FINAL

World Class Commissioning Panel Report NHS Cambridgeshire March 2010

CAMBRIDGESHIRE

Overview

• First, the Panel thanks Cambridgeshire PCT for participating in this round of assessments for World Class Commissioning • The Panel asks the PCT to accept this report in the spirit in which it is intended: a support tool on the journey to world class commissioning and as a considered perception of the organisation’s strengths and weaknesses based on the insight the PCT itself gave the Panel into its commissioning approach • The Panel identified 4 main recommendations that the PCT will need to consider as the PCT positions itself to drive transformation of health and healthcare in Cambridgeshire

1

CAMBRIDGESHIRE

Commentary The Panel identifies 4 major areas for consideration by the PCT at this stage on its journey 1 Progress over the past year has been substantive and impressive Observation • Has delivered financial balance this year while also paying-off legacy debt • Strategic and financial planning have progressed a lot since last year’s WCC assurance process • Has improved pathways making good use of clinical evidence (MSK, neuro rehab, dentistry in prisons, COPD, etc). Some of these target deprived sub-populations, e.g., diabetes pilot in Fenland • PCT’s achievements in improving health outcomes were not highlighted to Panel today. Panel also heard today that some of the good work the PCT does is intentionally not ‘branded’, with the result that its contribution is not always recognised by public and other stakeholders. • PCT is disappointed that CQC has remained at Fair/Fair for 07/08 and 08/09 • Has learned from last year by reducing its number of projects and implementing a PMO. However many projects have remained as ‘on-going business’ and PMO is in an early stage Recommendation • The PCT is on a good trajectory to reach the 2010/11 Operating Framework target of 3 x Green and 7 of 11 competencies at level 3, but will also need to: – Demonstrate it can deliver its strategy – Ensure good practices are consistent and systematic – across all competencies, and bring solid evidence of this to next year’s WCC assurance process • Ensure the PCT’s successes, once achieved, are celebrated at every opportunity - to enhance its reputation with stakeholders and bolster staff morale • PCT may wish to consider whether it has sufficiently slimmed-down its work programme 2

CAMBRIDGESHIRE

Commentary The Panel identifies 4 major areas for consideration by the PCT at this stage on its journey 2 Strategy is innovative and exciting; PCT will need to quickly demonstrate it is deliverable Observation • PCT very clear about local need, e.g., rapidly-ageing population. Got 3,500 responses to public consultation on strategic approach • Clear understanding of clinical evidence base for actions (although limited organisational use of improvement sciences) • Innovative commissioning model is planned: – GP clusters with greater autonomy and hard budgets doing pathway-based commissioning – High-performing GPs and the PCT’s extensive engagement with them and secondary clinicians will help this succeed – but getting and maintaining clinician support will be complex – Reinforced by on-going pathway redesign work – However this plan is still at an early stage: • GP cluster pilot(s) planned for 2010/11 – yet to decide how many. Panel is unsure whether roll-out to ‘industrial scale’ at the required pace will work with given plans and resources – a convincing story did not come across • It is an achievement that partners are bought-in now, especially Addenbrookes. However not evident this is secured for longer-term. Historical relationships across the system (including between PBCs and acute providers) have been difficult • Clinical engagement (in commissioning and delivery) today came-across as primarily doctor-focused – but other professions will be core to delivering the strategy (transfer of activity out of acute into the community). As PBCs do more and more commissioning, ensuring input from other professions will be critical • PCT is enhancing its ability to deliver (e.g., PMO being set-up) – and has a track record of delivering good pathway redesigns as mentioned Recommendation • Reflect on the timescale and resourcing (clinical and other) for the rollout to ‘industrial scale’ of the new commissioning model. Consider adopting an improvement methodology and training key staff as well as partners and clinicians in it to support this • Agree a longer-term strategic transition plan with partners (acute, PBCs, clinicians), which is explicit about the future-state for activity, beds, workforce, tariffs, etc • Ensure the PCT engages wider spectrum of clinicians who will deliver the strategy, including social care, community services, nurses, etc 3

CAMBRIDGESHIRE

Commentary The Panel identifies 4 major areas for consideration by the PCT at this stage on its journey 3

PCT has done well to deliver financial recovery and on-going balance; financial plan for the future needs more development Observation: • PCT has recovered financial control (last deficit £52m in 2006/07) • Has controlled finances to deliver a small surplus this year while also paying-back ~£9m debt. This despite 8-10% growth in acute activity, for which the PCT has analysed the drivers (mostly at Addenbrookes; referrals are average but activity once referred above average) • Working with partners to reduce costs, e.g.: – Relationship with Addenbrookes is now more collaborative. E.g., 8 joint cost-reduction projects identified with clinicians, e.g., chemo at end of life – Joint-working with LAs to reduce costs quite well-developed, e.g., intermediate beds on same site with sheltered housing; sharing legal advice service • Financial plan may need more work: – Financial balance relies on ~£100m in base-funding and ~£150m in worst-funding cases. Should these not deliver: • Implications for programmes/ initiatives not yet agreed – and impact on health outcomes and services not identified – although the PCT has some ideas, e.g., investments in primary care • Planned contingency far less than evaluated risks, e.g., £8.5m contingency for £66m risk in 2013/14 • PCT’s experience in turnaround will help – Unclear why the greater savings and more efficient delivery suggested for worst-case funding scenario not implemented in base case – Work with acute providers is collaborative but early-stage: • Some contractual levers in place for this year to control degree of treatment (e.g., right to audit activity above agreed levels by specialty) • Discussions with 2 main acute providers underway to jointly identify required changes to beds, workforce – but early-stage. Unclear whether such discussions started with other key acute providers Recommendation • Develop ASAP a plan for the worst-case scenario (where funding reduces and/or planned savings don’t materialise) – which initiatives to drop/ curtail with what impact on health and services • Ahead of the regional solution for AIV, ensure the PCT is maximising its local efforts • PCT should consider whether it is using contractual levers sufficiently to assure financial balance and the new model of commissioning

