World Class Commissioning Panel Report

1. World Class Commissioning Panel Report NHS Kirklees April 2010

2. Overview First, the panel thanks Kirklees PCT for participating in this round of assessments for World Class Commissioning, and for making us so welcome on the panel day and engaging with the panel in an open and constructive way. 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. During our review of Kirklees PCT, the panel developed an overall impression of the organisation, which is that the PCT has some significant strengths to build on, including clear areas of progress over the last 18 months, that the PCT needs to reposition its strategy to address the system and financial challenges, and that there are a number of areas the PCT will need to address to ensure the success of this strategy. The panel identified 3 main recommendations that the PCT will need to consider as the PCT positions itself to drive transformation of health and healthcare in Kirklees . These are set out at the beginning of this report. The report also contains a commentary on the PCT’s potential for improvement, panel scorecard, scores and ratings for governance, observations and recommendations on outcomes, and the scores/ratings and recommendations for the 11 competencies.

3. Commentary The panel identifies 3 major areas for consideration by the PCT at this stage on its journey • Headline: Clear strengths demonstrated that will serve the PCT well • Observation: The panel noted many strengths and areas of significant improvement over the last 18 months: (1) The PCT’s current strategy is firmly rooted in a detailed understanding of the needs of the population (2) The relationship with the council continues to be strong, and it was evident to the panel that the council and the PCT have clear joint sense of responsibility for the future and are working together to address it. (3) Good progress has been made in securing clinical involvement (4) Finally, the panel noted the PCT’s improved capability in execution. • Headline: Key areas to address to ensure success • Observation: The panel noted that there are 2 key areas for the PCT to address to ensure the success of its strategy: • (a) Aligning the financial plan with the strategic plan. The panel considered that prioritisation criteria did not fully reflect the financial challenge and that they did not appear to be firmly embedded in the organisation as a working tool. The panel did not see evidence of a coherent, credible plan for addressing the downside scenario. The panel believes that the context has now changed and a track record of delivery will not be sufficient to ensure financial stability in a downside scenario, so the PCT needs to re-assess prioritisation criteria in a downside scenario if its strategy is to be successful. • (b) Addressing the risk around its partner acute trusts. The PCT needs to build on the partnership arrangements with its acute providers to develop a shared vision for a sustainable care system. The next step is to ensures that there is a clear delivery plan so that transactions support the strategic intent of the partnerships. • Recommendations: • (1) The strategy needs to be as grounded in the financial challenge as it is in the health improvement challenge. This requires a focus on the effectiveness of all spend and well prioritised action to deliver greater efficiency as well as health gain. • (2) The PCT needs to develop a succinct, revised strategy that captures how it is balancing the need to manage the system, drive effectiveness of spend and move the needle on health outcomes. • (3) The PCT should develop more detailed plans for delivery in a downside scenario, which reflect an agreed set of priorities.

4. Potential for Improvement The PCT has made some progress over the past 18 months. The panel noted improvements in developing the analytical capability of the organisation, and a strong focus on understanding the health needs and opinions of its population. The panel observed that some of these apparent strengths were not reflected as well as they might in the survey results which have pulled the PCT’s scores down in a number of areas. Looking to the future, the panel noted a well-aligned board, with a reasonable record of delivery. The panel would recommend that the PCT takes a step back and reviews the focus of its current strategy in light of the economic climate. The PCT needs to develop a shared vision, not just of the health outcomes it is wishing to achieve, but the shape of a sustainable care system for the population of Kirklees. It needs to balance its tactical and operational actions against a stronger medium-term outlook. In the view of the panel, this will strengthen the chances of success both in health and financial terms.

