45

• District nursing

5.3
(ü)
Block
ü
-3

• Physiotherapy

5.2
Block

• BLT

ü
24

• Dental

5.1

• Various other sources

Block
ü
N/A

• Directly-managed GP

5.0
PCTMS
ü
-58

• Health visiting

ü
4.2
(ü)
Block
-127

• School nursing

ü
WiC -49

• Urgent care

3.0
Block
ü
N/A

• Learning disabilities

3.0
ü

• LBTH

Joint with LBTH
ü

• LBTH
• BLT

-10

• Occupational therapy

2.4
ü
Block
ü
7

• Woman and young peoples

2.3
Block
ü
-2

• Speech therapy

2.1

• Various other sources

Block
ü
-39

• Psychology

1.5
(ü)
Block
33

• Services for children

1.4
(ü)
Block?
ü
-4

• Podiatry

1.3
Block
ü
-14

• Audiology

1.3

• BLT
• City and Hackney

Mix
ü
-24

• Diabetic service and centre

1.0
Block
N/A

• Other

0.6
N/A
N/A
N/A
N/A
Source TH PCT interview with head of service
lines team discussion
12
EXAMPLE OUR PERFORMANCE DASHBOARD
NOT EXHAUSTIVE
Serious Untoward Incidents
Risk Register
Safety
Infection rates (Cdif, MRSA)
Patient survey metric
Quality
Patient satisfaction
Complaints and compliments
AE attendance of patients under care
Outcomes
Percent of patients with defined care plans
Waiting time
Forecast versus actual
Money
Actual versus expected costs
Actual versus expected income
Growth
Patient numbers (by borough)
Percent of time on direct patient care
Services
Patients Treated
Efficiency
Percent of time spent on travel
Sickness and absence rate (monthly)
Vacancy rate (monthly)
Morale
Correlation of pay grade and productivity
Staff
Staff complaints and complements
Supply
Satisfaction (from frequent staff survey)
Voluntary turnover (monthly)
13
ALL HEADS OF SERVICE CREATING PERFORMANCE
DASHBOARDS
A
ILLUSTRATIVE
Targets set by staff, using combination of
internal and external benchmarks to help guide
Graphical Output Shows trends
Designed to provide snapshot of performance
focused on the 10-15 most important metrics
Part of a larger performance management culture
dashboard used as a tool for continuous
improvement discussions and feedback
SMART metrics individual metrics are Specific,
Measurable, Actionable, Relevant, and Time-bound
Key metrics established and agreed upon by all
sides (incl. staff and commissioners)
Visual cues used to quickly identify status
14
CHALLENGE OF INNER NORTH-EAST LONDON
Inner NE London (INEL) PCT Alliance
Pan Borough Services
Pan Borough Services
e.g. Dental, Sexual Health
8 x ICT Networks HUBs
4 x Integrated Localities LBTH Polyclinics
Newham PCT
City Hackney PCT
Sub Networks? At GP Level
Tower Hamlets PCT
Integrated HS Care Model
15
TOWER HAMLETS NEXT STEPS

• INEL Alliance Devil in the detail
• Integrated Care Model with LBTH DofH Pilot
• APO Accreditation March 2009
• Externalised Provider Model 2009/10
• Social Enterprise?
• Integrated LA Model?
• Vertical Model (FT)?
• Community Foundation Trust?
• Business Transfers Model (Alliance)?
• Shadow Tariff District Nursing (Nov08)

16
TREATMENT COST DRIVER TREES IN DISTRICT NURSING
1
PRELIMINARY
Task 1 time, min
Patient facing time, min
Mobilisation time, min
Treatment time, min
. . .
Travel time, min
Non patient facing time, min
Admin time, min
Clinical staff cost/ treatment
. . .
Total salary p.a.
Total DN pay cost p.a.
Total annual pension expense
Direct clinical cost/treatment
Cost/minute
Total DN capacity, min
Sickness/absence, min
DN capacity p.a., min
Total treatment cost
Holiday, min
Clinical non-staff costs/ treatment
Training, min
Overhead cost/min
Overhead cost/ treatment
Treatment time, min
E.g., medical supplies Source Team analysis