4

CAMBRIDGESHIRE

Commentary The Panel identifies 4 major areas for consideration by the PCT at this stage on its journey 4 Panel today encountered a bold and competent Board Observation • Board comes across as bold and competent and NEDs clearly engaged • Governance structures seem good, e.g., Panel was impressed with the Healthcare Governance Committee. However innovative planned commissioning model will need robust governance – not evident that thinking fully-developed as yet • Board clearly engaged in the development of the strategy - but does it give the right balance of time to each of in-year operational delivery and delivery of the longer-term strategy? • PCT is acting to improve performance data that goes to Board: – Using LES to get weekly data from GPs – Working to ensure consistency and structure of GP performance reports – Could streamline and focus acute provider performance reports to Board (e.g., fewer pages) • Lots of work done on OD including actions to address last year’s WCC Panel’s suggestions. However the Board and the broader organisation has yet to define and disseminate its values – but PCT plans to address this • Really good work on-going with local partners and the 3rd sector, e.g., Cambridgeshire Horizons; coproduction; considering operational synergies such as estates, back-office • Board quite actively involved in managing the SCG Recommendation • Reflect on the balance of the Board’s time and focus between in-year operational delivery and delivery of the longer-term strategy • Quickly agree organisational values to inform individual and group behaviour – how the ‘difficult choices’ are made. Start with the Board and then spread throughout the organisation and to external stakeholders • Quickly develop and test governance arrangements for the new commissioning model

5

CAMBRIDGESHIRE

Panel scorecard

Previous Current

Health outcomes and quality

NHS Cambridgeshire

GOVERNANCE

COMPETENCIES

Outcomes Selection Date: 2009/10

Level 4 Strategic priority

Worst value

Best value

National median 0 0

PCT Rate of Change

100

Current Time Period

Level 1 Strategy

th percentile 1. Health inequalities (Males) & Health inequalities (Females)

M

F F

M: 15.6

01/01/2004 31/12/2008

3.5

M

F: 1.4

2.0

F

M: 83.7

0.5

M

F: 78.1

F: 87.8

0.4

F

3. Prevalence of obesity in Year 6 children

0.26

0.12

7.7

01/09/2007 31/08/2008

4. Smoking quitters

241.9

1573.4

2.7

01/04/2008 31/03/2009

5. Clostrid ium Difficile infection rate

171.7

20.3

-32.9

01/04/2008 31/03/2009

N a t io n a l

M: 4.0

M

F: 10.7 2. Life expectancy (Males) & Life expectancy (Female s)

F

M: 73.2

M M F

01/01/2005 31/12/2007

Local leader of NHS A Collaborates with partners Patient and public engagement Clinical leadership

Assess needs

Finance A

Prioritisation 0.54

0.75

-2.6

Local

6. Diabetes controlled blood sugar

01/04/2008 31/03/2009

Stimulates provision 7. Proportion of all deaths that occur at home

0.14

0.26

5.7

8. Achievin g independence for old er people through rehabilitation and intermediate care

n/a

SHA to complete from PCT provided data3

n/a

n/a

9. COPD emergency admis sions per 100,000 population (standardis ed rate)

n/a

SHA to complete from PCT provided data3

n/a

n/a

10. n/a n/a

01/01/2007 31/12/2007

Innovation

Board

n/a

Procurement and contracting n/a

n/a

G

Performance management Ensuring efficiency and effectiveness of spend

6

CAMBRIDGESHIRE

Governance – Panel assessment on Strategy Assessment

Measure 1. 2.

A

3. 4. 5.

Last year’s rating Panel Assessment

Red

This year’s self-rating

Amber

Green

Vision and goals Initiatives to ensure delivery of strategic goals and the PCT’s programme of change Consistency of financial plan with the strategy Board challenge, ownership and monitoring of strategic plan delivery Achievement of milestones to date

Rationale for scoring 1. PCT vision links to local health inequalities, prevalence of lifestyle risk factors and QIPP and aligns with NSR and Towards the Best Together. It is underpinned by analysis of the health needs of the population (JSNA, fact base report by Deloitte). Outcome aspirations include annual milestones, but some may be over-ambitious (e.g., obesity) and others under-ambitious (e.g., female health inequalities). Logical ‘golden thread’ through the strategic plan document – from vision through outcome aspirations to initiatives - is not clear: not evidenced that the 6 strategic change programmes will ‘add-up’ to the aspired-to outcome improvements; specific initiatives within each of the 6 strategic change programmes not clearly articulated; unclear how the 10 initiatives retained from last year’s plan fit-in. However given the longer-term, more ‘out-of-the-box’ nature of the PCT’s strategy, Panel does not want to over-weight this issue 2. 6 strategic change programmes and 10 carried-over initiatives address the vision – either through shorter-term health improvement or longer-term system optimisation. Prioritisation exercise for initiatives completed. (Dis)investments for the 6+10 explicit but unclear how amounts were determined. PCT articulates high-level changes to investments in each funding scenario, but not per initiative. Has not agreed which investments it will drop/curtail if planned savings do not materialise (although it has ideas). Changes to planned savings for each funding scenario more detailed but not credible – if greater savings possible in the worst funding scenario, why not pursue in the base case? Implications of (dis)investment changes for health and services not articulated. Measures of success identified but not yet quantified per year for each programme. Programmes 1, 2 and 6 do not identify health outcome measures, rather efficiency and patient experience. Unclear what health impact expected from 10 carried-over initiatives. No risks/ mitigations per programme/ carried-over initiative but high-level risks identified - understands the scale of challenge and is working to bolster internal capacity, capability and responsibilities. Stakeholders engaged in developing the plan, e.g., public consultation, ‘Storm’ event – although not evident that all clinical disciplines thoroughly engaged 3. Unclear what assumptions about improvement in health outcomes, reduction in inequalities and/or efficiency and effectiveness of services informed the (dis)investment amount for each programme/initiative. However overall thrust of spend aligns with PCT vision for longer-term health improvement. Financial plan addresses the 3 funding scenarios. It shows year-by-year (dis)investments for 6+10, but not for the initiatives within the 6 programmes. Lacks detail for the worst-case as mentioned above. Detail of how financial impact will be achieved, potential bottlenecks and mitigations not yet in place. Of all planned investments 09/10-13/14, ~24% relate to the strategic programmes/ initiatives – relatively-high compared to other PCTs 4. Board very involved in strategy development and refresh. NEDs have given robust challenge, e.g., on the GP clusters, where they are actively thinking about how to mitigate risks. Chair and NEDs very fluent in the strategy. Clear roles for NEDs on sub-committees. PMO being established and will produce quarterly strategic initiative scorecards 5. PCT acknowledges it had an unmanageable number of milestones last year, with 49 projects and 400 action points, which led to milestones being missed. Learning from this, it has reduced the number of projects – although Panel was not clear on how many of these had actually been dropped as opposed to being transferred from ‘strategic priority’ to ‘business as usual’. Impact on deliverability of vision and outcome targets of past milestones hit/ missed not articulated

Recommendations going forward The PCT is well placed to move to ‘green’ next year: • For staff and stakeholder motivation, PCT needs to ensure it is seen to succeed – may wish to consider whether it has sufficiently slimmed-down its work programme • Ensure the PCT engages the wider spectrum of clinicians who will deliver the strategy, including social care, community services, nurses, etc. in strategic planning • Develop a plan for the worst-case scenario (where funding reduces and/or planned savings don’t materialise) – which initiatives to drop/ curtail with what impact on health and services • Consider conducting regular (annual?) reviews of milestones hit/ missed to understand root causes and learnings for future. Milestones should include both targets and strategic initiatives

7

CAMBRIDGESHIRE

Governance – Panel assessment on Finance Assessment

A

Last year’s rating Panel Assessment

Measure 1. 2. 3. 4. 5.