5. Panel scorecard Previous Current COMPETENCIES GOVERNANCE NHS Kirklees Health outcomes and quality Outcomes Selection Date: 2009/10 Level 4 PCT Rate of Change Current Time Period Level 1 Strategy A Local leader of NHS 01/01/2004 - 31/12/2008 Collaborates with partners 01/01/2005 - 31/12/2007 Patient and public engagement 01/04/2008 - 31/03/2009 Clinical leadership Finance 01/09/2007 - 31/08/2008 A Assess needs 01/04/2008 - 31/03/2009 Prioritisation 01/01/2009 - 31/03/2009 Stimulates provision 01/04/2008 - 31/03/2009 Innovation Board G 01/04/2008 - 31/03/2009 Procurement and contracting n/a Performance management Ensuring efficiency and effectiveness of spend n/a

6. Governance – Panel assessment on Strategy Panel Assessment This year’s self-rating Rationale for scoring Recommendations going forward The PCT needs to develop a very brief, revised narrative that captures how it is balancing the need to manage the system, drive effectiveness of spend and move the needle on health outcomes. This revision should also note the 3-5 tactical areas the PCT needs to address. Last year’s rating Red Green Amber Measure Assessment • 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 A • 1: The PCT clearly showed how its vision links to the local and national health context. However the strategy did not articulate as successfully the national economic context. The selected outcomes are ambitious, but timelines other than the 2014 horizon were lacking. More detail could strengthen the links between initiatives and outcomes and the financial requirements. • 2: There are weak links between investment and initiatives. Although the PCT references a challenging financial situation and the need to make efficiency savings, specific disinvestment plans are not clear. The PCT evidenced during the panel day, how initiatives could impact on health outcomes and inequalities. The level of detail behind the timeline for impact on health outcomes from initiatives was variable. Whilst the PCT demonstrated the use of a prioritisation framework for its new initiatives, there was a concern about lack of plans to prioritise investments/ disinvestment in a downside scenario and the consistency with which the framework was applied in the base case. • 3: The links between investment and health outcome improvements were not as strong as needed and the panel had some concerns around a focus on the effectiveness of spend. Delivery plans were not as clear as needed. Small levels of additional investment are allocated in the strategic plan for 2010/11, but beyond that most investment was set aside for contingency. The PCT has a prudent approach, but the panel queried if it had considered sufficiently the risks to its desired health outcomes. • 4: The PCT evidenced during the panel day, the level of engagement of the board in the strategic planning process . The PCT further demonstrated use of performance scorecards for strategic initiatives and goals at board meetings, which are reviewed and challenged. Follow up action has been taken where required (e.g. underperformance of A&E at the Mid Yorkshire NHS Hospitals Trust). • 5: The PCT has referenced a number of achievements in terms of what it has managed to commission and has improved its performance on some outcome metrics (e.g. smoking quitters and CHD controlled blood pressure). The PCT evidenced during the panel day reviewing past performance against milestones and identifying the causes of non-delivery (e.g. A&E, breastfeeding and tracking delivery through LSP) and articulating the impact of achieving/ exceeding milestones on achieving the PCT’s goals and vision. 5 5

