The Commissioning Cycle

The Commissioning Cycle

The steps:

•Needs assessment•Service provision review•Priorities•Quality outcomes•Design services / pathways•Providers/suppliers•Demand management•Clinical decision making•Manage performance and outcomes

Underpinned by:

•Primary care involvement•Public and Patient engagement•Evidence based practice

Assessing Needs

Segment & trend analysis

Prevalence

Morbidity & mortality

Risk factors & lifestyle

Assessing Needs

Review

Service

Provision

Decid

e on

P

riorities

Specify

Quality

Outcom

es

Design

Services &

Pathways

Manage Quality

& Performance

Clin

ical

D

ecis

ion

Mak

ing

‘Market’ Intelligence

Data collection & reporting

Service access

Tools

Capabilities

Clinical Commissioning

Contract

providers

Man

age

Dem

and

What is needs assessment?Needs assessment identifies and strives to eliminate overuse, misuse and underuse of healthcare resources

• A variety of comprehensive evidence sources can be used that include, but are not limited to the following:

• Local knowledge of clinicians, health care providers, commissioners

• Local Authorities • Practice based commissioning data • Prescribing data • Prevalence and incidence data • Community health profiles • Housing data • Inpatient and outpatient data • Lifestyle data • Educational attainment data • Deprivation indices • Views of patients/service users • Census and other demographic data • Referral data

• Joint Strategic needs Assessments (JSNAs) are local assessments of current and future health and social care needs that could be met by the local authority, CCGs, or the NHS CB

• JSNAs and the Joint Health and Wellbeing Strategy is produced by health and wellbeing boards to set priorities for future action.

Review Service Provision

Best practice definition

Current performance

Benchmarking tools

Cost effectiveness analysis

National indicators

Clinical outcome measures

Assessing Needs

Review

Service

Provision

Decid

e on

P

riorities

Specify

Quality

Outcom

es

Design

Services &

Pathways

Manage Quality

& Performance

Clin

ical

D

ecis

ion

Mak

ing

Tools

Capabilities

Clinical Commissioning

Contract

providers

Man

age

Dem

and

Existing evidence base

Review current service provision

• Service reviews are undertaken to demonstrate a thorough understanding of current services provided in relation to the identified health needs. In essence, it is to ensure that services commissioned for the population are effective and of high quality.

• Key tasks to be considered as part of a service review include:-– Understanding the operational delivery, workforce issues and clinical factors for the

service – Developing knowledge of clinical effectiveness and evidence base – Benchmarking service against national or other indicators to access efficiency – Reviewing applicable performance indicators or monitoring clinical outcomes – Reviewing user experience and satisfaction with the service – Establish best practice clinical/public health guidelines for the service

Decide on Priorities

Assessing Needs

Review

Service

Provision

Decid

e on

P

riorities

Specify

Quality

Outcom

es

Design

Services &

Pathways

Manage Quality

& Performance

Clin

ical

D

ecis

ion

Mak

ing

Patient feedback

Capabilities

Evidence synthesis

Clinical Commissioning

Contract

providers

Patient population analysis

Systematic reviews

Health economic analysis

Man

age

Dem

and

Benefits case development

Patient communications

Decide and agree Priorities

• PCTs need to ensure that both national and local priorities are considered for inclusion in its Strategic Commissioning Plan and Annual Operating Plan, and that appropriate and sufficient stakeholder engagement (local clinicians, GPs, patients, public) is included in the decision making process.

• Priorities are generated from insights from:-– Public & patient engagement – Joint Strategic Needs Assessment – Clinical Evidence – Programme budgeting or equivalent. – Defined criteria for evaluation and prioritising investment and disinvestment should be

developed including:-– Quality – Local Needs – Impact on health outcome gains and inequalities – NICE guidance/guidelines – Costs and Productivity

Specify Quality Outcomes

Assessing Needs

Review

Service

Provision

Decid

e on

P

riorities

Specify

Quality

Outcom

es

Design

Services &

Pathways

Manage Quality

& Performance

Clin

ical

D

ecis

ion

Mak

ing

Existing outcome measures

Current Achievement

Outcome measure design

Capabilities

Benefits caseClinical

Commissioning

Contract

providers

Man

age

Dem

and

Audit design

National quality indicators

Specify and agree quality outcomes

• CCGs must align their strategic plan and priorities with the key quality outcomes which they intend to deliver for their population.