Red

This year’s self-rating

Amber

Green

Historical financial management Robust financial management Robustness of planning assumptions Sustainable financial position as ‘base case‘ Sustainable financial position under different financial scenarios

Rationale for scoring 1. The PCT has regained financial control since its deficit of £52.3m (8.1%) in 2006/07. PCT reported a break even position in 2007/08 and surplus of £760k (0.1% of income) in 2008/09, both in line with SHA expectations. Unclear, given the 2006/07 deficit, and the fact the rating definitions are quite technical and have not changed, why last year’s panel awarded a Green rating 2. PCT has robust financial management in place: has controlled finances to deliver a small surplus this year while also paying-back ~£9m debt (despite 810% growth in acute activity, for which the PCT has analysed the drivers); has a set of leading as well as lagging metrics to monitor financial performance, e.g., GP referrals, emergency admissions and other acute activity, ScriptSwitch, and projected monthly outturn position. The Finance and Performance Committee monitors financial performance in detail and reports to Board. The PCT has a manual acute invoice auditing system in place and challenged £3.5m of invoices in 2009/10, however Panel were not sure this constituted a clear and robust process. PCT has a clear and robust process for debt and asset management, including its estates strategy. PCT is currently working with partners on joint estates strategies and has already has examples of synergies, e.g., community hospital converted to sheltered housing with intermediary beds. 3. PCT’s assumptions for inflation, activity and population rates and financial scenarios are aligned with SHA guidance. Contingencies appear too low compared to the evaluated risks, which increase from ~£16m (184% of contingency) to ~£66m (773% of contingency) over the 5-yr plan period. Savings seem to be back-up by justifiable evidence but delivery planning needs to be developed further. Unclear why the greater savings and more efficient delivery suggested for worst-case funding scenario not implemented in base case. Work with acute providers is collaborative but early-stage. Some contractual levers in place for this year to control degree of treatment (e.g., right to audit activity above agreed levels by specialty). Discussions with 2 main acute providers underway to jointly identify required changes to beds, workforce – but early-stage. Unclear whether such discussions started with other key acute providers 4. Under the base case scenario, PCT is forecasting breakeven, reliant on ~£100m savings for which there is no evidence of a credible delivery plan. Should these savings not deliver, implications for programmes/ initiatives not yet agreed – and impact on health outcomes and services not identified – although the PCT has some ideas, e.g., investments in primary care 5. PCT is forecasting breakeven under the worst-case funding scenario (reliant on ~£150m savings) and a surplus under the best-case funding scenario of ~£105m. There is no evidence of a credible delivery plan to deliver these cost savings nor an agreed alternative plan for the scenario where they don’t deliver

Recommendations going forward • • •

Develop ASAP a plan for the worst-case scenario (where funding reduces and/or planned savings don’t materialise) – which initiatives to drop/ curtail with what impact on health and services Ahead of the regional solution for AIV, ensure the PCT is maximising its local efforts PCT should consider whether it is using contractual levers sufficiently to assure financial balance and the new model of commissioning

8

CAMBRIDGESHIRE

Governance – Panel assessment on Board Assessment

G

Measure 1. 2. 3. 4. 5. 6.

Last year’s rating Panel Assessment

Red

This year’s self-rating

Amber

Green

Organisation Risk Information Performance Delegation Board interaction

Rationale for scoring 1. PCT has a clear and well defined organisational structure which is well understood by the Board with roles and accountabilities clearly articulated and delineated. PCT outlined its capacity and capability gaps at all levels of the organisation, e.g., in the Talent and Leadership plan. OD plan includes actions in response to the staff survey, e.g., to increase % of staff with PDPs. However, PCT has not yet articulated a set of organisational values and communicated them to its internal and external stakeholders 2. Board Assurance Framework (BAF) covers risks and issues across all domains and is reviewed quarterly by the Audit Committee and monthly by Board. PCT has sufficient clinical input to Board decisions: 4 clinicians on Board including the CE; has appointed PBC leads to the PCT Executive Team; PEC Chair reports to Board at each meeting; PCT Chair regularly attends PEC. PCT is planning to run a joint Board-PEC development session to review the effectiveness of PEC as advisors, especially in light of the proposed changes to system configuration 3. PCT Board reports and provider performance and quality reports provide consistent and actionable data of a timely and accurate nature. It is changing its information systems to allow it access to weekly data on primary care performance 4. PCT tracks and uses quality, clinical and operational performance of its providers on a monthly basis. PCT reports to its Board at every Board meeting on quality, clinical, service and financial performance indicators, through the Contracts and Performance Report. Panel noted that provider performance review day meetings could include a greater role for senior clinical leadership. Progress on key initiatives relating to the six programmes is reported at every Board meeting but unclear whether the data is updated more often than quarterly. Board plays an active role in addressing disparities in performance, e.g., took action on health visits, smoking quitters and Chlamydia screening targets. PCT us using a PMO model for tracking performance and intends to improve the way in which this is reported by structuring around the six strategic change programmes. As at Jan 2010, PCT was meeting all Vital Signs Tier 1 indicator targets but missing 1 existing commitment 5. Schemes of delegation for SCG and PBC clearly describe roles, responsibilities and accountabilities relating to delegated commissioning. PCT monitors financial performance of SCG at every Board meeting but does not yet monitor quality. PCT takes ownership of specialised commissioning, e.g., engaged in refining the SCG Establishment Agreement. PCT does not describe a transparent process for decision making relating to SCG, but has clear processes for conflicts of interest and business case approval for PBC. Role of delegated and collaborative commissioning in the strategic plan is clear (supporting Strategic Change Programme 1) and the County Council is mentioned as part of strategy governance arrangements 6. The entire Board (executive and non executive directors) played an active role in shaping the strategy and prioritising areas and timings of investments. Board can speak of tradeoffs made in prioritisation and rationale for the priorities based on consistent set of criteria (commissioning model framework)

Recommendations going forward • • •

Reflect on the balance of the Board’s time and focus between in-year operational delivery and delivery of the longer-term strategy Quickly agree organisational values to inform individual and group behaviour – how the ‘difficult choices’ are made. Start with the Board and then spread throughout the organisation and to external stakeholders Quickly develop and test governance arrangements for the new commissioning model

9

CAMBRIDGESHIRE

Outcomes

x x

Top quartile rate of improvement Bottom quartile rate of improvement

Upper Quartile

Newly Selected

Lower Quartile

Previous Current

NHS Cambridgeshire health outcomes and quality Outcomes Selection Date: 2009/10 3 year historic rate of improvement (CAGR, %) 1

Strategic priority

National

1. Health inequalities (Males ) & Health inequalities (Females)

PCT

National

ONS cluster

Top decile 4

PCT aspiration (CAGR)

3.5

M

0.8

1.7

-3.9

-1.0

2.0

F

1.2

0.0

-9.4

-1.0

0.5

M

0.4

0.6

0.8

0.5

0.4

F

0.3

0.4

0.6

0.3

2.

