PCT Fitness for Purpose: Liverpool Board to Board document

1
PCT Fitness for Purpose Liverpool Board to
Board document
Board to Board Document 8a
CONFIDENTIAL
Discussion document
22 June 2006
This report is solely for the use of client
personnel. No part of it may be circulated,
quoted, or reproduced for distribution outside
the client organisation without prior written
approval from McKinsey Company. This material
was used by McKinsey Company during an oral
presentation it is not a complete record of the
discussion.
2
CONTENTS
Summary Financial assessment Non-financial
assessment Diagnostic Next steps Appendix
3
FINANCIAL ASSESSMENT OVERVIEW
Score Likelihood of failureover next 612 months
R
High
A
Medium
G
Low
Overall financial rating
Key issues identified
Overall score
Achievement of plan
G

• Strong and consistent delivery on past budgets
  and on cost improvement programmes

Future performance
G

• Financial balance is almost certain in 06/07
  through 08/09, with large explicit surpluses in
  07/08 and 08/09, strong financial control, and
  deep potential buffers and reserves

G
Source PCT financial assessment template, team
analysis
4
NON-FINANCIAL ASSESSMENT OVERVIEW
Score Likelihood of failureover next 612 months
R
High
A
Medium
G
Low
Key issues identified
Overall score
Operational framework

• Further work is needed around outpatient waits
  and AE waiting targets

Notscored
Governance
A

• No process for prioritising targets
• Has not complied with public sector prompt
  payments policy
• Lack of emphasis on clinical quality and patient
  experience
• Relative lack of workforce planning

Strategy
A

• Lack of emphasis on clinical quality and patient
  experience
• Absence of detailed value for money analysis
• Lack of plans around key enablers, e.g. IT, human
  resources

Relationship management
G

• Does not involve local service users in deciding
  priorities
• Does not seek service user views on quality of
  services

Emergency planning

• No major issues identified

G
Source PCT non-financial assessments, team
analysis
5
DIAGNOSTIC KEY POINTS

• Liverpool PCT faces two sets of challenges and
  development needs, focused around commissioning
  strategy and organisation
• On commissioning strategy, the PCT has three key
  needs
• Improved demand management, particularly around
  planned care (e.g. referral management) and
  unplanned care (e.g. a more robust AE deflection
  strategy)
• Operational strategy for upgrading primary care
  in a specified timeframe, aimed at securing
  consensus around ambitious and specific plans to
  improve infrastructure and services
• Managing secondary providers, including strategic
  procurement and the development of monitoring and
  validation procedures to enable better control
  under PbR
• On organisation, the PCT also has three key
  needs
• Rationalisation, systematisation and
  formalisation of plans, policies and procedures
  to improve transparency, consistency and
  communication, particularly between top and
  middle management
• Operationalisation, in terms of systematically
  translating visions and strategies into
  operational plans with clear targets, timelines,
  interventions, budgets and lines of
  accountability for each specific initiative
• Management restructuring, to seize the
  opportunities that consolidation presents to
  improve the skill mix and overall effectiveness
  of PCT team

Source PCT diagnostic central team and lead
diagnostician discussion
6
22
OVERVIEW OF IE BENCHMARKS
Areas significantly out of line with hub average
/Weighted Population
2005/06
2007/08
Hub average
Difference
Hub average
Difference
Liverpool
Liverpool
Net financial position
0.6
-138
29.9
60
-1.5
18.7
Total income
1,194.2
-3
1,400.3
-1
1,229.6
1,416.0

• Recurring

1,194.3
12
1,400.3
-1
1,067.7
1,410.1

• Non-recurring

-0.1
-100
0
-100
27.0
-1.6

• Other

0
-100
0
-100
6.0
7.5
Total costs
-1,193.6
3
-1,370.4
2
-1,230.0
-1,397.8

• Commissioning

-1,138.7
4
-1,315.9
1
-1,180.6
1,326.7

• Primary

-271.1
13
-321.3
11
-310.3
-360.1

• Secondary

-424.0
15
-450.8
14
-497.0
-523.9

• Community/Intermediate

-97.1
14
-111.5
19
-113.3
-138.5

• Mental Health

-172.4
-19
-233.1
-40
-144.4
-167.1

• Tertiary

-163.8
-67
-173.3
-49
-97.8
-116.4

• Direct provision

-108.6
4
-109.6
16
-112.8
-131.2

• Other

-54.9
-11
-54.5
23
-49.4
-71.2
Based on 10 hub PCTs Note All figures
given in absolute 2005/6, based on age/needs
weighted population figures provided by PCTs
Source PCT financial assessment template, team
analysis
7
CONTENTS
Summary Financial assessment Non-financial
assessment Diagnostic Next steps Appendix
8
SUMMARY OF FINANCIAL ASSESSMENT
Discussion

