Towards World Class Commissioning

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Towards World Class Commissioning
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World Class Commissioning Vision
World class commissioning is not an end in
itself, so in order to prove themselves
successful, commissioners will need to
demonstrate better outcomes adding life to years
and years to life

• Better health and well-being for all
• People live healthier and longer lives
• Health inequalities are dramatically reduced
• Better care for all
• Services are evidence based, and of the best
  quality
• People have choice and control over the services
  that they use, so they become more personalised
• Better value for all
• Investment decisions are made in an informed and
  considered way, ensuring that improvements are
  delivered within available resources
• PCTs work with others to optimise effective care

The vision for world class commissioning will be
one that is developed, articulated and owned by
the local NHS, with a strong mandate from local
people and other partners (such as local
authorities). PCTs should state what their vision
for world class commissioning is locally, and
what they will achieve through continually
commissioning better services and delivering
better outcomes based on local priorities.
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World Class Commissioning Competencies

• Are recognised as the local leader of the NHS
• Work collaboratively with community partners to
  commission services that optimise health gains
  and reductions in health inequalities
• Proactively seek and build continuous and
  meaningful engagement with the public and
  patients, to shape services and improve health
• Lead continuous and meaningful engagement with
  clinicians to inform strategy and drive quality,
  service design and resource utilisation
• Manage knowledge and undertake robust and regular
  needs assessments that establish a full
  understanding of current and future local health
  needs and requirements
• Prioritise investment according to local needs,
  service requirements and the values of the NHS
• Effectively stimulate the market to meet demand
  and secure required clinical and health and
  well-being outcomes
• Promote and specify continuous improvements in
  quality and outcomes through clinical and
  provider innovation and configuration
• Secure procurement skills that ensure robust and
  viable contracts
• Effectively manage systems and work in
  partnership with providers to ensure contract
  compliance and continuous improvements in quality
  and outcomes
• Make sound financial investments to ensure
  sustainable delivery of priority outcomes

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A Commissioning Assurance system will help to
understand PCT progress towards world class
commissioning

• Understand performance of PCTs as commissioners
  across the NHS and progress towards world class
  commissioning
• Consistently compare performance to ensure
  comparability for patients, staff and citizens

• Categories of assessment will be
• Health outcomes and quality
• Competency
• Governance (Board governance, strategy/medium
  term finance and business processes)
• Full review every 3 years with key data reported
  annually
• Mix of direct observation/data,
  self-certification and peer review

• Build on existing SHA regimes where appropriate
• SHAs will implement and incorporate into the
  annual cycle
• Commissioners demonstrating strong performance
  should
• Be subject to light touch review focussed on
  elements 1 and 2, with 3 based on
  self-certification
• Receive additional benefits e.g. borrowing,
  (non-) top slice

Adding years to life and life to years
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by reviewing there key areas
Health outcomes and quality
Competencies
Governance
HEALTH OUTCOMES AND QUALITY

• Measures health gain quality in health care and
  assigns ratings based on ability to deliver key
  health outcomes and services
• Public confidence
• Patient outcomes and satisfaction

• Measures evidence that identifies the extent to
  which the commissioner possesses the core
  competencies associated with World Class
  Commissioners
• Measures system and market management capabilities

• Current and forward looking review of board
  controls and processes , strategy, and long term
  financial controls

Content

• Focus on improvement

• Focus on improvement

• Maintain standards

Nature

• SHA Assessment
• Absolute performance against core outcomes, local
  stretch improvement targets
• Improvement against outcomes
• Peer review

• SHA Assessment
• Scoring against degrees of best practice
• Self assessment
• Peer/external review

• SHA Assessment
• Self-certification
• Direct review
• Peer review

Methodology

• Baseline assessment every 3 years, with annual
  review

• Baseline assessment every 3 years, with annual
  review
• Interim monitoring as appropriate

• Baseline assessment every 3 years, with annual
  review
• Interim monitoring as appropriate

Frequency
WCC
WCC
Rating
base
base
Including 360 degree feedback Source Input
from World Class Commissioning Events (September
and November)
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1. Outcomes Assessment will be based on Vital
Signs measures
Vital Signs
Help improve every citizen's overall health,
life-expectancy and emotional well-being

