"The Commissioning Landscape" Peter Kay, National Clinical Director for MSK

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     “The Commissioning Landscape”

    Peter Kay, National Clinical Director
                  for MSK

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            Money and Healthcare
• Commissioning History England
    – 1948-91 unitary system all funded through AHA
    – 1991 The split commissioners/providers
    – 1991-94 GP fund holding / DHAs (192)
    – 1997 Primary Care Groups 481
    – 2002 Primary Care Trusts 303-152
    – 2010 Clinical Commissioning Groups 211

Directly commissioned
Services (Not via CCG)

Orthopaedic CRG

All Specialist services
under review

MSK CRG issues
• Need to see specialist commissioning in the context of
  pathways of care
• Drivers to get the right patient in the right place
    – Facilitate Networks
    – Integration not fragmentation

•   The right amount of specialised commissioning
•   75+ CRGs realistically we reduce the number
•   Excellent CRGs, Rheumatology, Orthopaedics
•   Aspiration and work of the CRGs

• The wider strategy of NHS England
• Specialist Commissioning will become better supported
  both clinically and financially with better outcomes

The Clinical Commissioning Group

The Bolt on the Landscape?
or the solution?

MSK in the NHS England (£7 -10bn)
           4th largest area of spend
•   More years lived with MSK disability than any other disease
•   2nd cause of disability
•   More time off work
•   25% of all GP slots
•   etc etc
•   Not Kids, Cancer, Cardiac
•   Is it a priority for payers?

• Under the Spot light
     – Economy
         •   Expensive
     – General Election
         •   Waiting times
     – Work
         •   Benefits

Orthopaedics is part of MSK &
         MSK is part of a wider NHS

We need to continually make the case
Advantage Effective interventions
Patient focused but population based

www.england.nhs.uk/house-of-care

                                Organisational and Clinical Processes
                                                       • Guidelines, evidence and
                      • Information and technology
                                                         national audits
                      • Care Planning
                                                       • Care Delivery
                      • Safety and Experience

  Informed and                                                                           Health and Care
engaged patients                                                                          Professionals
    and carers                                                                            committed to
                                                                                           partnership
                                            Person centred-                                 working
• Self management
• Information and                           coordinated care                             •   Integration
  Technology                                                                             •   Culture
• Group and peer                                                                         •   Workforce
  support                                                                                •   Technology
• Care Planning                                                                          •   Care Co-ordination
• Carers                                                                                 •   Care Planning

                                               Commissioning
  • Needs Assessment and Planning       • Service User and Public Involvement       • Care Planning
  • Joint commissioning of services     • Contracting and procurement               • Tools and levers
  • Metrics and Evaluation

Models of Good Care
Good care:
• Transcends contractual arrangements that underpin it
• Is not the preserve of primary or secondary care
• Needs to be delivered by a wider team
• Needs to be integrated
   – across providers, carers, local authorities and employers
• Needs to be seamless in its delivery, user understanding it
• Needs to be delivered in appropriate settings
   – Near home / specialist centre
• Health Care Workers competent in delivering MSK care
   – Developing the MSK workforce
• user-driven; by needs, preferences and outcomes
• Prevention, public health, employment, social care.

Commisioning
• Quote of 6 % of independently provided services
• Disproportionate for MSK
• Bedford, Sussex, Oldham

• Big support for commissioning no support for tendering
• AQP issues cherry picking, co-dependency of T&O

• 5 to 6 year contracts
• Nothing left

Prime vendor model
•   Holding the whole budget for MSK (usually not trauma)
•   Where this has worked it has ben an evolution
•   As service has developed more of the budget devolved
•   Integrated over time
•   The program budget does not define success
•   Giving the money over and expecting it to work
•   Cop out for some CCGs
•   Big conflicts of Interest

The ARMA Project:
               Key findings so far (1)
• Why it’s important
• Key issues for MSK services:
   – Inadequate understanding
   – Under-referral for rheumatology, over and under referral
     for orthopaedics?
   – Right care, right place, right time. Effective triage
   – Role of AHPs and nurses
• Good MSK services:
   –   Address urgent need
   –   Tailored to personal needs and wishes
   –   Improve quality of life
   –   Support people to remain active (eg in work) and
       independent

The ARMA Project:
           Key findings so far (2)
• Successful implementation of innovative MSK
  services involved:
  – links with CCG/ secondary care specialists
  – pioneering and innovative clinician/ AHP; a
    “champion”
  – knowledge of change management
  – prior specialist training in MSK
  – persistence(!)

A shared vision for
        excellent MSK services
• Holistic patient-centred care
• Early intervention
• Improved clinical and personal outcomes
• Multidisciplinary with shared decision-making
• Co-ordinated care, empowering informed
  patients
• Maximises community-based care closer to home
• Excellent communication channels
• Effective and accurate monitoring systems

The “architecture” of
         MSK clinical networks

Workforce: education   Integrated, community-        FLS (specific projects)
and training           based care

                        Metrics / outcome measures

                            Patient involvement

Regional (SCN) level

Local (CCG) level

Workforce: education and training

• Direct Assess to Physiotherapy (Scotland)
• Community Pharmacy

• The musculoskeletal Practitioner
• BSR, BOA, CSP, RCN, Keele University etc
       • Physio, Nurse, OT, Radiographer
       • Rheumatology nurse practitioner,
       • Trauma co-ordinator
       • Fragility Fracture Co-ordinator
• National Transferable roles

Metrics / outcome measures

• Making metrics part of the day job (ARUK)
• Should the NHS buy anything it does not measure
   – Provide an estimate of disease burden
   – Musculoskeletal Calculator
   – Effectiveness of processes
       • (Best practice tariff NOF)
       • (Best practice tariff early rheumatoid)
   – Pre treatment level of severity
   – Outcomes after treatment
   – Experience
• Finance
• Variation
• Competence

PROMs – Hip Replacement
Improvement in Oxford Hip Score

Outcome Relates to Pre-op Function*

          Hip Replacement                      Knee Replacement

                Pre Op Score                        Pre Op Score

  Worse               Better           Worse              Better

                               *from PROMs Data April 2010

Commissioning
• The Orthopaedic Profession needs to engage
  more with commissioners locally not just DH
• The role for regional advisors BOA-RCS
• Downward pressure on AQP private providers
  – Circle, Big Politics, CCG worries
• Need to be proactive not just reactive
• The election may be significant but……
• We still need to be working to define and design
  services not just do surgery

“When you are done changing, you're done.”
Benjamin Franklin

We are not done

MSK is a priority – The writing is on the wall

Networks are the future in commissioning