• PCT has delivered on financial plans in both
  04/05 and 05/06, including CIPs
• Has comprehensive plans to reallocate spending
  from existing lines where necessary to manage
  risk is highly likely to maintain financial
  balance in the foreseeable future

Overall financial rating
Financial criteria
Rating
Metric used
PCT score
G
gt0
IE surplus distance from planned target
0.0 (04/05) 0.0 (05/06)
Achievement of plan
PCT is well insulated from financial risk and is
likely to maintain balance for the foreseeable
future
gt0.5
Normalised risk-adjusted IE surplus margin
0.7 (06/07) 3.3 (07/08)
Future perfor-mance
Measured in percentage points of total income
from target margin percentage Defined as cash
plus trade debtors minus trade and other
creditors and accruals, expressed as a number of
days operating expenses covered, for
2006/07 Source PCT financial templates team
analysis
9
ACHIEVEMENT OF PLAN
0.50
IE surplus (including brokerage) as percentage
of total income
Achievement of plan rating
Target was achieved with 57K in surplus
G
Outturn
Target
Solid financial performance relative to targets
Target was achieved with 380K in surplus
0
Outturn
0
Target
Source PCT financial templates team analysis
10
UNDERLYING FUTURE PERFORMANCE
51.7
Note Surpluses/deficits reflect PCTs ability to
absorb risk and do not necessarily reflect extra
cash
IE surplus, 2005/06 to 2008/09, m
Base case
Assessor risk adjustments
Assessor case (normalised position)

• Secondary care activity growth between 05/06 and
  06/07 revised upward from 0.6 to 3 as midpoint
  between highly ambitious projections and
  historical growth rates
• Prescribing growth in 06/07 revised upward from
  3.6 to 9 as per CMHA guidelines
• Reduction in CPM projections to account for
  diagnostic findings on care pathway management
• Recognition of risk-mitigating resources
  identified by Director of Finance

Normalised
Net
2005/ 06
2006/ 07
2007/ 08
2008/ 09
2005/ 06
2006/ 07
2007/ 08
2008/ 09
of total income
0.0
0.0
2.1
3.1
0.0
0.7
3.9
5.6
Future performance rating
G
Average adjusted IE margin for 06/07 and 07/08
is 2.4
PCT has included cost of achieving 18-week
target in its base case Note Surpluses/deficits
have been carried forward to obtain assessor case
numbers Source PCT financial assessment
template, team analysis
11
SHORT-TERM TRANSITION MAP, BASE CASE
1.0
IE, 2005/06 to 2006/07 , millions
13.8 million of this is accounted for the
incorporation of dentistry spend (7 million,
matched by rise in income) and other primary
costs (6.7 million)
Annual growth rate assumptions are linked to
investment plans, but money could probably be
re-allocated in the event of financial distress
1.7
1.2
This estimate appears to be unrealistically low
PCT explains it is trying to freeze activity it
receives a bonus from PbR (local price is above
tariff) PBC will hold in place but the
estimate remains too low
Given the relatively low scores for secondary
care demand management in the diagnostic, this
number will be adjusted downward
0.4
0.4
3.1
1.0
0
-1.0
Increase in primary care costs
Increase in com-munity/ inter-mediate care costs
Increase in other costs
Normal-ised position, excluding demand
manage-ment initiatives y/e 2006/07
Cost reduction from care pathway and other demand
manage-ment initiatives
Normalised result, y/e 2006/07
Net income adjust-ment
Norma-lised result, y/e 05/06
Increase in baseline secondary activity
Increase in tertiary and other commis-ioned
activity
Increase in Mental Health costs
Net result, y/e 05/06
Increase as of 2005/06 spend/ allocation
category
6
10
7
0
1
8
17
Source PCT financial assessment template
12
LONG-TERM TRANSITION MAP, BASE CASE
17.9
IE, 2005/06 to 2007/08 , millions
18.5 million of this is accounted for by
increases in prescribing (10.8 million) and
dentistry (7.6 million)
Annual growth rate assumptions are linked to
investment plans, but money could probably be
re-allocated in the event of financial distress
Given the relatively low scores for secondary
care demand management in the diagnostic, this
number will be adjusted downward
4.6
17.9
15.8
3.6
2.0
0
0.4
Increase in primary care costs
Increase in com-munity/ inter-mediate care costs
Increase in other costs
Normal-ised position, excluding demand
manage-ment initiatives y/e 2007/08
Cost reduction from care pathway and other demand
manage-ment initiatives
Normalised result, y/e 2007/08
Net income adjust-ment
Norma-lised result, y/e 05/06
Increase in baseline secondary activity
Increase in tertiary and other commis-ioned
activity
Increase in Mental Health costs
Net result, y/e 05/06
Cumulative annual growth rate from total 2005/06
spend/ allocation category
8
8
7
3
2
4
18
Source PCT financial assessment template
13
ANALYSIS OF PCT AND ASSESSOR CASE ASSUMPTIONS
INCOME AND ALLOCATION
Assessor case,
PCT base case growth,
2005/06 to 2006/07
2006/07 to 2007/08
2007/08 to 2008/09
2005/06 to 2006/07
2006/07 to 2007/08
2007/08 to 2008/09
Assessor commentary
Recurrent allocation
No changes made
7.2
8.3
6.5
-
-
-
Non-recur-rent allocation
No changes made
-279.2
-100.0
-
-
-
-
Other income
-
-
No changes made
-
-
-
-
Source PCT financial assessment template,
team analysis
14
ANALYSIS OF PCT AND ASSESSOR CASE ASSUMPTIONS
COSTS
Assessor case,
PCT base case growth,
2005/06 to 2006/07
2006/07 to 2007/08
2007/08 to 2008/09
2005/06 to 2006/07
2006/07 to 2007/08
2007/08 to 2008/09
Assessor commentary
Primary care costs
Prescribing costs have been adjusted to SHA
guidance
10.0
6.7
5.9
X.X
X.X
X.X