• PCTs will choose 5 measures from the Vital
  Signs that are consistent with their strategic
  objectives
• They will be given 5 nationally identified Vital
  Signs
• For each measure, absolute performance, ranking
  and the UK average / upper quartile will all be
  indicated
• For each measure there will also be a rating that
  takes into account the PCTs starting point, and
  quantifies improvement

Help improve citizen's quality of life
Help the most vulnerable achieve their
aspirations, building a fairer society
Improve the safety, cleanliness and delivery of
optimum care
Make services more personal
Improve experience for patients, users and carers
Ensure an effective system
Secure long-term sustainability
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2. Competencies Process for creating assessment

• Reviewed the World Class Commissioning
  competencies
• Identified components that could be measured
  across
• Inputs
• Process
• Outputs
• Assigned methodologies for assessment of each
  component
• Chose 3 measures, focusing on outputs where
  possible
• Developed the evidence required, and described
  the thresholds between base and world class

• For each competency there will be three measures
  that will be assessed
• Where possible, these have focused on outputs
• The descriptions of the thresholds are expected
  to develop over time to ensure thresholds are
  raised as performance improves
• The output of the assessment should support PCT
  organisation talent and capability plans

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Competency 1 Are recognised as the local leader
of the NHS

PCTs should lead and steer the local health
agenda in their community. PCTs will be the
natural first stop for local political and
community leaders. Through partnership, they seek
and stimulate discussion on NHS and wider
community health matters
Evidence
Below baseline
Baseline
Intermediate
World class

• gtX either agree or strongly agree with
  statement We recognise the PCT as the local
  leader of the NHS
• Open text feedback reinforces rating

Reputation as the local leader of the NHS

• Feedback from 360 survey
• Strategic plan linked to agreed LAA
• PCT prospectus
• Communication strategy

• Does not meet baseline requirements

• XY either agree or strongly agree with
  statement We recognise the PCT as the local
  leader of the NHS
• Open text feedback reinforces rating
• PCT has a communications strategy

• XY either agree or strongly agree with
  statement We recognise the PCT as the local
  leader of the NHS
• Open text feedback reinforces rating
• PCT regularly communicates local health agenda
  to community

360 feedback
Reputation as a change leader for local
organisations

• gtX either agree or strongly agree with statement
  The PCT has had a significant influence on our
  decisions and actions
• Open text feedback reinforces rating

• Feedback from 360 survey

• Does not meet baseline requirements

• XY either agree or strongly agree with
  statement The PCT has had a significant
  influence on our decisions and actions
• Open text feedback reinforces rating

• XY either agree or strongly agree with
  statement The PCT has had a significant
  influence on our decisions and actions
• Open text feedback reinforces rating

360 feedback
Position as the local healthcare employer of
choice

• Staff satisfaction is positive, and staff metrics
  are in upper quartile of national performance
• Recruitment
• Retention
• Satisfaction

• Average number of applicants per advertised post
• Total number of vacancy days per year
• of staff employed from locality
• Staff turnover rates
• Staff sickness rate
• Feedback from staff satisfaction survey

• Does not meet baseline requirements

• Staff satisfaction is neutral, and staff metrics
  are in line with the national average
• Recruitment
• Retention
• Satisfaction

• Staff satisfaction is positive, and staff metrics
  are above national average
• Recruitment
• Retention
• Satisfaction

Metric
9
Competency 2 Work collaboratively with
community partners to commission services that
optimise health gains and reduce health
inequalities
PCTs should not commission services in isolation.
In addition to commissioning healthcare services,
they will need to consider the wider determinants
of health and the role of other partners in
improving the health outcomes of their local
population. PCTs also share responsibility for
undertaking a joint strategic needs test (JSNA)
with local authorities. Partners include local
government, healthcare providers, third sector
organisations and clinical partners such as
practice based commissioners and specialist
consortia. Working collaboratively with
partners, PCTs will stimulate innovation,
efficiency and better service design, increasing
the impact of the services they commission to
optimise health gains and reductions in health
inequalities
Evidence
Below baseline
Baseline
Intermediate
World class

• Z of LAA targets have demonstrable supporting
  evidence in the JSNA or public and patient
  engagement information
• PCT creates joint accountability and clearly
  delegates roles with local partners on gtX of key
  targets
• PBC leadership and engagement in LAA