Life expectancy (Males ) & Life ex pec tancy (Female s)

3.

Prevale nce of obes ity in Year 6 children

7.7

8.5

3.8

-7.5

-1.0

4.

Smok ing quitters

2.7

3.0

2.7

22.1

5.3

Clos trid ium Difficile infec tion rate

-32.9

-35.5

-33.1

-65.3

-11.1

6.

Diabetes c ontrolled blood sugar

-2.6

-1.0

-1.8

3.1

2.4

Local

5.

7.

Proportion of all deaths that occur at home

5.7

1.8

0.8

6.5

6.3

8.

Ac hievin g independence for old er people through rehabilitation and intermedia te care

n/a

n/a

n/a

n/a

1.9

9.

COPD emergency admis sions per 100,000 population (s tandardis ed rate)

n/a

n/a

n/a

n/a

-2.9

10. n/a

Changes in outcomes from last year • These 9 outcomes were selected because PCT wanted: to focus; to be realistic about funds available; and to track outcomes not process • Not clear why deaths at home outcome was selected given best-in-class. PCT says because it is an important outcome for an ageing population which, based on international evidence, can be further improved yet further cost-effectively • Some local health needs are omitted - mental health and CHD • Independence for older people: PCT working with LA to develop supporting metrics, e.g., re-ablement programme grads, admissions Recent performance: • Good relative performance in health inequalities, life expectancy, obesity, deaths at home and COPD • Smoking quitters has been improving, but is still bottom-quartile. Lowest prevalence in EoE makes this difficult. Nonetheless PCT has reviewed current services and plans to enhance GP-supported quits and develop Pharmacy- and acute-supported quits. Also pursuing general tobacco control agenda • Diabetes has worsened significantly to lower end of the bottom quartile – unclear what root cause is Aspirations: • Panel has confidence in the level of aspiration for: – Health inequalities (males): Aspiration is well below top-10%-improving PCT’s historic rate – Smoking quitters: Aspiration exceeds national and ONS historic rates but is well-below top-10%-improving PCT’s historic rate. Given PCT’s low smoking prevalence it seems reasonable – Diabetes: Aspiration is close to top-10%-improving PCT’s historic rate, but Fenland pilot has demonstrated improvement • Panel feels aspirations for some outcomes may be over-ambitious: – Obesity: Aspiration is markedly different to PCT historic rate and unclear whether Childhood Obesity Pathway and LAA actions will suffice • Panel believes aspirations for other outcomes might be more aggressive: – Health inequalities (females): Aspiration is well-below top-10%-improving PCT’s historic rate and will not close current disparity between males and females – C-Diff: Aspiration is well below PCT’s own historic rate and current performance is below median Recommendations: • Ensure selected outcomes embedded in the new commissioning model such that they are owned by the GP clusters

1 3 year period where available – please see appendix for variations where applicable for some indicators 4 Top decile defined as the PCTs with the largest rate of improvement SOURCE: Team analysis

10

CAMBRIDGESHIRE

Overview – Competencies

This year’s self rating Last year’s rating

Level Competency

1

Panel Assessment 2

3

4

1. Locally lead the NHS 2. Work with community partners 3. Engage with public and patients 4. Collaborate with clinicians 5. Manage knowledge and assess needs 6. Prioritise investment 7. Stimulate market 8. Promote improvement and innovation 9. Secure procurement skills 10 Manage the local health system

PCT has made substantive progress, increasing its average competency rating from 1.8 in year 1 to 2.3 (excluding C11 for comparability – 2.2 if we include it). It has made particular progress in C1, C5 and C10 PCT will likely be disappointed with the lack of improvement to its rating for C2, C4 and C6: – C2: Stakeholder survey scores are lower this year than last suggesting PCT’s reputation as an active partner has worsened – C4: Stakeholder survey shows PCT’s reputation for clinical engagement has not improved and PCT also lacks examples of having reduced clinical variation – C6: Criteria have tightened this year and PCT does not have a pre-agreed plan for the worst-case scenario (where funding reduces and/or savings don’t materialise) – including which initiatives to drop/curtail. It also has not yet included enabling initiatives in its prioritisation exercise PCT has self-assessed for most competencies at a slightly higher level than reflected in the documentation and Panel Day discussions

11 Ensuring efficiency and effectiveness of spend* 1 Competency added this year, hence last year’s rating not available

11

CAMBRIDGESHIRE

Competency 1 – Panel assessment Competency

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Reputation as the local leader of the NHS Are recognised as the local leader of the NHS

• Reputation as a change leader for local organisations • Position as an employer of choice

Rationale for scoring 1a: Key stakeholders agree PCT is the local leader of the NHS (PCT score 4.91 vs. SHA av. of 5.01). PCT actively participates in and leads the local health agenda, e.g.: held stakeholder events to engage key partners in challenges (e.g., Storm Scenario) event; Hinchingbrooke Next Steps; ran multi-agency Swine Flu group for over 6 months. Public perception survey shows 61% (up 2% from last yr) of local respondents agree NHS improving services vs. 17% who disagree. PCT refreshed its strategic plan to include ~4,000 survey respondents’ views and sought bi-monthly feedback on plan updates from ~250,000 households. PCT has understood and acted upon patient experience, e.g., by changing the location of MSK service to make it more accessible, using Physio Direct and responded to comments regarding IAPT services. PCT understands its current/future leadership reputation. Media Analysis shows Cambridgeshire is the 2nd most favoured PCT in EoE 1b: Key stakeholders agree that PCT significantly influences their decisions and actions (PCT score 4.87 is the same as SHA average). PCT has led and implemented change with other local commissioners/ partners and LINk to find better solutions for patients, e.g.: Hinchingbrooke Next Steps; worked in partnership with Fenland DC to better serve community; opened GP-Led Health Care; and worked with Cambridgeshire County Council and CATCH to increase the no of households receiving intensive home care 1c: NHS Commissioning Staff survey results show staff turnover and sickness absence rate is the same as SHA and national averages. There are no non-medical vacancies. Training and development programmes include commercial awareness training, spotting talent and supporting staff for SHA leadership programmes, implementing e-learning, aspiring CEO/directors/clinicians programme and apprenticeships. Commissioning staff development and staff satisfaction are demonstrated by the 2008 commissioning staff survey results, which were at or above average for learning (75%), PDPs (52%), staff wanting to leave (2.6 out of 5), but below average for understanding role (56%), opportunities to develop (46%) and well structured appraisals (24%)