7. Panel Assessment Last year’s rating This year’s self-rating Rationale for scoring Recommendations going forward • The PCT should reassess its prioritisation criteria to more clearly take into account efficiency and VfM. These criteria should also be reflected in the development of the PCT’s downside scenario. Both the base case and downside scenario should be reflected in a revised plan, which is directly linked to the delivery of initiatives/outcomes. Governance – Panel assessment on Finance Red Amber Green Measure Assessment • Historical financial management • Robust financial management • Robustness of planning assumptions • Sustainable financial position as ‘base case‘ • Sustainable financial position under different financial scenarios A • 1: In 08/09, the PCT’s end-of-year outturn was within 0.5% of SHA expectations, with a surplus of £2.8m. The SIF balance at end-of-year in 08/09 was £15.3m. In 06/07 and 07/08, the PCT’s end-of-year outturn was within 0.5% of SHA expectations. • 2: The PCT board has good process reporting and monitoring on a key sets of metrics, and there is good evidence of the board reviewing and challenging performance against these metrics. The PCT has a clear, robust process for invoice management, with robust systems for invoice auditing and clearly established authorisation levels. The PCT has a clearly defined and robust debt and asset management process in place with clear division of duties. • 3: Although the PCT has used different planning assumptions from the guidelines, it was able to explain the rationale for these to the panel (e.g. on activity and prescribing). The PCT has set significant high levels of contingency against risk and defended this position to the panel. The PCT has set high levels of savings and it was not clear to the panel that these were backed yet by sufficiently robust plans which could guarantee delivery. The panel also had concerns about the extent to which provider capacity was matched to forecast reductions in activity growth. • 4: The PCT is projecting a surplus and a position less than 0.5% different of SHA expectations, every year over the next 5-year period. Although the PCT recognises challenges with the future economic climate and highlights the gap created as a result of significant financial pressures and outlines its approach over the next 5 years, there is limited information in relation to how it will deliver against the approach. The PCT cited on the panel day how it had demonstrated over the last year how, when faced with financial challenges, it had reduced spending to ensure it reached a surplus position, and that it had sufficient contingency set aside. The panel does not believe that this is a credible plan for addressing financial challenges and major risks and that the PCT needs a more sophisticated approach to investment/disinvestment to ensure it continues to identify challenges in advance and can make investment trade-offs when required. The panel also noted that it was not evidenced that the board consistently had a grip around the risks that exist in the base case. • 5: The PCT is projecting a surplus and a position less than 0.5% different of SHA expectations, under all financial scenarios every year over the next 5-year period. The PCT has identified a total saving target and outlined in some detail where savings will come from. However, the lack of a clear plan to break even under all financial scenarios is a particular concern, especially under the downside scenario. The PCT highlighted on the panel day that if the downside scenario emerged, it would look at risks and identify opportunities, while still focusing on the organisational priorities and that a large contingency would also support the PCT. While the panel recognises that this approach has been successful in the past, it does not believe this constitutes a plan for the downside.

8. Governance – Panel assessment on Board Panel Assessment Last year’s rating This year’s self-rating Rationale for scoring Red Amber Green Measure Assessment • Organisation • Risk • Information • Performance • Delegation • Board interaction G • 1: The PCT structure is clear and well-defined and roles and accountabilities are clearly stated. The PCT has outlined a range of capacity and capability gaps and has high level plans in place to address these. The PCT vision and values were developed in collaboration with staff. The PCT highlights 4 key areas from the staff survey to form the basis of the OD action plan and demonstrated the specific actions taken in response to this. • 2: The PCT prioritises risk through a risk stratification tool. The PCT demonstrated evidence of the board’s specific role on risk and gave some examples of the board agreeing mitigating actions for risk . The board has a clear process for ensuring clinical input through the “commissioning college”. A SWOT analysis was undertaken on the PEC, following which the PEC was reviewed and became the Clinical Executive. • 3: The board receives regular reports on performance, finance and quality of a timely actionable nature. • 4: Provider reports detail performance on a range of indicators including performance against stretch targets and CQUINS. There was evidence that the PCT reports to its board on performance, finance and quality at every meeting highlighting key issues . The PCT also plays a role in addressing disparities and the PCT outlined on the panel day a number of areas where this has occurred, (e.g. stroke) and what actions came out of this. The panel feels confident that the board, through its processes and the finance and performance committee, plays an active role in addressing disparities. However, the PCT's performance against Vital Signs means that the PCT did not merit a green scoring. • 5: The PCT could clearly describe arrangements for delegation and the reporting mechanism from joint, collaborative or specialised commissioning. The PCT gave good examples of how these areas are part of their overall strategy (e.g. arrangements with NHS Wakefield to work with Mid Yorkshire Hospitals NHS Trust). • 6: The board is involved in developing the strategic plan and members on sub-committees are clearly involved in developing strategies. Greater levels of board challenge particularly on being clear about the rationale for priorities, will be required to support improvements in strategy and finance ratings. 7