• GP costs

1.9
6.5
3.1
X.X
X.X
X.X

• Prescribing costs

3.8
9.0
9.0
9.0
X.X
X.X

• Dentistry

50.8
2.6
2.4
X.X
X.X
X.X

• Other primary care

43.5
0.1
3.3
X.X
X.X
X.X
Community intermediate spend
No changes made
6.8
6.5
5.5
X.X
X.X
X.X
Baseline secondary care costs
Projected baseline growth in 05/06 is
unrealistically low revised upward to 3
0.6
5.3
9.9
3.0
X.X
X.X
Tertiary care costs
No changes made
1.2
3.4
14.5
X.X
X.X
X.X
Mental health LD costs
No changes made
15.0
27.1
4.5
X.X
X.X
X.X

• MH commissioning

18.7
33.7
4.6
X X
X X
X.X

• LD commissioning

3.6
4.4
3.9
X.X
X.X
X.X
Other commissioning
No changes made
20.0
2.6
2.7
X.X
X.X
X.X

• Continuing care

60.9
5.4
5.4
X.X
X.X
X.X

• Other

7.6
1.4
1.5
X.X
X.X
X.X
Other PCT costs
No changes made
-2.1
0.4
-2.7
X.X
X.X
X.X
Including FMS, PMS, Out of Hours, other MS,
etc. Source PCT financial assessment template,
team analysis
15
ANALYSIS OF PCT AND ASSESSOR-CASE ASSUMPTIONS
DEMAND MANAGEMENT
Assessor case, cost reduction on previous year-
end forecast
Commentary on measures planned or taken
Activity, reduction on previous year-end
forecast
Cost, reduction on pre-vious year-end forecast
2007/08
2008/09
2006/07
2007/08
2008/09
2006/07
2006/07
2008/09
2007/08
x.x
x.x
x.x
x.x
x.x
x.x
Diagnostic score 1 on CPM suggests plans
should be adjusted downwards by 50
x.x
x.x
x.x
x.x
x.x
x.x
Source PCT financial assessment template
16
IMPACT OF ASSESSOR-CASE ADJUSTMENT
9,826
2006/07, m
5.7
5.2
-0.5
0
0
Normalised base-case surplus, 2006/07
Changes in income
Changes in costs
Changes in care pathway management
Normalised assessor-case surplus, 2006/7
2007/08, m
32.9
-0.5
10.3
23.1
0
Changes in care pathway management
Normalised assessor-case surplus, 2007/08
Normalised base-case surplus, 2007/08
Changes in income
Changes in costs
Source PCT financial assessment template, team
analysis
17
SUMMARY OF ADJUSTMENTS (PCT AND ASSESSOR)
Identified by PCT for 06/07, grown at
allocation growth rates in 07/08 and
08/09 Source LDPs PCT diagnostic inputs PCT
financial assessment template team interviews
and analysis
18
CONTENTS
Summary Financial assessment Non-financial
assessment Diagnostic Next steps Appendix
19
NON-FINANCIAL ASSESSMENT (1/2)
5
Rating
Self-score
Hub average
Assessor case
Gaps identified by PCT
Adjustments