Creation of Local Area Agreement based on joint
needs

• Local Area Agreement
• Joint Strategic Needs test

• Does not meet baseline requirements

• PCT and the local authority agree LAA priorities
• X of LAA targets directly address the needs
  highlighted in the JSNA
• PCT and LA both independently accountable for LAA
  targets

• PCT and the local authority and local strategic
  partners agree LAA priorities
• Jointly ensure that the LAA priorities are based
  on joint test of needs
• Y of LAA targets directly address the needs
  highlighted in the JSNA

Self test
Ability to conduct constructive partnerships

• gtZ of respondents either agree or strongly agree
  with statement The PCT pro-actively engages with
  my organisation to inform and drive strategy,
  service design and resource utilisation
• Open text feedback supports rating

• Feedback from 360 survey
• Example local strategic partnerships (LSPs)
• PBC survey results Qu 5

• Does not meet baseline requirements

• XY of respondents either agree or strongly
  agree with statement The PCT pro-actively
  engages with my organisation to inform and drive
  strategy, service design and resource
  utilisation
• Open text feedback supports rating
• Results from PBC survey, Qu 5 Agreed a
  commissioning plan are yes

• XY of respondents either agree or strongly
  agree with statement The PCT pro-actively
  engages with my organisation to inform and drive
  strategy, service design and resource
  utilisation
• Open text feedback supports rating

360 Feedback
Reputation as an active and effective partner

• gtZ of respondents agree or strongly agree with
  statement The PCT is an active and effective
  partner in delivering local health objectives
• Open text feedback reinforces rating

• Feedback from 360 survey
• List of joint milestones agreed with partners

• Does not meet baseline requirements

• gtX of respondents agree or strongly agree with
  statement The PCT is an active and effective
  partner in delivering local health objectives
• Open text feedback reinforces rating
• Meets milestones with partners

• gtY of respondents agree or strongly agree with
  statement The PCT is an active and effective
  partner in delivering local health objectives
• Open text feedback reinforces rating

360 feedback
10
Competency 3 Proactively build continuous and
meaningful engagement with the public and
patients to shape services and improve health
PCTs are responsible through the commissioning
process for investing public funds on behalf of
their patients and communities. In order to make
commissioning decisions that reflect the needs,
priorities and aspirations of the local
population, PCTs will have to engage the public
in a variety of ways, openly and honestly. They
will need to be proactive in seeking out the
views and experiences of the public, patients,
their carers and other stakeholders, especially
those least able to act as advocates for
themselves
Evidence
Below baseline
Baseline
Intermediate
World class
Influence on local health opinions and aspirations

• Feedback from 360 survey

• gtX of respondents either agree or strongly agree
  with statement The PCT has substantially and
  proactively shaped the health opinions and
  aspirations of the local population leading to
  demonstrable change
• Open text feedback supports rating

• Does not meet baseline requirements

• XY of respondents either agree or strongly
  agree with statement The PCT has pro-actively
  shaped the health opinions and aspirations of the
  local population leading to demonstrable change
• Open text feedback supports rating

• XY of respondents either agree or strongly
  agree with statement The PCT has pro-actively
  shaped the health opinions and aspirations of the
  local population leading to demonstrable change
• Open text feedback supports rating

360 feedback
Public and patient engagement

• PCT Engagement and consultation strategy,
  including strategy for reaching disengaged groups
• of practices with patient participation groups
• PBC survey results Qu 16

• PCT has successfully deployed innovative
  approaches to engagement
• Which have been shared with other PCTs
• Which have led to high levels of engagement with
  hard-to-reach groups
• Which accessed non-traditional partners e.g.,
  criminal justice system
• PCT can demonstrate how patient views have
  affected commissioning plans

• Does not meet baseline requirements

• PCT Engagement and consultation strategy
• Identifies engagement existing initiatives and
  processes
• Fulfils statutory obligations e.g. focus groups,
  open policy meetings
• Agreed through consultation
• Includes regular surveys to gather feedback
• Results from PBC survey, Qu 16 engagement with
  local population demonstrate methods that are
  used
• Clear distinction between information shared for
  reference vs. that shared for consultation

• PCT Engagement and consultation strategy
• Identifies local aspirations for PPI
• Explores use of new channels e.g., schools,
  businesses, voluntary groups
• PCT formally involves patients and public in
  review of services