9. Outcomes Newly Selected Upper Quartile x Top quartile rate of improvement Previous Lower Quartile x Bottom quartile rate of improvement Current NHS Kirklees health outcomes and quality Outcomes Selection Date: 2009/10 • Changes in outcomes from last year • #6 has replaced another stroke metric (% of stroke admissions scanned within 24 hours) • Performance over last year : • Strong improvement in: #1(females),3 and 8 • Some improvement but at slower rate than average national rate of improvement: #2,4 and 5 (for #4 evidence provided by PCT during the Panel day) • Poorer performance: #1 (males) and 7) although in line with predictions) • Aspirations: • The panel has confidence in the level of aspiration for 5 outcomes: • #1, 2 and 3 • The panel feels that aspirations for the following outcomes appear to be over-ambitious : • #4,6 and 7 • The panel believes that aspirations for following outcomes might be more aggressive: • #5 • Recommendations: • n/a 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 8 8 SOURCE: Team analysis

10. 55.0 Overview – Competencies This year’s self rating Last year’s rating Level Panel Assessment Competency 1 2 3 4 1. Locally lead the NHS 2. Work with community partners • Topline introduction • The PCT has improved on competencies: 1, 3, 4, 5, 8, 9, 10 • For competencies 2, 6 and 7, the PCT’s scores are less than previously assessed competencies • The panel agreed with the PCT’s self-assessment in 11 out of 33 sub-competencies 3. Engage with public and patients 4. Collaborate with clinicians 5. Manage knowledge and assess needs 6. Prioritise investment Stimulate market 7. 8. Promote improvement and innovation 9. Secure procurement skills 10 Manage the local health system 11 Ensuring efficiency and effectiveness of spend* 1 Competency added this year, hence last year’s rating not available

11. Competency 1 – Panel assessment 1 2 3 4 Rationale for scoring Panel Assessment Last year’s rating This year’s self-rating Level Competency Measure Are recognised as the local leader of the NHS • Reputation as the local leader of the NHS • Reputation as a change leader for local organisations • Position as an employer of choice • A: Key stakeholders agree that the PCT is the local leader of the NHS, although feedback is not consistent (survey score 4.91 is below the SHA average 5.14.). The PCT actively participates in the local health agenda, working with the local authority around targeted health programmes using metrics to measure success. The PCT collects patient experience data e.g. Camper van, local/national service user surveys. Whilst the PCT demonstrated during the panel day that it understands and acts upon patient experience and reputation levels e.g. maternity services at Mid Yorkshire Trust, the PCT were unable to score a level 3 on this sub-competency because of the views of the local population about the extent to which they believe Kirklees is improving services. (64.9% vs. SHA average of 67.5%). • B: The PCT evidenced working in partnership with the local authority , voluntary organisations and the independent sector, with joint investment in resources to shape service design and delivery. The PCT gave good examples during the panel day to demonstrate how it actively works with other local commissioners and other partners to influence their actions. Key stakeholders agree that the PCT significantly influences decisions and actions, although the score of 4.77 is below the SHA average of 4.93. The PCT provided evidence of working with other commissioners e.g. Kirklees has a joint “Efficiency board” with Calderdale PCT to deliver productivity opportunities. However the panel was unable to identify clear examples of where the PCT has specifically led on changes to influence and impact other local commissioners and local partners. • C: The staff survey results for Kirklees are good on a wide range of measures. The PCT has clear commissioning development programmes for staff in place e.g. the Kirklees way. 10 10

