PCT Commissioning, Business Models & Pathology

1. PCT Commissioning,Business Models & Pathology Dr Rick Jones Leeds Teaching Hospitals Trust

2. A Patient-led NHS requires: • Informed Patients: • responsibility • choice • tax payers • Effective Commissioners: • responding to Patients • understanding the evidence base • managing demand • Responsive providers: • liberated from central control • competing to improve • managing costs

3. Commissioning ‘the means by which we secure the best value for patients and taxpayers. By ‘best value’ we mean: • The best possible health outcomes • The best possible healthcare • With the resources made available by the tax payer’ DH 2006

4. Commissioning The term “commissioning” is interpreted in different ways by different people. It is often used to denote “contracting” but in reality refers to a much broader process encompassing planning, procurement / contracting and performance management underpinned by partnerships. Keith Douglas, Director of Planning and Service Redesign, Eastleigh and Test Valley South Primary Care Trust and New Forest Primary Care Trust

5. Commissioning: • ‘the set of linked activities required to assess the health care needs of a population, specify the services required to meet those needs within a strategic framework, secure those services and monitor and evaluate the outcome’ Woodin, 2007

6. The Commissioning Cycle Assess health needs monitor contract Decide priorities Award contract Review current service provision Procure provider Develop new service model

7. What people want • Local services there when you need them • Emergency care when you need it • No waiting • The best patient experience • To have a say, to have a choice • More emphasis on prevention • Health and social care working together • Improved health

8. Where does Pathology fit in?18 Weeks Tertiary 18 weeks A&E Diag (IP) OP GP OP OP IP Diag (OP) OP Assess Other 1st OutpatientAppointment Diagnostic phase Decision to treat Treatment/Discharge Follow-up Data flows Choose and Book Future Care Activity Outpatients (Care Activity) Elective Admission List Admitted Patient Care A & E

9. NOW: Clarify commissioning objectives Patient pathway Measurement Identify best practice Redesign patient flow and scheduling Plan demand & capacity Procure capacity 2008: No waiting Improved productivity Appropriate access points Demand & capacity in balance Clinical futures & commissioning aligned Delivery of 18 weeks: Diagnostics

10. Pathways Pathways need to be focussed on the needs / demands of the population and on resources available: one of the really difficult tasks for commissioning to address is what should and should not be delivered as clearly not everything can be afforded… Keith Douglas, Director of Planning and Service Redesign, Eastleigh and Test Valley South Primary Care Trust and New Forest Primary Care Trust

11. How should pathology engage? • Who to approach? • By what route? • What type of services to present? • Reactive or pro-active engagement? First know your customer and your product(s)

12. From Craftsmen to Service Providers • Our society has become what it is today through the forces of • Specialization • Standardization • Scalability • It is now almost exclusively “service” oriented • Transportation • Telecommunication • Retail • Healthcare • Financial services • … The IT industry which has many parallels to Pathology – high tech, rapidly developing, knowledge-based, ill understood by majority of users

13. Classic 1900’s Companies Control Delivery Control Services Control Information Have expensive acquisition processes and static relationships Managed pricing and expectations Information Age 21st Century Consumer is empowered by information access Businesses win by being open Businesses win by leveraging new mechanisms to drive their own costs down. Dramatic lower overall cost potential, higher level of services. Tidal Wave of Business Shift

14. Pathology Haem ClinBiochem Histo Micro Immuno Genetics Traditional Pathology Organisation Local Trust GPs Other TrustsScreening

15. Operations Management Capability Relationship Management Product Management DeliveryManagement Quality Assurance Cust 1 Service A Process X Service A Outcome Cust 2 Service B Process Y Service B Outcome Cust 3 Service C Process Z Service C Outcome Operations Execution Capability Product Development Process Engineering Measurement Sales Service-based Organisational Framework

16. + + = Technology, Products & Platforms People Process Service • Intangible • Non-persistent • Described in Benefit or Customer Terms • An Action, not a Thing What exactly is a service?

17. A Service “Giving assistance or advantage to another” These are NOT services

18. What is pathology? • Laboratory Processing • Near Patient Testing • Clinical Advisory Service • Screening Services • Chronic Disease Management • Direct Clinical Service to Patients • Training and Education • Research and Development • Clinical Audit • Policy support • ………………………….plus other services

19. What are the key features of good commissioning? • Not just the responsibility of one organisation - input from wide range of people with different skills • Strong local partnerships, e.g. • PCT, local authority • Network • local users • Different types of commissioning, e.g. • PCT commissioning • Joint commissioning • Practice based commissioning • Network commissioning • Specialist commissioning