Metric and self test
Delivery of patient satisfaction

• Healthcare Commission patient survey data

• gtX of respondents either agree or strongly agree
  with statements indicating overall satisfaction
  in survey

• Does not meet baseline requirements

• XY of respondents either agree or strongly
  agree with statements indicating overall
  satisfaction in survey

• XY of respondents either agree or strongly
  agree with statements indicating overall
  satisfaction in survey

Metric
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Competency 4 Lead continuous and meaningful
engagement of all clinicians to inform strategy
and drive quality, service design and resource
utilisation
Clinicians are best placed to advise and lead on
issues relating to clinical quality and
effectiveness. They are the local care pathway
experts who work closely with local people
understanding clinical needs. PCTs should ensure
that through the involvement of clinicians in
strategic planning and service design, services
commissioned build on the current evidence base,
maximise local care pathways and utilise
resources effectively. Professional Executive
Committees (PECs) have a crucial role to play in
building and strengthening clinical leadership in
the strategic commissioning process. Practice
based commissioning (PBC) is the key methodology
for this and should be maximised to drive
innovative and transformational change
Evidence
Below baseline
Baseline
Intermediate
World class
Clinical engagement

• Delegated authority to clinical committees
• Number of PBC proposals approved and live
• of clinicians leading initiatives

• PEC chairs, consortia reps, acute trusts, local
  social care, and allied health practitioners are
  embedded into and are active participants in PCT
  planning and service development

• Does not meet baseline requirements

• PCT can identify several non-PEC clinicians that
  have made substantive contributions to PCT
  strategy, planning and policy development
• Clinicians are regularly present and actively
  participate in PEC meetings

• Includes clinicians that represent all healthcare
  and well-being delivery methods

Self test/Metric

• Data analysis at PBC level e.g., number of
  defined procedures per
• Practice reports e.g., activity and financial
• Evidence of regular communications about quality
  improvement ideas
• PBC survey results Qu 15

Dissemination of information to support clinical
decision making

• PCT can calculate PBC return on investment and is
  in upper quartile
• PCT proactively solicits and disseminates status
  updates and quality improvement ideas from all
  practices on a monthly basis
• Quality reports include recent clinical evidence,
  benchmarks, and changes in clinical practice

• Does not meet baseline requirements

• PCT can calculate PBC level return on investment
• PCT proactively solicits and disseminates status
  updates and quality improvement ideas from all
  practices on a biannual basis
• Provided data is valued by clinicans
• Results from PBC survey, Qu 15 Rating of
  information are fairly good or very good

• PCT can calculate PBC return on investment and is
  in third quartile
• PCT proactively solicits and disseminates status
  updates and quality improvement ideas from all
  practices on a quarterly basis
• Quality reports include recent clinical evidence
  and benchmarks

Self test

• Feedback from 360 survey

Reputation as leader of clinical engagement

• gtX either agree or strongly agree with statement
  The PCT pro-actively engages all clinicians to
  inform and drive strategy, service design and
  resource utilisation
• Open text feedback supports rating

• Does not meet baseline requirements

• XY either agree or strongly agree with
  statement The PCT pro-actively engages all
  clinicians to inform and drive strategy, service
  design and resource utilisation
• Open text feedback supports rating

• XY either agree or strongly agree with
  statement The PCT pro-actively engages all
  clinicians to inform and drive strategy, service
  design and resource utilisation
• Open text feedback supports rating

360 feedback
12
Competency 5 Manage knowledge and undertake
robust and regular needs tests that establish a
full understanding of current and future local
health needs and requirements
Commissioning decisions should be based on sound
knowledge and evidence. By identifying current
needs and anticipating future trends, PCTs will
be able to ensure that current and future
commissioned services address and respond to the
needs of the whole population, especially those
whose needs are the greatest. The joint
strategic needs test (JSNA) will form one part of
this test but when operated at world class levels
will require more and richer data, knowledge and
intelligence than the minimum laid out within the
proposed duty of a JSNA. Fulfilling this
competency will require a high level of knowledge
management with associated actuarial and
analytical skill
Evidence
Below baseline
Baseline
Intermediate
World class
Analytical skills and insights

• Joint Strategic Needs test
• Reports analysing time-series progress toward
  PCT health status objectives