Recommendations going forward •

Continue progressing in this area 12

CAMBRIDGESHIRE

Competency 2 – Panel assessment Competency Work collaboratively with community partners to commission services that optimise health gains and reduce health inequalities and deliver increased productivity

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Creation of Local Area Agreement based on joint needs • Ability to conduct constructive partnerships • Reputation as an active and effective partner’

Rationale for scoring 2a: PCT and local strategic partners worked together to agree and reconfirm LAA priorities. LAA priorities are based on joint needs assessed through the JSNA. PCT leads on 5 LAA health related targets. Joint targets for smoking cessation, hospital admissions for childhood accidents and road traffic deaths and injuries, childhood obesity prevalence and older people achieving independence have been achieved. Evidence of best practice shared through partnerships and external input, e.g., National Tobacco Control Support. Joint accountability and delegated responsibility for all key targets are managed through Cambridgeshire Together which incorporates Children’s Trust Board, management of S75 agreement for adult social care, Public Services Board which has CEO membership from 9 key decision making organisations – County Council, 5 District Councils, fire, police and PCT. Community wellbeing Partnership reports to Cambridgeshire Together LAA Board and brings oversight to a range of health and wellbeing issues. With participation from GP practices, Children’s Centres and LA development workers, PCT secured a health trainer service for the 20% most deprived areas. Clinicians are involved in the delivery of LAA targets, e.g., PEC chair and Exec Nurse drive clinical engagement through membership of LAA partnership groups and connection to PBCs. Hospital paediatrician has championed development of childhood obesity pathway. Range of clinicians (community dieticians, hospital paediatrics) involved in developing childhood obesity pathways and clinical involvement in developing pathways for older peoples rehab in South Cambridgeshire. PEC Chair and Exec Nurse support clinical engagement on key LAA Partnership groups 2b:

Stakeholder feedback survey shows key stakeholders somewhat agree PCT proactively engages their organisations (PCT 4.13 vs. SHA average 4.3). Current/future/met/unmet health needs of population are identified in the JSNA using quantitative and qualitative info. Unclear whether/ how the effectiveness of partnership working arrangements has been evaluated. Governance and accountability of shared posts are outlined in the LAA. There is evidence of PCT working with the EoE Specialised Commissioning Group, e.g., on rare cancers however unclear to what extent it really takes ownership of the SC agenda

2c:

Stakeholder feedback survey shows key stakeholders somewhat agree the PCT is an effective partner in delivering health and well-being improvements (PCT 4.45 vs. SHA average 4.7). Collaboration of a range of local commissioners involved in childhood obesity pathway has led to demonstrable results, e.g., shift in spend, cost effectiveness, increase in quality and access. PCT has set out clear milestones with partners in LAA and has track record of delivery of key initiatives (LAA Performance Report). PCT works with leads of other local commissioners to agree plans and priorities as laid out in the LAA. Unfortunately, PCT does not meet level 3 due to stakeholder feedback survey results

Recommendations going forward • •

Improve joint working with other partners, e.g., by taking greater ownership of the Specialised Commissioning agenda Identify ways in which the PCT can improve its reputation as an active and effective partner, e.g., ways in which it can engage more with local partners in strategic planning and service redesign

13

CAMBRIDGESHIRE

Competency 3 – Panel assessment Competency

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Influence on local health opinions and aspirations

Proactively build continuous and meaningful engagement with the public • Public and patient engagement and patients to shape services and • Improvement in patient experience improve health

Rationale for scoring 3a: PCT’s communications strategy includes an intent to establish the evidence base for lifestyle behaviour change and build campaigns on this. It is unclear in this strategy, however, how seldom-heard groups will be influenced and whether the strategy has been informed by an EIA. Stakeholder feedback survey shows key stakeholders somewhat agree the PCT is proactive in shaping the health opinions and aspirations of public and patients (PCT 3.46, SHA average 4.06). PCT has examples of promoting independence, health, well-being and personalisation of services, e.g., smoking cessation campaign, Choice campaign, and PALS awareness roadshows. It is launching a new NHSC magazine. DH Obesity Consumer Insight Research data completed, mapped and used to target resources and interventions to reduce childhood obesity. PCT is using a social marketing organisation to scope a social marketing approach to improving health & well-being indicators 3b: PCT communications strategy includes active engagement of public and patients in PCT business. New patient experience team handles patient complaints and concerns as well as patient surveys. It also makes the public aware of local engagement channels and processes whereby they can raise concerns. It brings together reporting from providers, soft intelligence from MPs, councillor letters, LINk, OSC and the media. PCT refreshed its strategic plan to include ~4,000 survey respondents’ views and sought bimonthly feedback on plan updates from ~250,000 households. No specific reference in the PCT’s communications strategy to seldom heard and equality groups – but PCT includes stakeholders in the design and review of all services, as a matter of routine, e.g., LD users involved in all service reviews. PCT website has been redesigned to take account of the needs of LD users (and LD users have been involved in the development of the site). Public perception survey shows that 32% of respondents agreed that, “I can influence decisions affecting local NHS services in my area,” but 47% disagreed; this was the 2nd-best result in EoE and an improvement on last year. 3c: PCT has appointed a Patient Experience Manager to analyse patient experience data/information/trends in complaints, etc. This is used as part of performance management meetings with providers and reported to Board. PCT provided examples of timely response to feedback: • Chlamydia screening for home schooled and excluded girls • Leaflet drop to 250,000 homes to explain the provision of Commissioning decisions that have been driven by patient experience, e.g., OOH services • Enhanced provision in East Cambridgeshire and Fenland by local GPs • Improved staffing levels on Lavender Ward and Hinchingbrooke Hospital • Improved dental service and mental health services for prisoners PCT cites trends in areas of good and poor practise are often found through monitoring complaints and PALS calls. Patient feedback has enabled the PCT to focus on those with long term conditions, to improve their experience and that of future patients. In the public perception survey, 83% of respondents agreed that, “My local NHS helps improve the health and wellbeing of me and my family.“ PCT has adopted Making Experiences Count and set-up a one-stop-shop for complaints and PALS