• Does not prioritise targets
• Lack of emphasis on clinical quality
• Lack of workforce planning
• Has not complied with public sector prompt
  payments policy

• No adjustments

A
A
A
Governance

• Lack of emphasis on clinical quality and patient
  experience
• Absence of detailed value for money analysis
• Lack of plans around key enablers, e.g. IT, HR

• No adjustments

A
A
A
Strategy

• Movement of some questions into Governance raises
  RM score

• Does not involve local service users in deciding
  priorities
• Does not seek service user views on quality of
  services

Relationship Management
G
G
A

• No adjustments

• No issues identified

Emergency Planning
G
G
G
NW averages calculated as average of assessor
scores for 10 participating PCTs Source PCT NFA
submissions team analysis
20
NON-FINANCIAL ASSESSMENT (2/2)
Category
Question
2005/6 Q4 performance
Scoring
86.5
Percentage of patients waiting lt62 days from
urgent referral to treatment
Cancer waits
R
98.2
Percentage of patients waiting lt31 days from
diagnosis to treatment
G
0
Inpatients waiting six months (26 weeks) or more
(absolute number)
General waiting lists
G
R
1
Outpatients waiting three months (12 weeks) or
more (absolute number)
G
100
Patient choice
Percentage of patients referred offered a choice
of at least 4 providers
7
Percentage outpatient bookings made using Choose
and Book
95.8
AE
Percentage of patients meeting 4 hour maximum
wait in AE
R
Source CMHA data, team analysis
21
HEALTHCARE COMMISSION QUALITY FRAMEWORK
TBD
22
CONTENTS
Summary Financial assessment Non-financial
assessment Diagnostic Next steps Appendix
23
DIAGNOSTIC SYNTHESIS
PCT rating
Needs significant improvement
Meets minimum standards
Good to best practice
Below typical capabilities
Above typical capabilities
Strategic planning

• Primary care strategy and configurations require
  significant development to address major capacity
  challenges
• Lack of clear processes for identifying
  priorities and ranking them on the basis of value
  for money
• Practice-based commissioning requires rapid
  development
• Clinical quality and patient experience need to
  be integrated into planning

• Strong and accurate capacity planning for
  secondary care
• Strong patient and public involvement
• Good public health data and analysis
• Clear vision for core management team

Care pathway management

• Need to develop key demand management levers,
  particularly in planned referrals and unplanned
  and emergency attendances, and monitor to ensure
  that initiatives deliver impact at sufficient
  scale
• PBC has not yet been set up in a way that will
  permit it to deliver outcomes effectively

• Commitment to long-term condition management,
  case management, and intermediate care

Provider management

• Strategy for upgrading and modernising primary
  care in Liverpool requires greater operational
  detail
• PCT lacks negotiating objectives around clinical
  quality and patient experience metrics

• Relatively assertive stance on negotiating
  objectives, particularly with secondary care
  providers

Monitoring

• PCT does not have a clear escalation process for
  financial / volume and quality variances.
• Relatively under-developed clinical coding and
  clinical quality audit agenda.
• Contracts lack process for monitoring adherence
  to defined clinical quality standards.

• Well resourced information function.
• PCT has already assessed and identified
  development issues.