• PCT has a consistent and validated methodology
  for contributing to the JSNA
• PCT analyses progress and any gaps, identifies
  the key drivers of variance from expectations and
  develops solutions

• Does not meet baseline requirements

• PCT public health team conducts regular needs
  tests with a consistent methodology to identify
  gaps in care
• PCT prioritises major health needs for its local
  population

• PCT analyses progress towards reducing gaps and
  identifies the key causes of variance
• PCT has clear, robust segmentation of population
  by healthcare needs

Self test
Understanding of health needs trends

• Joint Strategic Needs test

• PCT has a view of unmet needs for disadvantaged
  subgroups and on an ongoing basis identifies gaps
  in care and opportunities to improve services for
  these populations
• PCT uses model to analyse progress, identify any
  gaps, identify the key drivers of variance from
  expectations, and monitor emerging trends. PCT
  uses this information to develop solutions

• Does not meet baseline requirements

• PCT has a fact-based list of the major health
  risks and priorities facing its local population
  by demographic and disease group, as identified
  in the JSNA
• Priorities are aligned with vital signs
• PCT can identify over time trends in major health
  and well being issues

• PCT has a view of unmet needs for its local
  population and can disaggregate to locality/ward
  level
• PCT uses its model to analyse progress, and
  identify any gaps

Self test
Use of health needs benchmarks

• Reports comparing local health status against
  national benchmarks
• Reports comparing local health status, vital
  signs and health deliverables relative to peer
  PCTs

• PCT benchmarks itself continuously against other
  PCTs, national and international targets on local
  health needs status
• PCT has developed plans to match the top
  performers on each benchmark and identifies the
  key capabilities it will need to develop to match
  their performance
• PCT has identified key health needs gaps

• Does not meet baseline requirements

• PCT occasionally benchmarks itself against
  national targets and other PCTs on local health
  needs status
• PCT has developed plans to improve its
  performance on each benchmark
• PCT effectively disseminates reports e.g., to
  providers, public

• PCT regularly bench-marks itself against national
  targets and other PCTs on local health needs
  status
• PCT has developed plans to improve its
  performance to meet third quartile performance on
  each benchmark

Self test
13
Competency 6 Prioritise investment according to
local needs, service requirements and the values
of the NHS
By having a clear understanding of the needs of
different sections of the local population, PCTs,
with their partners, will set strategic
priorities and make investment decisions, focused
on the achievement of key clinical and other
outcomes. This will include investment plans that
address areas of greatest health inequality.
Evidence
Below baseline
Baseline
Intermediate
World class
Predictive modelling skills and insights

• Example scenarios

• PCT staff can lead knowledgeable discussion and
  defence of all predictive models, including
  evidence to support modelling techniques and
  assumptions used
• PCT has, and effectively uses, predictive
  modelling to support its ability to target
  required interventions with precision
• PCT forecasting is based on full understanding of
  all relevant root causes, and linked with other
  public forecasts

• Does not meet baseline requirements

• PCT demonstrates simple analysis of extremes
  including best and worst case outcomes scenarios

• PCTs model conducts sensitivity analysis to
  project probable ranges by altering inputs to
  determine impact on scenario

Self test
Prioritisation of investment to improve
populations health

• Clear list of prioritisation criteria, or
  equivalent prioritisation tool or matrix
• Definition of value for money

• PCT has criteria for evaluating and prioritising
  projects and initiatives as a result of extensive
  consultation with key stakeholders, including GPs
  and other clinicians PCT managers, caregivers,
  service users and the public include criteria
  related to value for money

• Does not meet baseline requirements

• PCT has defined criteria for evaluating and
  prioritising of key initiatives, including value
  for money and return on investment
• PCT Board consults with PCT clinicians, local GPs
  and key stakeholders when evaluating strategic
  initiatives

• Value is linked directly to PCTs key public
  health objectives, such as significant reductions
  in morbidity, or the elimination of health
  inequalities

Self test
Incorporation of priorities into strategic
investment plan

• Prioritised list from last years strategic
  planning
• Current strategic plan
• Planning and budgeting cycles
• of allocation in pooled budgets
• Programme budgets

• Projects and initiatives evaluated against
  prioritisation with effective targeting of
  resources toward projects that offered the
  highest value for money
• Planning and budgeting cycles are aligned to
  facilitate coordination and joint financing
  arrangements
• Mature programme budgets for all key priority
  care pathways/ disease groups with integrated
  investment plans of up to 10 years