Recommendations going forward •

Learn from the successes of its smoking cessation campaign to develop its influencing of local health opinions and aspirations in other areas of health

14

CAMBRIDGESHIRE

Competency 4 – Panel assessment Competency Lead continuous and meaningful engagement of a broad range of clinicians to inform strategy and drive quality, service design, and efficient and effective use of resources

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Clinical engagement • Dissemination of information to support clinical decision making • Reputation as leader of clinical engagement

Rationale for scoring 4a: PCT has done a lot of work to engage clinicians in its vision for system change: • Clinicians lead pathway redesigns (e.g., childhood obesity, Brookfields Hospital, COPD); Diabetes Clinical Executive in place • Strategy co-produced including discussions at PBCs, clinical forums, etc. Clinicians involved in prioritising initiatives. GPs consulted on how to deal with acute activity resulting in co-created referral management • Big Conversation with GPs about proposed cluster arrangements; similar exercise about to start with secondary care clinicians. 8 strategic projects identified together with Addenbrookes clinicians to reduce low-value interventions, e.g., end of life chemo • PCT involved with heart and stroke and cancer networks; regular learning meetings with clinicians include secondary and primary to discuss SUIs, etc; Clinical Priorities Forum • Facilitating linkes between primary and secondary care: Dermatology spec co-created including secondary clinicians, GPSIs and an external expert from another acute provider. Primary care clinician leads for e.g., dermatology meet with secondary clinicians. Primary and secondary clinicians included in Storm Scenario event. However Dec 09 PBC survey shows 7 out of 7 respondents felt they had ‘a little’ or no influence with secondary care clinicians • Few examples of the PCT engaging clinicians across disciplines: Physio led MSK redesign • Dec 09 PBC survey results were mixed: – All 7 respondents rated their relationship with the PCT as ‘fairly good’ or ‘very good’ – All respondents had a PBC budget – 3 out of 7 respondents rated info and support received from the PCT as ‘fairly good’ or ‘very good’ – 1-2 of 7 respondents felt they had more than ‘a little’ influence on aspects of the PCT’s business (e.g., JSNA, strategy), with the exception of contributing towards the PCT health inequalities strategy where 4 out of 7 did 4b: PCT shares regular reports covering quality and efficiency, e.g., GP balanced scorecards. It also shares recent clinical evidence, e.g., Clinical Governance Journal, Prescribing Matters. PBC survey Dec 09 shows all 7 respondents had a PBC budget but only 3 out of 7 rated info and support received from the PCT as ‘fairly good’ or ‘very good’. PCT has a process for collecting improvement ideas from clinicians - fed up through PBC Forums to Area Commissioning Forums to PEC; 2 out of 3 business cases originated with GPs – although unclear how these ideas are then disseminated. Pathway redesign work published on PBC websites. PCT has taken steps to reduce variation in GP referrals (the ‘120%’ effort on-going through performance discussions) and responded appropriately to the recent out-of-hours SUI, but no examples provided of it proactively reducing unacceptable clinical variation. Dec 09 PBC survey, on the other hand, shows 5 out of 7 respondents feel involved in addressing variation in primary care standards 4c: Stakeholder survey shows that stakeholders somewhat agree the PCT proactively engages clinicians (PCT 4.09, SHA 4.28). PCT has a proven track record of pathway redesigns. PCT perceives its current processes for PBC business cases as overly-restrictive and plans to loosen them to get the right balance between innovation and governance. Dec 09 PBC survey shows only 3 out of 7 respondents believe timeliness and quality of business case feedback is ‘fairly good’ or ‘very good’. Unclear from PBC Agreement what conflict of interest policy is – and as PCT delegates greater autonomy to GP clusters this will become increasingly important. PCT relates having resolved issues relating to a failed GP bid for a service, but does not relate any examples of how it is mitigating conflicts of interest in PBC

Recommendations going forward • • • • •

Ensure the PCT engages wider spectrum of clinicians who will deliver the strategy, including social care, community services, nurses, etc Proactively engage with clinicians to reduce clinical variations. One intervention may be to facilitate learning across high- and low-performing practices on specific metrics, e.g., cholesterol for stroke/TIA Actively promote the PCT’s reputation as a leader of clinical engagement, e.g., by putting itself forward for awards or good-practice dissemination initiatives Ensure there is a clear policy for preventing conflicts of interest in PBC/ GP clusters Engage with PBCs to understand how the info and support the PCT provides to them could be improved

15

CAMBRIDGESHIRE

Competency 5 – Panel assessment Competency Manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Analytical skills and insights • Understanding of health needs trends • Use of health needs benchmarks

Rationale for scoring 5a: Dec 09 JSNA identifies gaps in care and major health needs (e.g., age-related need). JSNA assesses both current and future need, e.g., prevalence of diabetes now and 2015. JSNA includes qualitative data from stakeholders via Community Views. Examples of PCT analysing progress towards reducing gaps and taking action to assure it, e.g., smoking cessation. JSAN identifies specific needs by geographical areas (district, MSOA/ LSOA, etc) although not by ethnicity 5b: PCT has identified areas of health risks and unmet needs for local population and disaggregates to locality e.g., in Fenland the rates of diabetes and heart disease are higher than rest of the county. JSNA identifies health trends over time, e.g., trebling of Chlamydia prevalence. Insights from public, patients, clinicians and other stakeholders are used in JSNA refresh findings e.g., homeless section included views from the homeless, LD section was prepared by LD steering group – which includes partners, people with LD and specialist staff. PCT analyses progress and identifies gaps towards achieving improvement targets, e.g., smoking cessation 5c: JSNA includes benchmarks of local health need, health outcomes and some socio-economic indicators against national average and ONS cluster. Such benchmarking informs strategic plan health outcome improvement aspirations. Annual Public Health Report includes both national and regional benchmarking. Benchmarking shared with County Council, partners, LSPs, providers, libraries, voluntary groups, etc Recommendations going forward • Continue to progress in this area

16

CAMBRIDGESHIRE

Competency 6 – Panel assessment Competency Prioritise investment of all spend in line with different financial scenarios and according to local needs, service requirements and the values of the NHS

Last year’s rating

Panel Assessment

Measure •

Predictive modelling skills and insights to understand impact of changing needs on demand

•

Prioritisation of investment and disinvestment to improve population’s health

•

Incorporation of priorities into strategic investment plan to reflect different financial scenarios