20. Supply chain management: The commissioner needs to understand the supplier and aim for mutual success on behalf of local people... understanding the cost base and the problems… the provider needs to understand the commissioners problems, aspirations, targets. This requires honest and open lines of communication, using the right medium for the right message. Only with this can commissioners and providers deliver in partnership for communities. Martin Barkley, Chief Executive, Hampshire Partnership NHS Trust

21. Knowing your place in the Service Fulfilment Chain D =Patient There are many providers and customers in a service fulfilment chain, but… D C =Clinician A & B =Pathology C B = Provider C = Customer C = Provider D = Customer B A = Provider B = Customer A ….. services must be expressed in terms of the ultimate end customer,

22. Examples of PBC Service Redesign • Chronic obstructive pulmonary disease • Long-term conditions • Ophthalmology • Heart failure • BNP in community • In-house ECHO • Urology • Haematuria protocol for diagnostic tests • H.pylori

23. Knowledge: Commissioners need to know national policy, guidance, standards, targets. They need: a passion (or at least an interest) in the services being commissioned, to understand local needs and priorities, to be able to speak and commit on behalf of the organisation and know the service being commissioned. Martin Barkley, Chief Executive, Hampshire Partnership NHS Trust

24. Pathology Commissioning • Direct Access • Provider / Provider • Clinical contract with Trust • Specialist commissioning Do commissioners know what to commission?

25. Continuum of commissioning Level of commissioning Smith et al 3 individual……...practitioner……….practice……….locality……….community…….region……….nation Multi-practice or locality commissioning PCO/PCT commissioning Patient choice National commissioning Single practice based commissioning Joint commissioning Lead PCT/LHB commissioning micromesomacro

26. What SHAs will want • Strategic Planning (major investment / configuration / workforce) • Support for research, innovation and education / training • Help in creating new health system • System management with regulators • Performance management of PCTs / market • Possibly some tertiary level via PCT groups & networks

27. Commissioning Specialist Services Example: Haemoglobinopathy screening • Universal neonatal screening • NHS roll out programme, funded until March 2007 • Universal antenatal screening funded study for 2 years to screen women in Leeds / Bradford Post 2007: PCT sign up?

28. What PCTs will want • Strategic Commissioning - not short term fixes • Programmes to improve the health of the community • Reduction in inequalities - standard packages • Assurance of safe, high quality services • Managed contracts on behalf of Practices • Performance within budgets • Transparency on costs • Verification of secondary care requirements - checklists • Public engagement - informed choices • May need some community services

29. Commissioning Cancer Services Example – leukaemia • Panels of cell markers • Commissioning only from laboratories who meet current guidelines • Audit of current activity / practice • Need sufficient activity / expertise

30. North Bradford PCT Service Improvement Pyramid Corporate bodies Practice based commissioning PCT + PCT managed Groups of practices Practice managed Service delivery informed by patients

31. Performance Improvement Model Mission Performance Packages Vision Incentive Scheme Patient Experience Culture PBC PMS Practice Manager leads Support Advisory Groups PLT/PBE Unit of Service Delivery Education Pursuing Perfection Specialist Groups Practice Review Meetings Collaboratives Optimising Hospital Utilisation Patient/Consumer Involvement Clinical leads Information

32. What GPs Want From Pathology • Benchmarking data (test rates) • Integration of pathology into care pathway • Standardised guidance, up-to-date • Best practice guidelines • Reduction in inappropriate testing • Electronic requesting / reporting • Automatic prompts • Governance role of laboratories • Standardisation across the patch • POCT where appropriate VALUE ADDED PARTNERSHIP

35. Must be taken at least 12 hours post chest pain

39. What patients will want • Convenient and accessible services • To know why tests are being done • Tests are safe and kept to a minimum • Results in the shortest possible time • Reliable results • Information on meaning and implications of results

41. Putting it all together Strategic commissioning objectives • Long-term conditions • Diagnostics • Elective care • Urgent care Enabling projects

42. How should pathology engage? • Who to approach? • Trusts • PCTs • SHAs • GPs • By what route? • Some direct – POCT, INR, DMARDS • Some indirect – clinical bundles, composite services • What type of services to present? • Coherent - results & evidence & support • Complete – clinical answers not widgets • Reactive or pro-active engagement? • Pro-active – now or never

43. Service Orientated Organisation ServiceSupport Users Production & Back Office Clinically Orientated Service Delivery Patient Centric Approach Acute Trusts & PCTs Logistics BusinessSupport High Volume Core Lab Specialist Functions e.g. Molecular Cytological ScreeningDrugs Regional National Research / Training / Devel Quality Assurance / Audit Knowledge Management

44. Remember “ A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty” Sir Winston Churchill

45. Conclusion Price & Jones The challenges in commissioning laboratory medicine (pathology) services. Journal of Management & Marketing in Healthcare. VOL. 1 NO. 2. PP 1–13. Jan 2008