12. Competency 2 – Panel assessment Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Recommendations going forward • The PCT is clearly doing some excellent work in its partnerships, which is not reflected in its feedback from stakeholders. It may be worth the PCT ensuring it knows why this is the case, and dealing with any material issues. Level Competency Measure Work collaboratively with community partners to commission services that optimise health gains and reduce health inequalities and deliver increased productivity • Creation of Local Area Agreement based on joint needs • Ability to conduct constructive partnerships • Reputation as an active and effective partner’ • A: The PCT has worked in partnership with the LA to agree and refresh LAA priorities. There are strong monitoring arrangements in place. The PCT uses the context of place to tackle issues in the area, and the strategic plan is closely aligned to the Kirklees partnership strategy. Whilst the PCT clearly demonstrated during the panel day, broad clinical engagement in reconfirming LAA priorities e.g. commissioning college, involving PBC representatives and clinical leads, there was a lack of clear evidence of clinical leadership in creating, reconfirming and delivering the LAA , which would be necessary to reach level 4. • B: The PCT has good partnerships in place, with a clear joint focus on health across the PCT and local authority. There are a range of shared posts in place. However, the stakeholder survey only scored the PCT 3.82 for engaging their organisation compared to the SHA average of 4.45 and this will hold the PCT back from reaching level 3. • C: The LAA sets out clear milestones for delivery of PCT owned targets. The PCT outlined good examples of success in partnership working. However, the stakeholder survey was disappointing with a metric of 4.48 for scoring the PCT as an effective partner compared to the SHA average of 4.9 and this will hold the PCT back from reaching level 3. 11 11

13. Competency 3 – Panel assessment Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Recommendations going forward • In the view of the panel, the PCT has a good approach to public and patient engagement, which is not reflected by the views expressed in surveys. The PCT needs to understand why this is the case. Level Competency Measure Proactively build continuous and meaningful engagement with the public and patients to shape services and improve health • Influence on local health opinions and aspirations • Public and patient engagement • Improvement in patient experience • A: The PCT has effective strategies around areas such as PPI, social marketing and the “Share Your Views” database which have been informed via the equality impact assessments. Stakeholders scored the PCT 4.15 for shaping health opinions compared to SHA average of 4.48. There are good examples where the PCT has actively promoted health and well being e.g. social marketing approach to halt the rise in obesity on 16-24 year olds and a diabetes survey to obtain feedback for action on the care and support which local people with diabetes receive. However, the PCT were unable to achieve a level 3 for this sub-competency due to the below average stakeholder survey results on shaping health opinions (4.15 compared to the SHA average of 4.48). • B:The PCT has a strategy in place for public and patient engagement, and highlighted numerous practical examples of the strategy in action e.g. working with pregnant women in Dewsbury, midwifery care at Dewsbury District General and stroke care. It was clear that the PCT works with local forums including LINKS, and acts quickly on any soft intelligence. However, the PCT received a below SHA average score for patients agreeing that the PCT listens to their views and this will hold them back from achieving level 3. • C: The PCT demonstrated during the panel day how it actively reviews trends e.g. use of predictive tool, use of PALS and the role of the governance committee and initiates improvements as a result e.g. information used at start of commissioning process e.g. Stroke, outpatient appointments – clash with fasting/prayer times, residential care home – digital TV . 70.4% of patients agree that the NHS is helping to manage and improve the health and well-being of the population, compared to 71.5% SHA average (Public Perception Survey). 12 12

14. Competency 4 – Panel assessment Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Recommendations going forward • Greater clinical ownership, particularly with primary and secondary care, is vital in future leadership of the PCT’s health system. The PCT will need to continue to build on this for delivery. Level Competency Measure 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 • Clinical engagement • Dissemination of information to support clinical decision making • Reputation as leader of clinical engagement • A: The PCT evidenced during the panel day how it includes a range of clinicians from all healthcare and well being delivery methods and highlighted examples of clinically led improvements in quality and productivity. The PBC clinicians participate in quality boards with CHFT & KCHS, and help generate ideas for quality improvement. Pathway redesign groups consistently show evidence of primary and secondary care clinicians linkage to support commissioning e.g. ophthalmology, pain and cardiology . • B: The PCT evidenced during the panel day how quality of care information is regularly shared e.g. quality boards and primary care practice data. The PCT has established a data queries and reconciliation group with PBC representatives to improve data quality and confidence. The PCT further demonstrated during the panel day, how it proactively solicits and disseminates status updates and quality improvement ideas from a broad range of clinicians on a regular basis e.g. use of quality boards, performance reports, primary care peer to peer practice reviews etc. PBCs rate the PCT Fairly Good in the information they receive and fully agree that they receive relevant information. • C: The PCT provided good evidence of where they have implemented initiatives to redesign care and evidenced robust processes in place to ensure all business cases are considered for approval within 8 weeks and address conflict of interest issues. The PCT demonstrated during the panel day some good examples of clinicians leading initiatives to improve quality and productivity e.g. respiratory, stroke. However, the panel considered that a track record is needed to be considered level 3, and stakeholder survey results would also need to improve.