This year’s self-rating

Level 1

2

3

4

Rationale for scoring 6a: PCT has modelled future activity by HRG using population and prevalence forecasts as well as assumptions on waiting times. Resulting costs are calculated. Quality other than waiting times not modelled. Unclear whether scenarios used. Deloitte ‘Fact Base’ report forecasts activity for major disease areas (e.g., dementia, stroke) 6b: PCT has used a defined set of criteria to group investments into Red, Amber or Green categories. While they seem effective, they are not easy to understand and RAG system doesn’t allow relative prioritisation between ‘Green’ initiatives. (Dis)investment initiatives have been generated through public engagement, local needs, clinical evidence (lots of this!) and programme budgeting; contain predicted outcome improvements and are evaluated together with clinicians, GPs and stakeholders 6c: Initiatives align with identified gaps and include investment and disinvestment. Financial scenarios based on SHA guidance. Cross-cutting initiatives identified but not evidently included in the prioritisation exercise. Investments not reprioritised for worst-case funding or savings scenario, i.e., no agreement on which to drop or curtail should funding reduce or savings not materialise

Recommendations going forward • • •

Ensure the PCT has forecasts of need (activity), quality and resulting cost, with scenarios (higher/ lower levels of need), for all disease areas or care pathways relating to its strategic priorities Include disinvestments and enabling initiatives in the prioritisation exercise – on the basis of, ‘If this were a new investment, would it make the grade?’ Review approach to prioritisation – consider whether it could be amended to allow relative prioritisation between ‘Green’ initiatives, e.g., by producing a priority ‘score’ for each initiative. Then take the resulting prioritised list of investments, disinvestments and enabling initiatives, and identify the ‘cut-off’ point for the worst-case scenario (where funding reduces and/or savings don’t materialise). Then assess impact on services and health of dropping/ curtailing initiatives below the cut-off, and accordingly reprioritise if needed

17

CAMBRIDGESHIRE

Competency 7 – Panel assessment Competency Effectively stimulate the market to meet demand and secure required clinical and health and wellbeing outcomes

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Knowledge of current and future provider capacity and capability • Alignment of provider capacity with health needs projections • Creation of effective choices for patients

Rationale for scoring 7a:

Robust market analysis performed on all segments of the market as part of the EoE-wide Health Market Analysis (HMA) initiative. Market analysis used in commissioning decisions comparing cost, quality & analysis of patient feedback. This helped to identify priority focus areas, e.g., PCT and key stakeholders undertook an analysis of providers for childhood obesity pathway. Predictive demand modelling, including risk factors, used to identify capacity shortfalls in acute care. Storm event identified potential improvements across the market and the end result is likely to be new providers. Supplier days now regularly used to identify potential providers and ‘warm-up’ the local market (days are run jointly with other PCTs where possible, e.g., OOH tender). The three submitted pathway descriptions (obesity, COPD and Brookfields Hospital) assessed the relative cost, quality and patient feedback of providers and the services they deliver

7b:

PCT uses the JSNA to inform projections of population need and combines this with demand management assumptions to project required capacity as part of pathway service redesigns, e.g., given its ageing population, the PCT revised the MSK pathway to avoid the need for some orthopaedics services by establishing an integrated one-stop shop. PCT used the procurement route to find alternative providers who could provide this service. For the diabetes pathway, PCT looked at current and future need based on the JSNA and collaborated with Addenbrookes to revise the service capacity to provide more community-based services. Three examples given of the PCT using various market management approaches: MSK (formal tendering), diabetes pathway (collaboration approach), vascular checks (benchmarking between current providers with alternative providers)

7c:

PCT has made progress in creating new contracts working with GPs to increase the uptake of choice. AWPs agreed for geographical areas that required additional services. PCT is reviewing GPSI provision to ensure they are located in places where patients require the service. PCT provided good examples where it offers patient choice in access (Brookfields Community Hospital), location (neuro rehab beds in the county as well as outside of the county). 2009 patient choice survey shows below-average % of patients were offered a choice of hospital for their first appointment (37%, no improvement from 2008) but an above-average % were able to go to their choice of hospital (74%, up from 71% in 2008). In order to progress to level 2, PCT needs to demonstrate how it regularly reviews the healthcare provision marketplace and the choice patients have, including patients in creating the choice offer, as part of a clear strategy for creating more choice

Recommendations going forward Panel recommend the Board work with the Executive team to develop a clear strategy for creating more choice

18

CAMBRIDGESHIRE

Competency 8 – Panel assessment Competency Promote and specify continuous improvements in quality (e.g., CQUIN, IQI) and outcomes through clinical and provider innovation and configuration

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Identification of improvement opportunities • Implementation of improvement initiatives • Collection of quality and outcome information

Rationale for scoring 8a: PCT demonstrates extensive use of clinical evidence and benchmarks. For example, the submitted COPD and obesity pathway redesigns showed benchmarking against NICE guidance. Submitted redesigns show specific interventions at each point in the pathway and the obesity pathway shows criteria for moving patients along it. PCT says pathway protocols are published on its PBC website and plans to publish them on a more public website. It also reinforces these interventions through the use of proforma. Pathway redesigns involve patients, e.g., Brookfield, COPD. Clinical leads from both primary and secondary care meet regularly to review existing pathways for improvement opportunities according to a schedule. PCT aggregates PARR data from GP practices to target high-risk patients 8b: PCT clearly understands impact of pathway redesigns on provider economics and works with them to mitigate risks, e.g., is involved in discussions with Addenbrookes about activity, bed and workforce implications of proposed shift of activity out of acute. Unclear what the steering-group arrangement is for pathway redesigns and therefore how progress against objectives is tracked. PCT can demonstrate results from pathway redesigns in terms of admissions reduced (COPD), quality increased (diabetes), etc. Improvement initiatives have spanned a range of services (COPD, out of hours, diabetes, obesity, MSK, etc) and PCT is also very involved with regional clinical networks. The PCT has an improvement philosophy (“Cambridge together”) but not an improvement project methodology (such as Lean) that is well-understood and used consistently by staff 8c: PCT tracks outcome, quality and process metrics for all pathway redesigns (e.g. for COPD, number of rescue packs issued number of emergency admissions) and agrees them with stakeholders. Provider performance meetings are monthly but it is less clear how often pathway redesigns per se are monitored. Data on pathway redesigns seems to include enough detail to identify drivers of performance and quality and to link quality and efficiency. Some near-real-time monitoring in place, e.g., daily ‘flash’ report on A&E; weekly referral data; 5day ‘fast-track’ report on acute activity