• Outcomes that are chosen will need to be underpinned by quantifiable data, in order to provide a basis against which they can be monitored.

• Increasingly, national indicators which quantify health and patient reported outcomes are being used by PCTs to measure quality improvement.

• Further information on key quality outcomes agreed for NHS Milton Keynes are outlined in the Strategic Commissioning Plan & Annual Operating Plan . For a full list of national indicators which the PCT is measured against see NHS Milton Keynes Care Quality Commission’s Annual Health Check.

• The CCG should also take account of the NHS, Adult Social Care and Public Health Outcomes Frameworks, the Commissioning Outcomes Framework and outcome strategies

Design Service & Pathway

Assessing Needs

Review

Service

Provision

Decid

e on

P

riorities

Specify

Quality

Outcom

es

Design

Services &

Pathways

Manage Quality

& Performance

Clin

ical

D

ecis

ion

Mak

ing Evidence synthesis

Guideline enablement

Pathway adaptation

Evidence summaries for single interventions

Capabilities

Existing pathways

Clinical Commissioning HTAs

Contract

providers

Man

age

Dem

and

Pathway development

Design services and pathwaysThis element of the commissioning cycle is all about PCTs being able to identify improvement opportunities, based on national/international best practice, which ensure that services across settings are coordinate and integrated.

1. Prioritise – rationale for the work, based around strategic priorities2. Start Up – preparing for the review, establishing project team3. Review – conducting the review, including gap analysis and needs assessment4. Redesign & Option Appraisal – identifying the optimal model of care, testing of options and option appraisal5. Provider Development – assessing the market, shaping supply & contract issues6. Business Case – establish value for money & effectiveness of the proposed new service/pathway.7. Vision – recommend and promote the ethos of new service, gain stakeholder support.

8. Specification – develop service or pathway specification, including quality outcomes desired, for the proposed change9. Approval – gain organisational approval and financial resources for progressing the new service/pathway.10.Procurement – agree process by which new service/pathway will be contracted for.11. Implement – develop a plan for implementing the new service/pathway and delivering the change12. Monitoring & Review – monitor progress in achieving the required outcomes and service specification compliance.

Contract with Providers

Assessing Needs

Review

Service

Provision

Decid

e on

P

riorities

Specify

Quality

Outcom

es

Design

Services &

Pathways

Manage Quality

& Performance

Clin

ical

D

ecis

ion

Mak

ing

KPIs, Outcomes

Contract management

Capabilities

National and local contractsClinical Commissioning

Quality Standards

Contract

providers

Man

age

Dem

and

Negotiation skills

Tools

CQUINs, PROMS

Data

Contract with Providers / Supply

• The contracting process ensures that formal agreements with all providers (acute, primary, community, mental health, voluntary sector) are in place, and that these contracts clearly set out what is expected from both the commissioning and the provider.

• Within these contracts, PCTs can• Specify quality requirements or outcomes (e.g. CQUIN, PROMs) • Incentivise the development of new service models or patient pathways • Ensure quality of care for service users • Ensure value for money

Manage Demand

Assessing Needs

Review

Service

Provision

Decid

e on

P

riorities

Specify

Quality

Outcom

es

Design

Services &

Pathways

Manage Quality

& Performance

Clin

ical

D

ecis

ion

Mak

ing

Evidence base for reducing LOS, complications and cost

Risk assessment tools

Tools

Educational resources

Existing service usage

Variation between providers

Clinical Commissioning

Man

age

Dem

and

Contract

providers

Order sets / care bundles

Referral best practice

Prescribing data

Manage demand and ensure appropriate access to care• CCGs will need to have in place a range of responsive providers that they can

commission healthcare services from. • However, they also need to be able to understand and predict current and future

demands on those services to ensure that they can accurately predict required future capacity for the population needs identified.