• Does not meet baseline requirements

• Projects and initiatives evaluated against
  prioritisation
• Some alignment between identified gaps, current
  initiatives to address those gaps, and strategic
  investment plan

• Clear and consistent alignment between identified
  gaps, current initiatives to address those gaps,
  and strategic investment plan
• PCT, local authority and other stakeholders have
  identified clear responsibility for financing
• PCT develops programme budgets demonstrating a
  whole system approach to investment

Self test
14
Competency 7 Effectively stimulate the market
to meet demand and secure required clinical and
health and wellbeing outcomes
PCTs will need to have in place a range of
responsive providers that they can choose from.
They must understand the current and future
market and provider requirements. Employing
their knowledge of future priorities, needs and
community aspirations, PCTs will use their
investment power to influence improvement, choice
and service design through new or existing
providers to secure the desired outcomes and
quality, effectively shaping their market and
increasing local choice of provision. This will
include building upon local social capital and
encouraging provision via third sector
organisations. Where adequate provider choice
does not exist, PCTs will need clear strategies
to address this need, especially in areas of
relatively poor health experience, access or
outcome
Evidence
Below baseline
Baseline
Intermediate
World class
Knowledge of current and future provider capacity
and capability

• Complete list of providers in the region
• Itemised list of spend by provider
• PBR test of providers

• PCT has identified cost and quality for each
  procedure in each area of care by HRG / tariff
• PCT has dedicated resource containing expertise
  and experience to support provider capability
  development
• PCT can demonstrate several cases where knowledge
  and influencing of provider capacity and
  capability led to noticeable improvements

• Does not meet baseline requirements

• PCT has identified a range of core providers for
  each speciality and level of care, including NHS
  providers and independent sector providers
• PCT assesses relative cost and quality of
  providers
• Uses patient feedback to gain richer
  understanding of commissioned services

• PCT has a complete and prioritised list of NHS
  providers, independent sector providers and PCT-
  or GP-organised diagnostic and treatment centres,
  third sector and social enterprise groups
• PCT assesses relative cost and quality of
  providers by disease group / care pathway

Self test
Alignment of provider capacity with health needs
projections

• Demand projections
• Capacity plans
• JSNA

• PCT takes demand projections and incorporates
  demand management assumptions from strategic plan
  (e.g., pathway redesign) to identify required
  capacity by provider type, by speciality and by
  care/patient pathway
• PCT indicates specific changes to provider
  capacity driven by needs modelling, including
  long term structural changes
• PCT understands real capacity of local providers
  and directs patient flow accordingly

• Does not meet baseline requirements

• PCT uses demand projections to project required
  capacity by speciality and matches this with
  provider capacity

• PCT takes demand projections and incorporates
  demand management assumptions from strategic plan
  
• PCT indicates specific changes to provider
  capacity
• PCT models demand and supply scenarios that can
  be varied and tested with risk test

Self test
Creation of effective choices for patients

• Capacity plans
• Patient choice metric

• PCT has clear investment/disinvestment processes
  which achieve an optimal mix of providers based
  on clinically defined cost/quality trade-off

• Does not meet baseline requirements

• PCT occasionally reviews the healthcare provision
  marketplace and identifies potential providers
• PCT investigates potential providers and examines
  both costs and quality

• PCT uses patient experience data to develop
  specification of services
• PCT has clear investment/ disinvestment processes

Self test
15
Competency 8 Promote and specify continuous
improvements in quality and outcomes through
clinical and provider innovation and configuration
PCTs are the driver of a continually improving
NHS. They seek innovation, knowledge and best
practice, applying this locally to improve the
quality and outcomes of commissioned services.
In partnership with local clinicians, PBCs, and
providers, they will specify required quality and
outcomes, facilitating supplier and contractor
innovation that delivers at best value. Through
open and effective commissioning and
decommissioning decisions, PCTs transform
clinical and service configuration, meeting local
needs and securing world class improvements in
outcomes and quality
Evidence
Below baseline
Baseline
Intermediate
World class
Identification of improvement opportunities

• Patient pathway redesign initiatives, including
  process maps and implementation plans
• of clinicians leading initiatives

