Choice

1. CREATING A PATIENT-LED NHS: COMMISSIONING - FIT WITH SYSTEM REFORM Desired Outcome Patient experience Taxpayer returns Policy Drivers PbR Choice Commissioning 18 weeks Contestability New Service Models Relevant Enablers & Prerequisites Demand Management Balance demand/supply Manage growth Control environment Market Management Entry/accreditation process Competition policy/level playing field Exit framework

2. CREATING A PATIENT-LED NHS: COMMISSIONING FRAMEWORK B) HOW AND WHO A) WHAT Phase Process Service type • Setting strategy Hi volume Low complexity Low volume High complexity • Identifying need • Planning supply/managing failure 1 Population coverage • Micro-level • Financial planning • Specifying services (Strategic Commissioner) • Managing demand • Procuring Large STRATEGIC COMMISSIONING Small • Contracting • Contracting 2 • Managing contract performance Practice • Settlement • Billing, invoicing and claims 3 • Monitoring activity • Shared Functions • Fee for service • Buyer power • Best practice sharing • Reducing costs • Monitoring outcomes 4 • Reporting • Analyzing causalities • Patient experience • Managing information

3. CREATING A PATIENT-LED NHS: COMMISSIONING WORKSTREAMS Workstream Practice-based commissioning Contracting and Procurement Payment settlement & reporting Demand management Creating a commissioning market Service Specification • Assess and minimise risk of supplier induced demand • Identify legitimate increases in demand • Counterbalance to increased capacity, new incentives, reduced controls • Drive out efficiencies in commissioning • Ensure commissioning functions are undertaken by someone with most appropriate skills at most appropriate “level” (i.e. regional, local) • Better value for money • Reduced purchasing transaction costs • Improved purchasing outcomes • Promote GP engagement • Promote local innovation and service redesign • Create efficiencies in service provision • More efficient management of patients into secondary care • Minimise bureaucracy • Support PBC and PbR • Provide timely, accurate information on activity , volume and cost • Underpin new contracting model • Support Demand Management countermeasures Policy Rationale • PCTs will have arrangements in place for universal coverage of PBC by Dec 2006 • Contract management and administration to be organised more efficiently, possibly procurement hubs • Development of national and regional standard contacts • Further consideration will be given to the development of a system similar to PACT • PCT functions can be provided by external agencies, partners and consortia working on their behalf • Comprehensive service spec’s by April 06 Intention • Scoping study of existing UK and International best practice • Assessment of value of national program, etc by Sept 05 • Options appraisal to be completed by 30/9/05 • Recommendations to ministers in autumn 05 • Scoping study of extent of market, range of services and stakeholders, entry requirements, costs, etc by Sept 05 • Scoping study to be completed by 9/9/05 • Recommendations to ministers in autumn 05 • Model scale and extent of SID by Autumn 05 • Assessment of measures to manage SID by autumn 05 • PMDU review of current policy by Aug 05 Next Steps

4. NLN Lead: David Nicholson SRO: Julie Taylor Practice-based commissioning Contracting and Procurement Demand management Service Specifications Creating a commissioning market Payment settlement & reporting Commercial Directorate Ken Anderson Caitlin Francis Primary Care - Access Gary Belfield Helen Edwards System Reform Miles Ayling/ Sarah Hall Delivery Analytical Team Richard Murray Keith Derbyshire • Commercial Directorate • Ken Anderson • Caitlin Francis System Reform Miles Ayling/ Sarah Hall NATIONAL PRIMARY CARE CONTRACTING TEAM Lead: Helen Northall NATIONAL PRIMARY CARE DEVELOPMENT TEAM Lead: Ruth Kennedy STOCKPORT PCT Lead: Alison Tonge (Director of Finance and Estates) SHEFFIELD PCT Lead: Simon Hampton (Director of Service Improvement and Innovation) CUMBRIA & LANCASHIRE SHA and GREATER MANCHESTER SHA Lead: [tbc] SOUTH YORKSHIRE SHA Lead: Mike Palmer STOCKPORT PCT Lead: Alison Tonge (Director of Finance and Estates NORTH MANCHESTER PCT Lead: Mandy Wearn NEYNL SHA Lead: THAMES VALLEY SHA Lead: PA Consulting Lead: Shera Allen PWC Lead: Simon Leary Flute Consulting Lead: John Gurnett ----- McKinsey Lead: Barrett Reumping ---- Streamlining PCTs PbR Connecting for Health Streamlining ISTCs Payment by Results Connecting for Health Streamlining Payment by Results Market Management Choice Market Management CPL NHS: COMMISSIONING POLICY LEADS, POLICY DEPENDENCIES AND NHS PARTNERS Programme Lead: Miles Ayling Workstream Joint DH Policy Leads NHS Partners Consultants Engaged Policy Dependencies

