Commissioning for Chronic Illness Ideas for the future of NHS commissioning

1
Commissioning for Chronic IllnessIdeas for the
future of NHS commissioning

• Noel Plumridge and Anita Maynard
• SE London Health Authority
• June 2004

2
The strategic context autumn 2003
Unknown User
3 year PCT allocations, Foundation Trusts - need
for national standards accountability
DEVOLUTION
DTCs, Foundation Trusts, Franchising, Independent
sector, PCTs
Money flows with the patient
CHOICE
PLURALITY
INVESTMENT
Largest ever sustained increase in NHS funding -
75 held at local level
Framework underpinned by Payment by Results and
the new GMS contract
3
Two key commissioning tools

• Payment by Results
• A national tariff
• - derived from NHS average costs
• - adjusted for regional cost variations
• Payment for activity actually delivered
• - activity defined by HRGs
• - activity measured in spells
• In-year realignment of agreements

• New GMS contract
• Quality and Outcomes Framework
• points mean prizes
• practices are paid for achieving against a range
  of indicators
• some local discretion
• Potential to reduce outpatient work
• PCTs can invest in QOF services from their
  unified budget

4
Patient choice

• Summer 2004 patients waiting more than 6 months
  will be offered the choice of moving to another
  hospital for faster treatment
• December 2005 patients should be offered 4-5
  choices at the point of GP referral
• Option of treatment in private or foreign
  hospitals as well as NHS
• What does this mean for commissioners of chronic
  care?

5
A broader (and international) strategic context

• 1950-2000
• Acute focus
• Emphasis on
• throughput
• increasing capacity
• improving access
• efficiency

• 2000-?
• Chronic illness and public health focus
• Emphasis on
• self-management
• reducing need
• effectiveness (and efficiency)

6
Chronic Care Model
Community

• Resources and Policies
• Provide access to key services incommunity

• Health Care Organization
• Encourage better care through leadership,
• quality improvement incentives
• Role of commissioning

• ClinicalInformationSystems
• Collect and use patient data to plan care
• Monitor treatment and outcomes

• DeliverySystem
• Design
• Organize health care team,clarify roles
• Planned visits and follow-up

• Self-Management Support
• Support self management and prevention at every
  patient contact

• Decision
• Support
• Equip health care team with expertise and tools
• Provide care informed by evidence

Improved Outcomes
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Commissioning for chronic illness within this
context

• Can Payment by Results work outside of acute
  care?
• - chronic illness
• - mental health
• - community
• What does Choice mean for someone with a
  long-term illness?
• - choice of provider
• - control of model of care

8
Respiratory illness is this the care pathway we
want?
9.00am. My chest feels tight today
1.30pm. Wonder if I could get in to see my GP
l
8.00pm. Youd better go down to AE, just to be
on the safe side
10.00pm. Well keep you in overnight, just in
case
While youre here well just do a few tests
9
Multiple changes, implemented quickly

• What will be the consequences?
• How can we best respond?
• What might the new commissioning models be?

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Learning opportunities

• From the way we currently commission and provide
• - mental health using a lead provider
• - chronic renal care outreach
• - HIV/Aids the role of the patient
• From our own experience
• Weve been talking for years about shifting
  resource from secondary to primary care. What
  works? What gets in the way?
• From elsewhere not just the US!

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Some possible commissioning models

• Commissioning along a care pathway
• Commissioning from a single provider
• - an acute trust? (as with renal care)
• - primary care?
• - voluntary or independent sector?
• Putting the patient in control
• Whatcom
• For the system to work, acute providers need a
  positive incentive not to admit! What might it
  be?

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Chronic disease management12 commissioning
principles

• Enable self-care/self-management
• Adopt the Planned Care Model
• Strengthen the public health campaigning role
• Some behaviours damage our health. Use health
  professionals to tell people so.
• Involve users in service redesign
• Commission along a care pathway
• Rebalance the specialist/generalist contribution
• Use technology and policy levers to support
  change
• Respond to peoples physical and mental health
  needs via one service
• Describe new workforce roles
• Provide leadership and incentives for redesign
• Measure/monitor outcomes

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Now its your turn

• You are in charge of commissioning care for a
  chronic illness. How might you do this in the
  new world of payment by results, the new GMS
  Contract and patient choice?
• Specify which disease or group of diseases.
• Outline your preferred commissioning model/s
• Describe which tools you might use.
• Consider what help and support you might need.