Recommendations going forward • •

Consider adopting an improvement methodology and training key staff as well as partners and clinicians in it Ensure the impact on quality, outcomes and cost of each pathway redesign is regularly tracked 19

CAMBRIDGESHIRE

Competency 9 – Panel assessment Competency

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Understanding of provider economics Secure procurement skills that ensure robust and viable contracts

• Negotiation of contracts around defined variables • Creation of robust contracts based on outcomes

Rationale for scoring 9a: PCT has developed an understanding of provider economics and market dynamics, e.g., understood the relationship with Hinchingbrooke and cost procedures to ensure services were financially viable; has a good understanding of the economics of GP clusters; understands tactical approaches to create competition; and understands the provider dynamics of mental health provision in the region. PCT considers patient experience, quality of care and productivity for its key providers. Procurement processes in place are compliant with Principles and Rules for Cooperation and Competition 9b: PCT identified locally-defined negotiation variables in the contracts, e.g.: local caps imposed on chemotherapy services; thresholds imposed on admission for the first two hours of the national 4-hour waiting time target; thresholds imposed for delayed transfers of care. Contract negotiation preparation included service specification and price, BATNA, negotiation strategy and negotiation team roles 9c: Negotiation variables such as cost, quality and clinical indicators are clearly identified in contracts, e.g., using QOF and CQUIN. Standard arbitration process is included in contracts. PCT uses QOF and CQUIN framework to negotiate new contracts with defined performance improvement targets and improvements to patient pathways. In the contracts submitted, Panel noted: the Cambridge University Hospital NHS Trust contract was signed on 8 May 2008, although the services had commenced on 1 April 2008; Cambridgeshire Community services contract was signed on 20 July 2009 although the services had commenced on 1 April 2009. PCT recognised this as an issue and has since implemented robust processes to ensure contracts are signed before activity commences. PCT has not yet progressed to a level 3 since it has yet to demonstrate effective use of contract levers to assure financial balance and the new model of commissioning

Recommendations going forward • Develop an in-depth understanding of provider economics as this will be central to the PCT’s strategic approach • Negotiate appropriate contractual levers and act upon them as necessary to deliver the new model of commissioning

20

CAMBRIDGESHIRE

Competency 10 – Panel assessment Competency Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvement in quality and outcomes and value for money

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Use of performance information • Implementation of regular provider performance discussions • Resolution of ongoing contractual issues

Rationale for scoring 10a: Provider performance data is less than 6 weeks old and discussed at contract performance meetings. Performance issues are discussed at Executive Management Team meetings. Provider data collected supports key performance indicators across quality, access and workforce (e.g., vacancies, turnover and sickness rates). Performance information is made available via the Public Board minutes and the PCT website. Near-real-time monitoring measures are used, e.g., daily data on delayed transfers of care which can result in PCT visiting the wards to identify what actions can be taken to address the problems. PCT does not meet all level 3 criteria because although it cited data such as HCAI and out of hours (GP clusters), Panel did not think this demonstrated sufficient evidence of contract agreements including local data relating to quality and outcomes 10b: PCT holds regular performance improvement discussions with key providers at monthly provider performance days. The Integrated Governance Group monitors risk analysis reports which identify top-5 clinical risks for each provider, covering data on quality, access, patient feedback and workforce issues. These reports have in the past identified patient safety issues at Hinchingbrooke. In addition, patient feedback data is obtained through patient surveys and used in monitoring services such as Out Of Hours and MSK. PCT provided examples of working with providers on root cause analysis, e.g., C-diff, Chlamydia screening and delayed transfers of care. For delayed transfers of care, Chief Executives of both the PCT and hospital worked together to identify the root causes which has resulted in rates reducing. For Chlamydia screening an alternative approach was taken, e.g., promoting screening in cinemas which has resulted in an increase in uptake 10c: PCT is proactive in contract compliance management evidenced by increased number of performance notices issued during the year. This has resulted in action plans with assigned leads, timeframes and milestones on areas of contract underperformance such as HCAIs, emergency care pressures and elective capacity. Action plans need to be implemented within 10 days upon issue of the notices. The Healthcare Integrated Governance Committee oversees implementation of these action plans

Recommendations going forward • Adopt a systematic approach to monitoring patient feedback as part of contract performance management for all providers

21

CAMBRIDGESHIRE

Competency 11 – Panel assessment Competency

Ensuring efficiency and effectiveness of spend

Last year’s rating

Panel Assessment

Measure

This year’s self-rating

Level 1

2

3

4

• Measuring and understanding efficiency and effectiveness of spend • Identifying opportunities to maximise efficiency and effectiveness of spend • Delivering sustainable efficiency and effectiveness of spend

Rationale for scoring 11a: EOE wide anaylsis and benchmarking of output efficiency has been of use and relevance to this competency, but has not been a determining factor for ratings. PCT collects outputs (e.g., number of episodes or patients), spend and outcomes for priority pathways and pathway redesigns. While it knows output efficiency for a few selected areas (e.g., cost per COPD admission, continuing healthcare cost per bed per week), it does not analyse or benchmark it for all priority pathways (e.g., cost per patient-year for LTCs or cost per episode for short-term illnesses). No evidence that the PCT understands the optimal economics of major care settings, e.g., the most efficient and effective size of GP practices, community services or mental health 11b: PCT has identified opportunities in priority pathways to: • Improve efficiency and effectiveness of spend (e.g., shifting care out of acute into the community • Maximise impact into targeted local populations (e.g., diabetes pilot in Fenland) • Minimise non value interventions (e.g., by reducing ALOS in Brookfields hospital; by using thresholds and ticklists to reduce interventions of limited clinical effectiveness) • Capture provision efficiencies by switching provider (e.g., switched continuing care provider to lower cost per bed-week; recommissioned out-of-hours to reduce cost as well as increasing quality; changed mental health provider) • Within its own cost base the PCT is identifying opportunities for improved: ￚ Operational efficiency (considering sharing some back office functions with the Local Authority) ￚ Capital efficiency (working with Local Authority to explore potential estates synergies) … but not yet spend efficiency (no examples of PCT seeking to optimise its spend on supplies, IT, etc) 11c: PCT has several examples of initiatives to deliver identified efficiencies – transfer of minor oral surgery into the community; reducing treatments of limited clinical effectiveness; increasing use of statins; and neuro rehab redesign. For the neuro rehab example, the PCT could describe how it had worked-through clinical opposition; maintained a risk register; undertaken a public consultation; measured impact in terms of savings; held a weekly project meeting. Going forward, the PMO will likely help support such initiatives

Recommendations going forward •

Develop a system for measuring and benchmarking the output per £ and relevant outcomes for priority existing pathways as well as for redesigns 22