5. Service planning Contracting Payment Settlement Micro-level (PBC) Demand Management Creating a commissioning market Better use of PH & Epidemiology data, market segmentation Co-ordinated by PCT Delivered by ‘Agency’, possibly bought in Accountability remains with practice/PCT One contract only for each Trust Procured and managed through lead PCT or procurement hub Standard model contract (similar to FTs) To include demand management measures & PSA target req’s Billing, invoicing & reconciliation will be automated Hosted by shared service or agency Initially secondary care but extend to all settings Underpinned by FRM Development of evidence based care pathways to improve the patient experience Practice level commissioning budgets for the appropriate ranges of healthcare services High quality management information to inform decisions on utilisation and service redesign Measure risk and pinch points Proportionate response (80/20) Likely to include mix of supply & demand side controls, linked to non payment, e.g. Utilisation reviews Prior approval/notification systems PROMS Built into contracts Open market to private sector No fee – shared efficiencies Entire range of commissioning function Accountability remains with practice/PCT CREATING A PATIENT-LED NHS: COMMISSIONING – LIKELY SCENARIOS Likely scenarios

6. CREATING A PATIENT-LED NHS: COMMISSIONING – NON SPECIALISED SERVICES FUTURE MODEL • PLAN • Set strategy • Identify need • Plan finances • Manage demand • Specify services • PURCHASE • Procure • Contract • Manage contract • Bill, invoice & claims • MONITOR • Monitor activity • Monitor outcomes • Analyse causalities • Review patient experiences • Manage information [Monitor: Health outcomes] MESO Geography 0.5m – 1m Need All needs in geo population Services Procured Med/Hi complexity Monitoring whole population Procurement Agency Central Paying Agency Terms Accountability PCT Activity Strategic Commissioner Strategic Commissioner Specifications + ext support? Delivery [monitor: contract performance] Need Activity MICRO Geography – 2k – 20 k Need – All needs in geo population Services Procured – Lo complexity Monitoring – practice population Practice Accountability PCT PCT Practice/ Consortia Practice/ Consortia BIF Delivery BIF Agency Agency

7. CREATING A PATIENT-LED NHS: COMMISSIONING – KEY QUESTIONS Key Questions Policy Area • Allocations methodology – will change? • Rules, conventions that National Settlement System will need to abide by • Same for Trusts and FT’s? • PbR and PBC policing regimes • Who guards and is accountable for the cash limit Financial Regime • How comprehensive and by when? • How flexible – marginal rates? • Macro or micro - will we unbundle? Payment by Results • Scope/Scale of contestability • Failure Regime Market Management • Roll-out of SUS, scope and reliability Information Systems • PbR • Care Pathways • Co-payments Social Care

8. 2005 2006 2007 2008 2009 J A S O N D J F M A M J J A S O N D J F M M A M J J A S O N D J F M A M J J A S O N D J F M Key Reporting Date End August 2005 Commissioning A M J Demand Management DM workshop & Scope ToR Implementation Model scale/extent of risk of SID Evaluation & review Guidance Issued Scope & tests counter measures Report to SRB/Minister Demand Management design completed Interim guidance PBC PBC scope finalised Report & rec’s First wave of enhanced PBC All PCTs with arrangements in place to offer PBC Interim guidance Contracting & Procurement ITT issued Report and Rec’s Implementation Evaluation Contracting design completed Guidance issued Payment Settlement ITT issued Guidance issued Evaluation Stakeholder engagement Procurement Early adopter design complete Risk analysis National roll-out Specification design Early adopter implementation Report & recommendations Slippage Major Milestone: V0.01 4th July 2005 As Planned