Source PCT diagnostic, team analysis
24
CONTENTS
Summary Financial assessment Non-financial
assessment Diagnostic Next steps Appendix
25
DIAGNOSTIC NEXT STEPS

• Liverpool PCT faces two sets of challenges and
  development needs, focused around commissioning
  strategy and organisation
• On commissioning strategy, the PCT has three key
  needs
• Improved demand management, particularly around
  planned care (e.g. referral management) and
  unplanned care (e.g. a more robust AE deflection
  strategy)
• Operational strategy for upgrading primary care
  in a specified timeframe, aimed at securing
  consensus around ambitious and specific plans to
  improve infrastructure and services
• Managing secondary providers, including strategic
  procurement and the development of monitoring and
  validation procedures to enable better control
  under PbR
• On organisation, the PCT also has three key
  needs
• Rationalisation, systematisation and
  formalisation of plans, policies and procedures
  to improve transparency, consistency and
  communication, particularly between top and
  middle management
• Operationalisation, in terms of systematically
  translating visions and strategies into
  operational plans with clear targets, timelines,
  interventions, budgets and lines of
  accountability for each specific initiative
• Management restructuring, to seize the
  opportunities that consolidation presents to
  improve the skill mix and overall effectiveness
  of PCT staff

Source PCT diagnostic central team and lead
diagnostician discussion
26
CONTENTS
Summary Financial assessment Non-financial
assessment Diagnostic Next steps Appendix
27
DIAGNOSTIC STRATEGIC PLANNING (1/5)
Sub-section
Strengths
Development needs
Evidence

• Can provide high levels of detail in financial
  reporting

• Interview with Director of Finance

• In Board reports, need to link activity to
  finance more clearly
• Need to provide a full set of primary financial
  statements

• Clear focus on health needs and inequalities in
  population

• Interview with Director of Public Health

• Work more closely with primary care independent
  contractors on public health

Health review
2

• Interview with Director of Commissioning,
  Director of Patient Services

• Need to develop a consistent corporate view
  around levels of clinical quality in commissioned
  services
• Need to improve reporting and review systems
  around these standards

Quality review
3

• Interview with Director of Public Health,
  Director of Commissioning, Director of Patent
  Services

• Develop a more structured approach toward
  collecting and utilising patient experience data
  in secondary care and mental health

Patient experience review
4

• Interview with Director of Commissioning

Progress review
5

• Interview with Director of Commissioning, Deputy
  Chief Exec, Director of Finance

• Good at developing clear strategies for
  partnership working with local authority and
  stakeholders

• Need to operationalise and implement strategies
  with clear timelines and lines of accountability

Engagement with local authority
6a
Source Team analysis
28
DIAGNOSTIC STRATEGIC PLANNING (2/5)
Sub-section
Strengths
Development needs
Evidence

• Have strong structure and processes for clinical
  engagement

• Need to monitor effectiveness and perceptions of
  outreach e.g. clinician satisfaction
• Need to review and develop relationships with LMC

• Interview with LMC, Director of Nursing, PEC Chair

• Interview with Head of Community Involvement

• Have good structures to engage the public and
  feed in patient views to public health and
  commissioning

Patient public involvement
6c

• Need to develop transparent process for including
  directorates in planning
• Need to communicate more effectively about
  prioritisation

• Interview with Deputy Chief Executive

• Strong control around developing common agenda

Integration of insights
7
Pop. health goals
8

• Strong and detailed grasp of population needs

• Interview with Director of Public Health

• Need to ensure that quality goals cover all
  levels of care commissioned and provided,
  particularly secondary and mental health

• Interview with Director of Patient Services,
  Director of Commissioning

Quality goals
9

• Interview with Head of Community Involvement,
  Director of Commissioning

• Have developed effective local networks to engage
  patients around patient experience

• Need to draw upon work in primary care to develop
  clear goals and incentives around patient
  experience in secondary care and mental heatlh

Patient exp goals
10
Source Team analysis
29
DIAGNOSTIC STRATEGIC PLANNING (3/5)
Sub-section
Strengths
Development needs
Evidence

• Need to develop view on how quality and pathways
  need to evolve
• Need long-term view and operational strategy for
  how and where primary care will be delivered and
  on PBC
• Need to engage stakeholders in developing
  vision, particularly at primary care level

• Interview with Director of Finance

• Clear quantitative view on how provision needs to
  change in next 10 years

• Very strong secondary care activity projection
  model

• Need to supplement bed-based modeling with more
  detail around specific conditions

• Interview with Director of Finance, Director of
  Commissioning

Forecast demand for services
12a

• Need to identify, prioritise and operationalise
  specific opportunities to manage demand more
  effectively
• Need to define role of PBC in care pathway
  management
• Need to define what capabilities are needed to
  implement CPM effectively