• PCT and providers regularly review and agree
  clinical pathways and engage on opportunities for
  improvement and innovation
• For each pathway initiative, PCT has outlined
• A process map listing the specific
  interventions that are required at each point in
  the pathway and clear criteria for moving
  patients along the pathway
• Clinical guidelines sourced from international
  best practice
• Plans to ensure smooth patient flow along the
  pathway and between different levels of care

• Does not meet baseline requirements

• PCT demonstrates some recent examples of clinical
  pathway reconfiguration due to innovative
  initiatives led by PCT and providers
• PCT has identified a process map listing the
  specific interventions that are required at each
  point in the pathway

• PCT and providers review and agree clinical
  pathways and engage on opportunities for
  improvement and innovation
• For each pathway initiative, PCT has outlined a
  process map listing the specific interventions
  that are required at each point in the pathway
  and clear criteria for moving patients along the
  pathway

Self test
Implementation of improvement initiatives

• Example report of patient pathway redesign
• of spend shifted to new clinical pathways
• Initiative milestones

• Milestones of clinical pathway change programmes
  are actively tracked
• Initiatives demonstrate overall improvement in
  service as a result of initiatives
• Map of Medicine pathways used to inform
  improvement initiatives

• Does not meet baseline requirements

• PCT conducted a pilot of the pathway redesign and
  measured progress against objectives (e.g.
  improved quality, improved patient experience)

• Changes in clinical pathways has led to
  demonstrable changes e.g. shift in spend,
  improvement in access

Metric and self test
Collection of real time quality and outcome
information

• List of key clinical quality and outcome metrics
  for in-year and annual monitoring
• Example reports that include clinical evidence /
  international best practice

• PCT has developed strategies for monitoring the
  impacts of specific initiatives on clinical
  quality/ outcomes
• Reporting arrangements process and transmit data
  directly to key decision-makers
• PCT actively seeks out clinical evidence for
  comparison with international best practice

• Does not meet baseline requirements

• Identification of key clinical quality and
  outcome metrics to monitor
• Specified monitoring frequency and reporting
  arrangements with major providers

• Information is able to be disaggregated to
  sufficient detail to support identification of
  drivers of performance

Self test
16
Competency 9 Secure procurement skills that
ensure robust and viable contracts
Procurement and contracting processes ensure that
agreements with providers are set out clearly and
accurately with both commissioner and provider
clear about what is expected. By putting in place
excellent procurement and contracting processes,
PCTs can specify quality standards and outcomes
and facilitate good working relationships with
their providers, offering protection to service
users and ensuring value for money.
Evidence
World class
Below baseline
Baseline
Intermediate
Understanding of providers economics

• PCT can use its database to sort and extract a
  variety of metrics and bench-marks by providers
  and by disease group e.g., capacity, average
  and marginal cost and financial results.
• PCT uses target costing, i.e. forecasts service
  cost before providers supply estimate
• PCT understands the cost impact of
• Increasing activity volume through a provider
• Changing service specification
• PCT also has an ongoing process for challenging
  and disseminating the fact base of providers

• Examples of provider cost vs. quality
• Baseline reference costs

• Does not meet baseline requirements

• Understanding of
• Provider economics
• Provider market dynamics

• PCT has a database on economics of existing
  providers and performs analyses on commissioned
  or in-house providers economics
• Uses cost-benefit analysis

Self test
Negotiation of contracts around defined variables

• Examples of defined provider negotiation
  variables
• Tariff re-negotiations
• Examples of negotiation preparation

• Negotiation has successfully delivered changes to
  variables
• PCT rigorously prepares for contract negotiations
  including
• Establishing a target price
• Establishing the best alternative to a negotiated
  agreement (BATNA)
• Defining a negotiation strategy
• Defining negotiation team roles

• Does not meet baseline requirements

• Identification of negotiation variables e.g.,
  cost, quality
• Competitive tendering forall new services in
  excess of 2m

• PCT explicitly uses negotiation variables

Self test
Creation of robust contracts based on outcomes

• Example contracts
• contracts in place on time (ALE metric)

• 100 of contracts include clearly specified,
  measurable, and practical outcomes and quality
  metrics, with a transparent arbitration process
• Clinicians are involved in review and
  finalisation of contracts
• Specific measurable performance improvement
  targets are jointly agreed
• Contract incentives drive desired provider
  performance which results in health improvements