• Employing their knowledge of future priorities, needs and community aspirations – CCGs can use their role as leader of the local NHS to influence improvement, choice and service design in ways that can best meet future demands.

Clinical Decision Making

Assessing Needs

Review

Service

Provision

Decid

e on

P

riorities

Specify

Quality

Outcom

es

Design

Services &

Pathways

Manage Quality

& Performance

Clin

ical

D

ecis

ion

Mak

ing

Clinical Commissioning

Contract

providers

Man

age

Dem

and

Best practice guidance

Tools

‘Just in time’ learning

Guidelines

Pathways

Clinical prompts

Referential decision support

Integrated decision support

Order sets / care bundles

Clinical decision making

• The CCG must build a strong framework of clinical involvement in its decision making to ensure that it can:-

• Develop a greater range of more integrated services in community settings • Secure great investment for upstream or preventative interventions that keep people

healthy for longer, prevent ill health and reduce inequalities • Drive continuous quality improvement and innovation across the whole system.

Quality & Performance

Assessing Needs

Review

Service

Provision

Decid

e on

P

riorities

Specify

Quality

Outcom

es

Design

Services &

Pathways

Manage Quality

& Performance

Clin

ical

D

ecis

ion

Mak

ing

Performance analysis

Decision support tools

Tools

Real time performance

Variation between providers

Learning needs assessment

Clinical Commissioning

Contract

providers

Man

age

Dem

and

Performance linked educational resources

Best practice guidance

Manage quality, performance & outcome• In order to assess whether their strategic goals are being achieved, CCGs need to

manage quality and performance of commissioned healthcare effectively. • This will involve monitoring and managing the performance of providers against

their contracts, including specific quality indicators or key performance indicators.• Good data and information sharing systems, plus constructive performance

discussions are crucial to this element:-– Ensuring monthly, quarterly or annual performance reviews are in place as appropriate – Clarity as to what checking/ verification is to be done, by whom and how frequently – Agreement on what Indicators /KPIs are to be measured, by whom and how frequently. – How are the results to be communicated and to whom – Who is responsible for following up concerns and in what forums.

NHS MK CCGBoard

NHS MK CCG Senior

Management Team

NHS MK CCGDelivery Group

Stakeholders

Service providers

Health and Wellbeing Board

Clinical Networks

Clinical Senate

Acute Service Review

Partner Organisations

Patient Congress

Practice Participation Groups

LINk:MK

Commissioning Support Hub

Joint Commissioning Team

External resources

Neighbourhood Quality &

Performance Groups (4)

Planned Care Programme

Urgent Care Programme

Mental Health Programme

Children & Maternity

Programme

Long Term Conditions

reports to

Co-operation & Competition Panel

Clinical Programmes& Projects Network of member practices

advisory

NHS Milton Keynes CCG Management FrameworkInternal decision making structure

http://www.miltonkeynesccg.nhs.uk/governance_structure/

Commissioning in Milton Keynes• Read about commissioning in Milton Keynes

http://www.miltonkeynesccg.nhs.uk/commissioning-in-mk/

• Read about the work of the Milton Keynes CCG Programme Boards:http://www.miltonkeynesccg.nhs.uk/commissioning_programmes/

• See the Commissioning Toolkit of resources to support the work of commissioners:

http://www.miltonkeynesccg.nhs.uk/commissioning_toolkit/

• Sign up for alerts to keep you abreast of the latest commissioning resources – Anne Gray - Commissioning.librarian@miltonkeynes.nhs.uk

Compiled by Anne Gray, Knowledge OfficerNHS Milton Keynes CCGSeptember 2012

With acknowledgement to Dr Andrew Jones, Clinical Specialist and Lead for Commissioning, BMJ