• Interview with Director of Commissioning, Head of
  Primary Care

Care pathway management strategies
12b

• Interview with Director of Commissioning, Head of
  Primary Care

• Primary care capacity plans need to be linked to
  population access needs and gaps relative to
  existing capacity, then translated into an
  operational estates strategy
• Need to work with practices to assess and develop
  strategies to increase practice productivity
• Need to assess implications of practice-based
  commissioning for primary care capacity

• Clear operational distinction between provider
  and commissioning arms

Capacity planning primary care
13a
Source Team analysis
30
DIAGNOSTIC STRATEGIC PLANNING (4/5)
Sub-section
Strengths
Development needs
Evidence

• PCT has identified key future risks and actively
  worked to shape and modify provider aspirations
  and plans

Capacity planning secondary care
13b

• Interview with Director of Finance

• Need to receive better activity data from
  providers, particularly around community care
  provision

• Interview with Lead Mental Health Commissioner

Capacity planning mental and other
13c

• Contracts need to specify outcomes around
  clinical quality and patient experience

• Interview with Director of Finance

• Clear view of require-ments, linked through to
  LDP and individual contracts

Develop contracting strategy
13d

• Need to identify key metrics around clinical
  quality

• Interview with Director, IMT

• Have defined clear metrics to monitor around
  finance and public health and patient experience

Identify key metrics
14a

• Need to cultivate expertise around monitoring for
  PbR

• Interview with Director, IMT

• Have developed required structures and resources

Develop monitoring strategy
14b

• Interview with Director of Finance

• Have integrated public health and linked plans to
  LDP

Ensure plans are comprehensive
15

• Interview with Director of Finance, Director of
  Commissioning

• Need to develop clear definition and process for
  evaluating value for money
• Need to develop a formal process or standards for
  prioritisation

Prioritisation
16
Source Team analysis
31
DIAGNOSTIC STRATEGIC PLANNING (5/5)
Sub-section
Strengths
Development needs
Evidence

• Interview with Director of Commissioning,
  Director of Finance

• PCT participates in SHA plans for shared services

Outsourcing and partnership
17

• Interview with Director of Commissioning,
  Director of Finance

• Need to take account of practice-based
  commissioning

• Highly detailed and comprehensive budgeting
• Well linked to capacity plans

Annual budget
18a

• Interview with Director of Commissioning,
  Director of Finance

• Need to develop clear process for identifying and
  escalating financial risks (e.g. variances above
  a certain tolerance)
• Need to develop contingency plans for addressing
  in-year imbalances

• Aware of key risks in the system

Contingency plans
18b
Source Team analysis
32
DIAGNOSTIC CARE PATHWAY MANAGEMENT (1/2)
Sub-section
Strengths
Development needs
Evidence

• Need to develop strategies of sufficient scale to
  manage referral demand
• Need to develop systematic plans for
  implementation with timelines and clear targets

• Interview with Director of Commissioning, Planned
  Care Lead

• Evidence of plans to manage referrals

Referral management
1

• PCT has experimented with diverse strategies to
  manage AE attendance

• Need to build evidence-based approach to
  understand and address key drivers of AE
  attendance
• Need to evaluate current AE mitigation measures
  to assess effectiveness and value for money

• Interview with Director of Commissioning, Urgent
  Care Lead

Optimise AE / emergency care
2

• Need to develop clear targets and monitoring
  strategies to evaluate comprehensively the
  effectiveness of programs

• Interview with Director of Commissioning,
  Director of Nursing

• Have made a commitment and investment to
  long-term conditions, with funding and training

Manage long-term conditions
3
Case management
4

• Have done a needs assessment of intermediate care

• Interview with Director of Commissioning,
  Director of Nursing, Older Peoples Services

• Need to develop clear targets and monitoring
  strategies to evaluate comprehensively the
  effectiveness of programs

Intermediate care
5

• Have earmarked funding for patient pathway
  redesign

• Interview with Director of Commissioning, Planned
  Care Lead

• Need to clearly map and document patient pathway
  changes
• Need to develop financial and clinical view of
  priorities for pathway redesign

Patient pathway redesign
6

• Have undertaken initial scoping and specification
  around diagnostics strategy

• Need to accelerate specification process and
  implement strategy

Diagnostics
7

• Interview with Director of Commissioning, Planned
  Care Lead

Source Team analysis
33
DIAGNOSTIC CARE PATHWAY MANAGEMENT (2/2)
Sub-section
Strengths
Development needs
Evidence