• Does not meet baseline requirements

• All elective and non-elective acute existing
  contracts include clearly specified outcomes and
  quality metrics, with a transparent arbitration
  process, including ISTC
• All newly negotiated contracts are based on
  desired outcomes and service quality with defined
  performance improvement targets
• All contracts agreed and signed by 1st April

• Outcome and quality targets are an explicit part
  of all negotiations and are incorporated in
  contracts
• gtX existing contracts include clearly specified
  outcomes and quality metrics, with a transparent
  arbitration process, including ISTC

Self test
17
Competency 10 Effectively manage systems and
work in partnership with providers to ensure
contract compliance and continuous improvement in
quality and outcomes and value for money

Commissioners will need to manage their
relationships and contracts with providers in
order to ensure that they deliver the highest
possible quality of service and value for money.
This will involve working closely with providers
to sustain and improve provision, engaging in
constructive performance discussions to ensure
continuous improvement. Commissioners will need
to ensure that their providers understand and
promote the values of the NHS.
Evidence
World class
Below baseline
Baseline
Intermediate
Use of real time performance information

• Examples of provider performance reports /
  comparative scorecards
• Example of public dissemination of performance
  information

• Ownership and management control of data is
  clearly defined
• Data is proactively shared with providers to
  drive fact-based continuous improvement in
  quality and outcomes
• Data is readily available and actively managed
• Data supports key performance indicators across
  all domains (clinical quality, access, etc)
• Performance information is available for and
  accessible to the pubic

• Data is shared with providers when requested
• Data is accessible and used to monitor provider
  performance

• Data is proactively shared and discussed with
  providers
• Data is accessible and actively managed
• Data supports key performance indicators

• Does not meet baseline requirements

Self test
Implementation of regular provider performance
discussions

• Provider reports performance tracking
• Comparative scorecards
• Meeting minutes

• Regular reports addressing performance of major
  providers, acute care, primary and community care
  and social care
• Quarterly performance discussions with key
  providers
• Annual performance improvement discussions

• Continuous performance improvement discussions
  leading to demonstrable change
• Ongoing provider capability building through
  sharing of international best practice
• PCT clearly defines responsibility for the
  performance management interface for each supplier

• Quarterly performance improvement discussions
• Performance tracking for all providers, segmented
  by type

• Does not meet baseline requirements

Self test
Resolution of ongoing contractual issues

• Breach of contract escalation guidance, including
  formal arbitration
• Example contracts with defined governance
  framework
• Example interventions

• Contracts indicate when intervention is required
• Contracts ensure PCT can intervene when necessary
• Non-compliance with contracts is investigated

• Strict, pro-active contract compliance management
  with all providers
• Actionable next steps for improvement are agreed,
  with assigned leads, time frames and milestones
• Required improvements are delivered

• Contract compliance management with major
  providers
• Actionable next steps for improvement are agreed
• Improvement plans are actively monitored and
  tracked

• Does not meet baseline requirements

Self test , metrics
18
3. Governance Assessment will address four
questions
Question
Assessment methodology

• Is there a coherent strategy in place that will
  deliver quality and health outcomes?

• Panel review of Strategic plan

• Is the strategy underpinned by a long term
  financial plan?

• Panel review of long term Financial plan

• Does the organisation have controls in place to
  know what is going on?
• Is the organisation developing talent and
  capability to support organisation development?

• Board self certification
• Panel review to verify certification

Adding years to life and life to years
19
There are 4 methods of assessment that will be
utilised
Description
Adding years to life and life to years
20
Sample output for a PCT
PCT XXXXX Review Date XXXX
3 yrs
Now
Governance
Health outcomes and quality
Competencies
A
Outcomes measures chosen from vital signs by PCT
Improvement of outcomes are quantified
Metrics and assessments aggregate to give an
overall rating
10
0

• Stroke
• CVD
• Cancer
• Life expectancy
• Inequality
• Obesity
• Choice
• 18 weeks
• LTCs
• MRSA

3

• Local leader of NHS
• Collaborates with partners
• Engagement
• Clinical leadership
• Assess needs
• Prioritisation
• Stimulates provision
• Innovation
• Procurement and contracting
• Performance management
• Investment

7
5
2
10
8
7
23
Historic performance and improvement could also
be shown as well as UK average
6
12
Adding years to life and life to years