Transforming Planned Care – some ideas and some evidence

“Transforming” “planned care”


Once a month, I’m asked about “how to transform planned care”

I thought I’d better write a stock answer to the question. It’s below

Its not easy, nor is it straightforward. Nor do I pretend that the below is the nirvana answer. Furthermore Im under no illusions that I have the “right” answer. Other views are equally valid.


1          System vs commissioner

Done be “commissionery”………..I’d reckon doomed unless clear and central input from sec care clinicians as well as prim care clinicians (with their provider hat on)…. It’s there where the detailed knowledge of how system really works is + where the skeletons are hidden

Don’t turn it into a “commissioner led exercise” (the levers are too weak) But about the “how we build a better system”


2          where do you look

With all it’s weaknesses, the PB data is as good as you will get to guide relative spend, and the SPOT tool ditto to guide relative outcomes.

Off the cuff areas

Topics – the road specialties principally planned care stuff, or where high volume of LTC outpatient appointments – these are the areas that “make cash” for the hospital.

However – remember that the hospital still has bills to pay (mostly staff) – so if CCG cutting down flow into planned care through policies, pathways and other – and the staff bill remains – then the provider WILL find the cash in other ways,


2a        Don’t forget the RCS tools and policies……

Some great stuff in there

Data and RCS led policies and advice.


2b       don’t waste too much time on “procedures of limited clinical value”

Its largely wasted time

See points made in Bhatia – and especially Schwartz

So act strategically as a PAYER and either set price for procedure, for bundle of care or total volume of care for a population of patients – and hold people to that price with contracting method. Make the clinicians feel the need to look for value and transfer the responsibility to them.


2c        don’t invest in “referral management” centres.

There’s decent evidence they add cost but make no difference

There is a decent evidence review on “managing demand” from Sheffield.

Read it, understand it, act accordingly.

There IS scope, significant scope, for more nuanced approaches say involving audit, feedback and education – both one to one academic detailing for a practice and wider mass education events. This is largely untested evidence wise in THIS context, but plenty of evidence from the wider QI literature.


3          Tools to focus on VALUE (and I use that term advisedly)

  1. a) Programme level tools

PBMA (I know you hate it) analysis (from provider perspective I’d suggest) so we have a collective grip on spend in the areas of focus and some analysis to guide investment and or disinvestment options


  1. b) System level tools

Use if STAR or similar to highlight where volume, cost and outcome may not be optimally distributed. For example – use of STAR in management of OA or RA?

If there is a will to really focus in on a specific area. Is best lent to system level (RA) than programme level (MSK). These tools are intended principally to guide a decision and a process, rather than the decision itself


  1. c) the “general lock in method” (© Fell 2013)



4          If you are really serious

Factory surgery

Eg Bradford does O&T, CHT does opth, MYT does gynae etc etc

I would reckon a step too far? And complex to deliver. Certainly been some discussion about it at leaders meetings locally.


5          I would reckon might be some mileage in considering the notion of supply induced demand

Ie if I’ve got 12 Orthopod salaries to pay in my hospital with catchment of 400,000….I’m going to get them to find ways of getting to old ladies with gammy knees to fix….and will be more inclined to do this that if I only had 6 Orthopod salaries to pay in same catchment

Plenty of evidence of this – tho mostly all anecdotal… v v hard to come by…..

But be minded it’s a multi year journey


6          Contacting models

Prime contractor (or some such) as a method of contractualising. Tho this is more about culture than contract I suspect. See appendix.Impprtant to note that this is no panacea, nor is it easy work.


Appendix – Dianne Bell (COBIC) on MSK prime contractor (notes I took at a conference)

“Don’t manage people but change the way they think”


Language people use creates reality

Use the terms system programme pathway

Consistently Over a long time

And it creates reality………


Change the currency of commissioning

OP FU ratio Contract over trading Etc etc



Clinician view

Talk to docs who provide MSK care

What do they think

What are the issues and good points



Talk to patients

Start with customer experience


System and commissioner view




Currently no focus on value (outcome AND cost)

Financial view

No new money

What is the cash envelope




Functional improvement and ability to live the life that patients want to lead.

Outcomes at all levels

  • System
  • Institution
  • Clincial
  • Patient



  1. Population and scope (for MSK done by ICD chapter 10)
  2. Desired outcome and indicators (ask providers what they are measuring and could do)
  3. Financial value (calculation of the contract and scope, PB data not good enough for going to market with a tender – financial modelling and actuarial analysis)
  4. Duration of contract (long term stability, time to make significant change happen 7-10 years)
  5. Commercial structure and incentives / handling risk


Structure of contract.

Broadly structured by commissioner

Four main aspects

  1. Pt support and empowerment. Self care – When you give patients information about what can they do for themselves. Self support, exercise etc…. They don’t touch health care at all. We don’t WANT to spend our days in the Physio waiting room etc
  2. Support, education and advice to GP
  3. community based MSK
  4. Hospital facilities only when needed


Incentivised game changing outcomes


Incentivised quality measures



Four Workstreams



  1. System spec

GPs and patients

National experts


  1. Contract development


  1. Stimulate the market

Introduce the contract method

Further define the contract method

Explain contract method and PQQ


Engaging CCG member practices


Standard MSK template for all MSK

Prompts GP to ask risk qs

Right dx

Right clincial tools



Qs to be considered

RISK DUMPING – whats to stop GPs “dumping” patients into another system they are not part of

Make sure local GPs are part of the consortia so as they are bought into success of the concept.


Open book data. All assumptions are testable with data.


talk through risk and gain share….


Getting collaborative stuff across the different clincial groups and or population health problems


Incentives for trust to play….


Separating acute v elective work – especially problematic in T&O


Threat to trusts……

Turn it on it’s head……how can a trust turn this into a business opportunity……..


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