“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
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)
- 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
- 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
- c) the “general lock in method” (© Fell 2013)
4 If you are really serious
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…..data 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
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)
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
- Population and scope (for MSK done by ICD chapter 10)
- Desired outcome and indicators (ask providers what they are measuring and could do)
- 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)
- Duration of contract (long term stability, time to make significant change happen 7-10 years)
- Commercial structure and incentives / handling risk
Structure of contract.
Broadly structured by commissioner
Four main aspects
- 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
- Support, education and advice to GP
- community based MSK
- Hospital facilities only when needed
Incentivised game changing outcomes
Incentivised quality measures
- System spec
GPs and patients
- Contract development
- 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 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……..