• Interview with Director of Public Health,
  Director of Commissioning

• Clear understanding of local needs and health
  inequalities

Health improve-ment, protection and equity
8

• Interview with Director of Commissioning

• Solid information base and monitoring

• Need to clearly identify how PCT will use PBC to
  deliver on key objectives
• Need to operationalise PBC in a detailed
  governance plan, including clear view on
  incentives
• Need to demonstrate commitment to PBC through
  engagement with practices

Practice-based Commissioning
9
Source Team analysis
34
DIAGNOSTIC PROVIDER MANAGEMENT (1/1)
Sub-section
Strengths
Development needs
Evidence

• Good fact base under development with
  tablecloth system

• Need to improve fact base on provider economics
• Need to develop clear strategy and negotiating
  objectives for primary care
• Need to find more effective ways of engaging with
  practices and building relationships

• Interview with Director of Commissioning, Head of
  Primary Care

Primary care
1

• Strong capacity planning
• Assertive negotiating stance with trusts
• Have cultivated contestable market

• Need to improve fact base on provider economics
• Need to broaden negotiating objectives beyond
  high-level volumes and affordability (e.g.
  clinical quality and patient exp)

• Interview with Director of Commissioning,
  Director of Finance

Secondary care
2

• Basic data and some comparative detail available

• Director of Adult Social Services, Head of Older
  Peoples Services

• Need more data to aid in the commissioning process

Social care
3

• Participation within N. Mersey partnership has
  delivered good results

• Need to prepare negotiating objectives and
  strategies around key dimensions, such as
  clinical quality and patient experience

• Interview Mental Health joint commissioner

Mental health
4
Source Team analysis
35
DIAGNOSTIC MONITORING (1/2)
Sub-section
Strengths
Development needs
Evidence

• Well resourced info department with clear
  reporting processes.

• Need to develop formal escalation processes with
  clear tolerances, parameters and timelines

• Interview with Director, IMT

• Interview with Director of Finance

• PCT has strong track record of delivering
  financial balance and a culture focussed on
  financial control

• Need to develop formal escalation with
  prioritisation of exceptions and recording in
  risk register

Monitoring financial balance
2

• Clear awareness that PCT needs to operate in PbR
  environmentt has identified appropriate
  resources and aspirational changes to processes

• Implement plans to refocus clinical coding
  resources on auditing as opposed to training.
• Translate aspirations on invoice review into
  monthly close down procedure with escalation.
• Continue reviewing services commissioned in and
  out of PbR to prevent duplicate payment.

• Interview with Director of Finance

Invoice review and adjudication
3-7

• Interview with Director, IMT

• Need to strengthen connection between activity
  monitoring and financial performance in board
  reporting and financial variance escalation
  procedures

• Strong information base for monitoring contract
  performance
• PCT has made progress on reconciling activity
  with providers

Activity volumes
8

• Strong performance monitoring and ability to
  model capacity volume impact on waiting times

• Interview with Director, IMT

• Further develop model to incorporate impacts of
  new initiatives, e.g. diagnostics capacity
  development

Care and service levels
9
Source Team analysis
36
DIAGNOSTIC MONITORING (2/2)
Sub-section
Strengths
Development needs
Evidence

• Good evidence of consistently collecting evidence
  from patients

• Needs to extend scope to all services
• Patient satisfaction information should be fed
  into service redesign

• Interview with Director of Commissioning

Patient satisfaction
10

• Need to implement individual primary care
  provider reports.
• Commission independent audit of secondary care
  quality and /or direct priority areas for
  secondary care providers own audits.
• Develop central database for monitoring quality
  of outcomes.

• Interview with information and primary care
  commissioner

• Tablecloth report for primary care services.

Quality of outcomes
11

• Develop central database
• Define clinical standards that PCT requires to be
  delivered within contracts and structure for
  monitoring delivery of these
• Systematically review implementation of above
  standards in clinical policy group

• Interview with Director of Patient Services,
  Director of Nursing.

• Clear processes for verifying credentials of
  providers / CRB checks.

Clinical processes
12

• Interview with Director of Public Health

• Need to improve linkages to commissioning
• Lots of talented staff, but they need to
  demonstrate evidence of greater impact

Health status outcomes
13
Source Team analysis