15. Competency 5 – Panel assessment Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Level Competency Measure Manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements • Analytical skills and insights • Understanding of health needs trends • Use of health needs benchmarks • A: The JSNA shows evidence of PCT using consistent methodology to identify gaps in care, including health inequalities. The PCT has developed and used a prioritisation framework to prioritise major health needs for its local population and demonstrated during the panel day how it uses the JSNA to assesses current and future, unmet needs e.g. psychological well being, women life expectancy and lung cancer in women. The JSNA shows evidence of use of a consistent and validated methodology, using insights from a range of stakeholders. The PCT analyses progress towards reducing gaps and identifies the key causes of variance from expectations and has a clear, robust segmentation of population by healthcare needs. • B: The JSNA shows evidence of the PCT having a fact-based list of the major health risks and priorities facing its local population by demographic and disease group and of the PCT identifying over time, trends in major health and well-being issues e.g. breast cancer. The PCT has gathered key insights from the public, patients, clinicians and other stakeholders in JSNA findings. The PCT evidenced during the panel day, clear views of unmet needs for its local population, which can be disaggregated to locality/ward level e.g. obesity, Dewsbury plans. LAA performance reports show evidence of the PCT analysing progress and identifies any gaps towards achieving improvement targets. • C: The PCT evidenced benchmarking itself against national targets and peer PCTs on local health needs status and priority health outcomes. The performance strategy establishes a framework for the PCT and partners to work towards a more detailed, responsive understanding of underperformance and identify potential solutions. The PCT demonstrated during the panel day, how it effectively disseminates reports to providers, partners and the public e.g. the JSNA is on the PCT website, use of press, dissemination through locality discussions and information shared with schools. 14 14

16. Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Recommendations going forward • As highlighted elsewhere, the panel recommend the PCT review their prioritisation criteria, and how they are used, to develop clear priories for disinvestment/investment in a downside scenario. Competency 6 – Panel assessment Level Competency Measure Prioritise investment of all spend in line with different financial scenarios and according to local needs, service requirements and the values of the NHS • 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 invest-ment plan to reflect different financial scenarios • A: It is clear that the PCT has done some financial best and worst case scenario modelling and it appears that they have commissioned services based on activity projections. The panel felt that predictive modelling is an emerging story for the PCT and notes that the OD plan recognises a capability gap in scenario planning. The PCT is building this skill through the use of the predictive risk tool and scenario generator. This is clearly an area where the PCT is making rapid strides, and the panel are confidence that the PCT will very quickly improve its competency. • B: The PCT provided clear prioritisation criteria on the panel day. Initiatives are generated from a range of insights. However it was not clear that the PCT conducts a full annual review of all investments and disinvestments. • C: The PCT has considered priorities in a worst case scenario (saying they would remain the same), but the overall message is that initiatives will have to be delayed or cancelled, rather than specific initiatives being prioritised above others. The panel noted that the PCT has not evaluated and reprioritised investment or disinvestment decisions under multiple scenarios. On the panel day, the PCT described its approach to cross-cutting initiatives, e.g. IT, but recognised that its criteria do not fully apply to cross-cutting initiatives. The panel did not feel the PCT had sufficiently thought through how cross-cutting initiatives weigh up against other areas on the prioritisation criteria.

17. Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Competency 7 – Panel assessment Level Competency Measure Effectively stimulate the market to meet demand and secure required clinical and health and wellbeing outcomes • Knowledge of current and future provider capacity and capability • Alignment of provider capacity with health needs projections • Creation of effective choices for patients • A: The PCT has begun to map the current provider landscape through the work across Y&H and has recognised some challenges with the market, e.g. having 2 large acute providers. However this work does not cover all segments of the market, map future providers or cover relative costs of providers. The PCT also outlined on the panel day how it had done some further work around primary care, e.g. understanding practice types, mapping list sizes and relative performance, and was able to outline how it is using this information to tackle underperformance, e.g. with the primary care independent provider in Dewsbury. The panel recognises that the PCT is demonstrating some good level 3 examples already, reviewing trade offs between acute providers from a cost perspective. • B: The PCT shared examples on the panel day of how commissioning decisions have been based on demand projections, e.g. Dewsbury oral health and LTCs, although these did not feel embedded in the PCT, nor did they demonstrate how provider capacity has been adjusted accordingly. It was not clear that the PCT has identified gaps in the market or developed mitigation plans for these risks. The PCT state that they are developing a market management strategy but it is not clear that this has been implemented as yet. • C: It was not clear that the PCT regularly reviews the provider market in light of choice, or that a strategy for creating choice is central to the PCT. However, the PCT did outline examples on the panel day of how it has worked with patients to create choice, e.g. ADD, alcohol/drug counselling improvements and LTCs. The PCT scores higher than national and SHA averages for % of patients offered a choice of hospital for first appointment, although its strategy for working with referrers was not transparent.

18. Competency 8 – Panel assessment Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Level Competency Measure Promote and specify continuous improvements in quality (e.g. CQUIN, IQI) and outcomes through clinical and provider innovation and configuration • Identification of improvement opportunities • Implementation of improvement initiatives • Collection of quality and outcome information • A: The PCT has taken some steps to engage with its acute providers to identify improvement opportunities based on BCBV indicators. The obesity and mental health pathways are clear, with specific interventions and criteria for moving patients along. The intermediate care pathway lists interventions but without criteria for moving patients. There was limited evidence of the PCT aggregating GP system data to run patient risk analysis and target patients, although the PCT has work underway which should deliver this very shortly and enable the PCT to reach level 3. • B: The PCT demonstrated during the panel day, a clear approach to quality improvement and staff who are capable of applying the approach e.g. KirkleesWay, quality boards and programme management training for staff . Some examples of demonstrable results from changes in clinical pathways were cited in the strategic plan. Improvements span a range of services and networks. • C: The PCT evidenced clear identification of quality and outcome metrics to monitor (both national contract and locally agreed). Performance management is identified as an organisational enabler that needs further development . The PCT demonstrated during the panel day, near real time monitoring on measures where the PCT could have influence such as emergency admissions data, LOS, MRSA and C.diff, but there was less clarity on how information links quality and efficiency. 17

19. Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Competency 9 – Panel assessment Level Competency Measure Secure procurement skills that ensure robust and viable contracts • Understanding of provider economics • Negotiation of contracts around defined variables • Creation of robust contracts based on outcomes • A: The PCT highlights in its self assessment the development of provider economic database covering all key sectors and an associated analysis to see providers of high spend, low quality and high influence, and the PCT is supplementing this with work on primary care (although it recognises this has not been fully populated). The PCT does evidence monitoring and considering a broad range of available patient experience, quality of care and productivity metrics for all key providers. The recent procurement of a predictive risk tool, that will utilise information on GP practice systems and enable the PCT to identify those patients most likely to experience deterioration in their condition, was in line with the PCT procurement strategy. The PCT did provide the panel with some examples of making level 3 tradeoffs. • B: The PCT has clearly identifiable local negotiation variables. It has clear processes for preparing for negotiations and displays many characteristics at level 3, but will need to develop its approach to risk negotiation and risk sharing to secure this. • C: Contracts show evidence of specifying defined outcomes, quality and service metrics, cost, productivity and activity expectations, and the PCT highlighted that the arbitration process is covered by all national contracts. The PCT uses national and PCT defined outcome and quality metrics to negotiate new contracts. Contract documentation submitted was signed in advance of activity commencing. The panel recognises that the PCT is exhibiting some early level 3 behaviour.

20. Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Competency 10 – Panel assessment Level Competency Measure Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvement in quality and outcomes and value for money • Use of performance information • Implementation of regular provider performance discussions • Resolution of ongoing contractual issues • A: The evidence submitted gave clear references to locally defined metrics. Ownership of data was clear, with details of what the provider is responsible for submitting. Performance reports include data that is less than 6 weeks old, and there are examples of the frequency with which the providers must report to the PCT. The PCT monitors a good range of performance metrics including quality, access and workforce. Provider performance reports are published on the website as part of the board minutes. The PCT gave good examples of taking action on real time monitoring. • B: The PCT has regular performance discussions with providers on at least a monthly basis. Provider performance reports are generated monthly, and the PCT monitors a range of providers across acute, community and primary care. The PCT has established contract and quality boards with acute and mental health providers which frequently monitor performance, e.g. stroke performance was escalated to the quality board where root causes were identified and addressed. • C: The PCT has pro-active contract compliance management in place for key providers and in its self assessment references a contract management structure. The contracting forms contain clear descriptions of KPIs and the process for agreeing improvement plans is clear. Improvement plans are monitored closely and the PCT has a strong record of delivery in terms of improvement plans, e.g. mental health, cancer services at Mid Yorks.

21. Panel Assessment Last year’s rating This year’s self-rating 1 2 3 4 Rationale for scoring Recommendations going forward • The PCT will need to consolidate their plan to deliver identified efficiency and effectiveness initiatives. Competency 11 – Panel assessment Level Competency Measure Ensuring efficiency and effectiveness of spend • Measuring and understanding efficiency and effectiveness of spend • Identifying opportunities to maximise efficiency and effectiveness of spend • Delivering sustainable efficiency and effectiveness of spend • A: On the panel day, the PCT showed how it analyses relevant outcomes for pathways but there was limited evidence to prove that the PCT analyses outputs, spend level and output efficiency for all pathways relating to priority outcomes. The panel noted that the PCT’s focus was on effectiveness in this area not efficiency. The PCT showed on the panel day how they benchmark relevant outcomes and output efficiency against national best practice, which was used to identify opportunities for HITs to further explore. The PCT highlighted that while it understands the economics of some providers, this is not true across the board, e.g. there was a recognition that it is a risk to the PCT that it does not fully understand the nature of CHFT economics, although this is starting to emerge through the transformation board. • B: The panel recognises the PCT is in the early days of its work on pathways and there are more areas to explore. The PCT has highlighted the redesign of the diabetes pathway in moving significant levels of activity from secondary to primary care and the PCT highlighted on the panel day other pathways that address efficiency and effectiveness of spend and provision efficiencies, e.g. intermediate care and rehab and alcohol services. The PCT outlined how it is identifying opportunities for improvement within its own cost base: operational efficiency through joint posts and co-commissioning; capital efficiency through an estates review and procurement efficiency through the introduction of Scriptswitch software to support GP decisions. • C: The strategic plan shows evidence of the PCT defining a set of initiatives to deliver the identified efficiency and effectiveness opportunities and this ‘QIPP list’ was further discussed on the panel day. The PCT did not consistently articulate what these opportunities were and what their potential value was. The panel was not able to elicit sufficient details around how efficiency and effectiveness initiatives are delivered and there was a perception that this work is in early days, e.g. diabetes and CAMHS.